[Federal Register: November 9, 2006 (Volume 71, Number 217)]
[Rules and Regulations]
[Page 65883-66006]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr09no06-12]
[[Page 65883]]
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Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 414 and 484
Medicare Program; Home Health Prospective Payment System Rate Update
for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes to
Medicare Payment for Oxygen Equipment and Capped Rental Durable Medical
Equipment; Final Rule
[[Page 65884]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 414 and 484
[CMS-1304-F]
RIN 0938-AN76
Medicare Program; Home Health Prospective Payment System Rate
Update for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes
to Medicare Payment for Oxygen Equipment and Capped Rental Durable
Medical Equipment; Final Rule
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This final rule sets forth an update to the 60-day national
episode rates and the national per-visit amounts under the Medicare
prospective payment system for home health services. In addition, this
final rule sets forth policy changes related to Medicare payment for
certain durable medical equipment for the purpose of implementing
sections 1834(a)(5) and 1834(a)(7) of the Social Security Act, as
amended by section 5101 of the Deficit Reduction Act of 2005. This
final rule also responds to public comments on the August 3, 2006,
proposed rule that pertain to a number of issues including the
requirement that home health payments are based on the reporting of
specific quality data by home health agencies.
DATES: Effective Date: These regulations are effective on January 1,
2007.
FOR FURTHER INFORMATION CONTACT: Randy Throndset, (410) 786-0131, or
Sharon Ventura, (410) 786-1985 (for issues related to the home health
prospective payment system). Doug Brown, (410) 786-0028 (for issues
related to reporting home health quality data). Alexis Meholic, (410)
786-2300 (for issues related to payments for oxygen equipment and
capped rental durable medical equipment).
SUPPLEMENTARY INFORMATION:
I. Background
A. Statutory Background
The Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33), enacted on
August 5, 1997, significantly changed the way Medicare pays for
Medicare home health services. Until the implementation of a home
health prospective payment system (HH PPS) on October 1, 2000, home
health agencies (HHAs) received payment under a cost-based
reimbursement system. Section 4603 of the BBA governed the development
of the HH PPS.
Section 4603(a) of the BBA provides the authority for the
development of a PPS for all Medicare-covered home health services
provided under a plan of care that were paid on a reasonable cost basis
by adding section 1895, entitled ``Prospective Payment For Home Health
Services,'' to the Social Security Act (the Act).
Section 1895(b)(1) of the Act requires the Secretary to establish a
PPS for all costs of home health services paid under Medicare.
Section 1895(b)(3)(A) of the Act requires that (1) the computation
of a standard prospective payment amount include all costs of home
health services covered and paid for on a reasonable cost basis and be
initially based on the most recent audited cost report data available
to the Secretary, and (2) the prospective payment amounts be
standardized to eliminate the effects of case-mix and wage levels among
HHAs.
Section 1895(b)(3)(B) of the Act addresses the annual update to the
standard prospective payment amounts by the home health applicable
increase percentage as specified in the statute.
Section 1895(b)(4) of the Act governs the payment computation.
Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act require the
standard prospective payment amount to be adjusted for case-mix and
geographic differences in wage levels. Section 1895(b)(4)(B) of the Act
requires the establishment of an appropriate case-mix adjustment factor
that explains a significant amount of the variation in cost among
different units of services. Similarly, section 1895(b)(4)(C) of the
Act requires the establishment of wage-adjustment factors that reflect
the relative level of wages and wage-related costs applicable to the
furnishing of home health services in a geographic area compared to the
national average applicable level. These wage-adjustment factors may be
the factors used by the Secretary for the different area wage levels
for purposes of section 1886(d)(3)(E) of the Act.
Section 1895(b)(5) of the Act gives the Secretary the option to
grant additions or adjustments to the payment amount otherwise made in
the case of outliers because of unusual variations in the type or
amount of medically necessary care. Total outlier payments in a given
fiscal year cannot exceed 5 percent of total payments projected or
estimated.
On February 8, 2006, the Congress enacted the Deficit Reduction Act
(DRA) of 2005 (Pub. L. 109-171). This legislation made additional
changes to the HH PPS.
Section 5201 of the DRA changed the CY 2006 update from the
applicable home health market basket percentage increase minus 0.8
percentage points to a 0 percent update.
Section 5201 of the DRA amended section 421(a) of the MMA. The
amended section 421(a) of the MMA requires, for home health services
furnished in a rural area (as defined in section 1886(d)(2)(D) of the
Act) with respect to episodes and visits beginning on or after January
1, 2006 and before January 1, 2007, that the Secretary increase by 5
percent the payment amount otherwise made under section 1895 of the
Act. The statute waives budget neutrality for purposes of this increase
as it specifically requires that the Secretary not reduce the standard
prospective payment amount (or amounts) under section 1895 of the Act
applicable to home health services furnished during a period to offset
the increase in payments resulting in the application of this section
of the statute.
The 0 percent update to the payment rates and the rural add-on
provisions of the DRA were implemented through Pub. 100-20, One Time
Notification, Transmittal 211 issued February 10, 2006.
In addition, section 5201(c) of the DRA amends the statute to add
section 1895(b)(3)(B)(v) to the Act, requiring HHAs to submit data for
purposes of measuring health care quality. This requirement is
applicable for 2007 and each subsequent year. For 2007 and each
subsequent year, in the case of a HHA that does not submit quality
data, the home health market basket percentage increase would be
reduced by 2 percentage points.
B. Updates
1. 2000 Final Rule
On July 3, 2000, we published a final rule (65 FR 41128) in the
Federal Register to implement the HH PPS legislation. That final rule
established requirements for a new PPS for HHAs as required by section
4603 of the BBA, and as subsequently amended by section 5101 of the
Omnibus Consolidated and Emergency Supplemental Appropriations Act
(OCESAA) for Fiscal Year 1999 (Pub. L. 105-277), enacted on October 21,
1998; and by sections 302, 305, and 306 of the Medicare, Medicaid, and
SCHIP Balanced Budget Refinement Act (BBRA) of 1999 (Pub. L. 106-113),
enacted on November 29, 1999. The requirements include the
implementation of a PPS for home
[[Page 65885]]
health services, consolidated billing requirements, and a number of
other related changes. The PPS described in that rule replaced the
retrospective reasonable-cost-based system that was used by Medicare
for the payment of home health services under Part A and Part B.
2. 2005 Final Rule
On November 9, 2005, we published a final rule (70 FR 68132), which
set forth an update to the 60-day national episode rates and the
national per-visit amounts under the Medicare prospective payment
system for home health services for CY 2006. As part of that final
rule, we adopted revised area labor market Metropolitan Statistical
Area designations for CY 2006. In implementing the new area labor
market designations, we allowed for a 1-year transition period. This
transition consists of a blend of 50 percent of the new area labor
market designations' wage index and 50 percent of the previous area
labor market designations' wage index. In addition, we revised the
fixed dollar loss ratio, which is used in the calculation of outlier
payments.
C. System for Payment of Home Health Services
Generally, Medicare makes payment under the HH PPS on the basis of
a national standardized 60-day episode payment, adjusted for case mix
and wage index. For episodes with four or fewer visits, Medicare pays
on the basis of a national per-visit amount by discipline, referred to
as a low utilization payment adjustment (LUPA). Medicare also adjusts
the 60-day episode payment for certain intervening events that give
rise to a partial episode payment adjustment (PEP adjustment) or a
significant change in condition adjustment (SCIC). For certain cases
that exceed a specific cost threshold, an outlier adjustment may also
be available. For a complete and full description of the HH PPS as
required by the BBA and as amended by OCESAA and BBRA, see the July 3,
2000 HH PPS final rule (65 FR 41128).
D. Changes in Payment for Oxygen and Oxygen Equipment and Other Durable
Medical Equipment (Capped Rental Items)
The Medicare payment rules for durable medical equipment (DME) are
set forth in section 1834(a) of the Act and 42 CFR part 414, subpart D
of our regulations. General payment rules for DME are set forth in
section 1834(a)(1) of the Act and Sec. 414.210 of our regulations, and
Sec. 414.210 also contains paragraphs relating to maintenance and
servicing of items and replacement of items. Specific rules for oxygen
and oxygen equipment are set forth in section 1834(a)(5) of the Act and
Sec. 414.226 of our regulations, and specific rules for capped rental
items are set forth in section 1834(a)(7) of the Act and Sec. 414.229
of our regulations. Rules for determining a period of continuous use
for the rental of DME are set forth in Sec. 414.230 of our
regulations. The Medicare payment basis for DME is equal to 80 percent
of either the lower of the actual charge or the fee schedule amount for
the item. The beneficiary coinsurance is equal to 20 percent of either
the lower of the actual charge or the fee schedule amount for the item.
In accordance with the rules set forth in section 1834(a)(5) of the
Act and Sec. 414.226 of our regulations, since 1989, suppliers have
been paid monthly for furnishing oxygen and oxygen equipment to
Medicare beneficiaries. Suppliers have also been paid an add-on fee for
furnishing portable oxygen equipment to patients when medically
necessary. Before the enactment of the DRA, these monthly payments
continued for the duration of use of the equipment, provided that
Medicare Part B coverage and eligibility criteria were met. Medicare
covers three types of oxygen delivery systems: (1) Stationary or
portable oxygen concentrators, which concentrate oxygen in room air;
(2) stationary or portable liquid oxygen systems, which use oxygen
stored as a very cold liquid in cylinders and tanks; and (3) stationary
or portable gaseous oxygen systems, which administer compressed oxygen
directly from cylinders. Both liquid and gaseous oxygen systems require
delivery of oxygen contents.
Medicare payment for furnishing oxygen and oxygen equipment is made
on a monthly basis and the fee schedule amounts vary by State. Payment
for oxygen contents for both stationary and portable equipment is
included in the fee schedule allowances for stationary equipment.
Medicare fee schedules for home oxygen equipment are modality neutral;
meaning that in a given State, there is one fee schedule amount that
applies to all stationary systems and one fee schedule amount that
applies to all portable systems.
Effective January 1, 2006, section 5101(b) of the DRA amended the
Act at section 1834(a)(5) of the Act, limiting to 36 months the total
number of continuous months for which Medicare will pay for oxygen
equipment on a rental basis. At the end of the 36-month period, this
section mandates that the supplier transfer title to the stationary and
portable oxygen equipment to the beneficiary. Section 5101(b) of the
DRA does not, however, limit the number of months for which Medicare
will pay for oxygen contents for beneficiary-owned stationary or
portable gaseous or liquid systems, and payment will continue to be
made as long as the oxygen remains medically necessary. Section 5101(b)
of the DRA also provides that payment for reasonable and necessary
maintenance and servicing of beneficiary-owned oxygen equipment will be
made for parts and labor not covered by a supplier's or manufacturer's
warranty. In the case of beneficiaries using oxygen equipment on
December 31, 2005, the 36-month rental period prescribed by the DRA
begins on January 1, 2006.
In accordance with the rules set forth in section 1834(a)(7) of the
Act and Sec. 414.229 of our regulations, before the enactment of the
DRA, suppliers of capped rental items (that is, other DME not described
in paragraphs (2) through (6) of section 1834(a) of the Act) were paid
on a rental or purchase option basis. Payment for most items in the
capped rental category was made on a monthly rental basis, with rental
payments being capped at 15 months or 13 months, depending on whether
the beneficiary chose to continue renting the item or to take over
ownership of the item through the ``purchase option.'' For all capped
rental items, the supplier was required to inform the beneficiary of
his or her purchase option, during the 10th rental month, to enter into
a purchase agreement under which the supplier would transfer title to
the item to the beneficiary on the first day after the 13th continuous
month during which payment was made for the rental of the item.
Therefore, if the beneficiary chose the purchase option, rental
payments to the supplier would continue through the 13th month of
continuous use of the equipment, after which time title to the
equipment would transfer from the supplier to the beneficiary. Medicare
would also make payment for any reasonable and necessary repair or
maintenance and servicing of the equipment following the transfer of
title. If the beneficiary did not choose the purchase option, rental
payments would continue through the 15th month of continuous use. In
these cases, suppliers would maintain title to the equipment but would
have to continue furnishing the item to the beneficiary as long as
medical necessity continued. Beginning 6 months after the 15th month of
continuous use in which payment was made, Medicare would also make
semi-annual maintenance and servicing payments to suppliers. These
payments were approximately equal to 10 percent
[[Page 65886]]
of the purchase price for the equipment as determined by the statute.
Total Medicare payments made through the 13th and 15th months of rental
equal 105 and 120 percent, respectively, of the purchase price for the
equipment.
In the case of power-driven wheelchairs, since 1989 payment has
also been made on a lump-sum purchase basis at the time that the item
is initially furnished to the beneficiary if the beneficiary chooses to
obtain the item in this manner. Most beneficiaries choose to obtain
power-driven wheelchairs via this lump-sum purchase option.
Effective for items for which the first rental month occurs on or
after January 1, 2006, section 5101(a) of the DRA of 2005 amended
section 1834(a)(7) of the Act, limiting to 13 months the total number
of continuous months for which Medicare will pay for DME in this
category. After a 13-month period of continuous use during which rental
payments are made, the statute requires that the supplier transfer
title to the equipment to the beneficiary. Beneficiaries may still
elect to obtain power-driven wheelchairs on a lump-sum purchase
agreement basis. In all cases, payment for reasonable and necessary
maintenance and servicing of beneficiary-owned equipment will be made
for parts and labor not covered by the supplier's or manufacturer's
warranty.
E. Requirements for Issuance of Regulations
Section 902 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) amended section 1871(a) of the Act and
requires the Secretary, in consultation with the Director of the Office
of Management and Budget, to establish and publish timelines for the
publication of Medicare final regulations based on the previous
publication of a Medicare proposed or interim final regulation. Section
902 of the MMA also states that the timelines for these regulations may
vary but shall not exceed 3 years after publication of the preceding
proposed or interim final regulation except under exceptional
circumstances.
This final rule finalizes provisions set forth in the August 3,
2006 proposed rule. In addition, this final rule has been published
within the 3-year time limit imposed by section 902 of the MMA.
Therefore, we believe that the final rule is in accordance with the
Congress' intent to ensure timely publication of final regulations.
II. Provisions of the Proposed Regulations
We published a proposed rule in the Federal Register on August 3,
2006 (71 FR 44081) that set forth a proposed update to the 60-day
national episode rates and the national per-visit amounts under the
Medicare prospective payment system for home health services. In
addition, that proposed rule set forth proposed policy changes related
to Medicare payment for certain durable medical equipment for the
purpose of implementing sections 1834(a)(5) and 1834(a)(7) of the
Social Security Act, as amended by section 5101 of the Deficit
Reduction Act of 2005. That proposed rule also invited comments on a
number of issues including payments based on reporting quality data,
the adoption of health information technology, as well as how to
improve data transparency for consumers.
A. National Standardized 60-Day Episode Rate
The Medicare HH PPS has been effective since October 1, 2000. As
set forth in the final rule published July 3, 2000 in the Federal
Register (65 FR 41128), the unit of payment under the Medicare HH PPS
is a national standardized 60-day episode rate. As set forth in Sec.
484.220, we adjust the national standardized 60-day episode rate by a
case mix grouping and a wage index value based on the site of service
for the beneficiary. The proposed CY 2007 HH PPS rates used the same
case-mix methodology and application of the wage index adjustment to
the labor portion of the HH PPS rates as set forth in the July 3, 2000
final rule. In the October 22, 2004 final rule, we rebased and revised
the home health market basket, resulting in a labor-related share of
76.775 percent and a non-labor portion of 23.225 percent (69 FR 62126).
We multiply the national 60-day episode rate by the patient's
applicable case-mix weight. We divide the case-mix adjusted amount into
a labor and non-labor portion. We multiply the labor portion by the
applicable wage index based on the site of service of the beneficiary.
As required by section 1895(b)(3)(B) of the Act, we have updated
the HH PPS rates annually in a separate Federal Register document.
Section 484.225 sets forth the specific annual percentage update. To
reflect section 1895(b)(3)(B)(v) of the Act, as added by section 5201
of the DRA, we proposed to revise Sec. 484.225, paragraph (g) as
follows:
(g) For 2007 and subsequent calendar years, the unadjusted
national rate is equal to the rate for the previous calendar year
increased by the applicable home health market basket index amount
unless the HHA has not submitted quality data in which case the
unadjusted national rate is equal to the rate for the previous
calendar year increased by the applicable home health market basket
index amount minus 2 percentage points.
For CY 2007, we proposed to use again the design and case-mix
methodology described in section III.G of the HH PPS July 3, 2000 final
rule (65 FR 41192 through 41203). For CY 2007, we will base the wage
index adjustment to the labor portion of the PPS rates on the most
recent pre-floor and pre-reclassified hospital wage index as discussed
in section II.F of the August 3, 2006 proposed rule (not including any
reclassifications under section 1886(d)(8)(B) of the Act).
As discussed in the July 3, 2000 HH PPS final rule, for episodes
with four or fewer visits, Medicare pays the national per-visit amount
by discipline, referred to as a LUPA. We update the national per-visit
amounts by discipline annually by the applicable home health market
basket percentage. We adjust the national per-visit amount by the
appropriate wage index based on the site of service for the beneficiary
as set forth in Sec. 484.230. We will adjust the labor portion of the
updated national per-visit amounts by discipline used to calculate the
LUPA by the most recent pre-floor and pre-reclassified hospital wage
index, as discussed in section II.F of the August 3, 2006 proposed
rule.
Medicare pays the 60-day case-mix and wage-adjusted episode payment
on a split percentage payment approach. The split percentage payment
approach includes an initial percentage payment and a final percentage
payment as set forth in Sec. 484.205(b)(1) and Sec. 484.205(b)(2). We
may base the initial percentage payment on the submission of a request
for anticipated payment (RAP) and the final percentage payment on the
submission of the claim for the episode, as discussed in Sec. 409.43.
The claim for the episode that the HHA submits for the final percentage
payment determines the total payment amount for the episode and whether
we make an applicable adjustment to the 60-day case-mix and wage-
adjusted episode payment. The end date of the 60-day episode as
reported on the claim determines which calendar year rates Medicare
would use to pay the claim.
We may also adjust the 60-day case-mix and wage-adjusted episode
payment based on the information submitted on the claim to reflect the
following:
[[Page 65887]]
A low utilization payment provided on a per-visit basis as
set forth in Sec. 484.205(c) and Sec. 484.230.
A partial episode payment adjustment as set forth in Sec.
484.205(d) and Sec. 484.235.
A significant change in condition adjustment as set forth
in Sec. 484.205(e) and Sec. 484.237.
An outlier payment as set forth in Sec. 484.205(f) and
Sec. 484.240.
B. CY 2007 Update to the Home Health Market Basket Index
Section 1895(b)(3)(B) of the Act, as amended by section 5201 of the
DRA, requires for CY 2007 that the standard prospective payment amounts
be increased by a factor equal to the applicable home health market
basket update. The proposed rule contained a home health market basket
update of 3.1 percent. Since publication of the proposed rule, we have
estimated a new home health market basket update of 3.3 percent for CY
2007.
CY 2007 Adjustments
In calculating the annual update for the CY 2007 60-day episode
rates, we first look at the CY 2006 rates as a starting point. The CY
2006 national 60-day episode rate, as modified by section 5201(a)(4) of
the DRA (and implemented through Pub. 100-20, One Time Notification,
Transmittal 211 issued February 10, 2006) is $2,264.28.
In order to calculate the CY 2007 national 60-day episode rate, we
multiply the CY 2006 national 60-day episode rate ($2,264.28) by the
estimated home health market basket update of 3.3 percent for CY 2007.
The estimated home health market basket percentage increase reflects
changes over time in the prices of an appropriate mix of goods and
services included in covered home health services. The estimated home
health market basket percentage increase is generally used to update
the HH PPS rates on an annual basis.
We increase the CY 2006 60-day episode payment rate by the
estimated home health market basket update (3.3 percent) ($2,264.28 x
1.033) to yield the updated CY 2007 national 60-day episode rate
($2,339.00) (see Table 1 below). The CY 2007 HH PPS rates apply to
episodes ending on or after January 1, 2007, and before January 1,
2008.
Table 1.--National 60-Day Episode Amounts Updated by the Estimated Home Health Market Basket Update for CY 2007,
Before Case-Mix Adjustment
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Multiply by the Estimated Home
Total CY 2006 Prospective Payment Health Market Basket Update (3.3 CY 2007 Updated National 60-Day
Amount Per 60-day Episode Percent)\1\ Episode Rate
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$2,264.28 x 1.033 $2,339.00
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\1\ The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc,
3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.
National Per-Visit Amounts Used To Pay LUPAs and Compute Imputed Costs
Used in Outlier Calculations
As discussed previously in the August 3, 2006 proposed rule, the
policies governing the LUPAs and outlier calculations set forth in the
July 3, 2000 HH PPS final rule will continue during CY 2007. In
calculating the annual update for the CY 2007 national per-visit
amounts we use to pay LUPAs and to compute the imputed costs in outlier
calculations, we look again at the CY 2006 rates as a starting point.
We then multiply those amounts by the estimated home health market
basket update for CY 2007 (3.3 percent) to yield the updated per-visit
amounts for each home health discipline for CY 2007 (episodes ending on
or after January 1, 2007, and before January 1, 2008) (see Table 2
below).
Table 2.--National Per-Visit Amounts for LUPAs and Outlier Calculations Updated by the Estimated Home Health
Market Basket Update for CY 2007
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Multiply by the
Final CY 2006 per- estimated home CY 2007 per-visit
Home health discipline type visit amounts per health market payment amount
60-day episode basket (3.3 per discipline
for LUPAs percent) \1\ for LUPAs
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Home Health Aide....................................... $44.76 x 1.033 $46.24
Medical Social Services................................ 158.45 x 1.033 163.68
Occupational Therapy................................... 108.81 x 1.033 112.40
Physical Therapy....................................... 108.08 x 1.033 111.65
Skilled Nursing........................................ 98.85 x 1.033 102.11
Speech-Language Pathology.............................. 117.44 x 1.033 121.32
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\1\ The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc,
3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.
C. Rural Add-On
As stated above, section 5201(b) of the DRA requires, for home
health services furnished in a rural area (as defined in section
1886(d)(2)(D) of the Act) with respect to episodes and visits beginning
on or after January 1, 2006 and before January 1, 2007, that the
Secretary increase by 5 percent the payment amount otherwise made under
section 1895 of the Act. The statute waives budget neutrality related
to this provision as it specifically states that the Secretary shall
not reduce the standard prospective payment amount (or amounts) under
section 1895 of the Act applicable to home health services furnished
during a period to offset the increase in payments resulting in the
application of this section of the statute.
While the rural add-on primarily affects those episodes paid based
on CY 2006 rates, it also affects a number of CY 2007 episodes. For
example, an episode that begins on December 20, 2006 and ends on
February 17, 2007 for services furnished in a rural area, will be paid
based on CY 2007 rates because the episode ends on or after January 1,
2007 and before January 1, 2008; and the
[[Page 65888]]
episode will also receive the rural add-on because the episode begins
on or after January 1, 2006 and before January 1, 2007.
The applicable case-mix and wage index adjustment is subsequently
applied to the 60-day episode amount for the provision of home health
services where the site of service for the beneficiary is a non-
Metropolitan Statistical Area (MSA). Similarly, the applicable wage
index adjustment is subsequently applied to the LUPA per-visit amounts
adjusted for the provision of home health services where the site of
service for the beneficiary is a non-MSA area. We implemented this
provision for CY 2006 on February 13, 2006 through Pub. 100-20, One
Time Notification, Transmittal 211 issued February 10, 2006. The 5
percent rural add-on is noted in tables 3 and 4 below.
Table 3.--Payment Amounts for 60-Day Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the
Estimated Home Health Market Basket Update for CY 2007 with Rural Add-on, Before Case-Mix Adjustment
----------------------------------------------------------------------------------------------------------------
CY 2007 Payment amount per 60-day
episode beginning in CY 2006 and
CY 2007 Total prospective payment 5 Percent rural add-on before January 1, 2007 and ending in
amount per 60-day episode CY 2007 for a beneficiary who
resides in a non-MSA area
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$2,339 x 1.05 $2,455.95
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Table 4.--Per-Visit Amounts for Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated
Home Health Market Basket Update for CY 2007 with Rural Add-on
----------------------------------------------------------------------------------------------------------------
CY 2007 per-visit
payment amount
per discipline
for 60-day
episodes
CY 2007 Per-visit Multiply by the 5 beginning on or
Home health discipline type amounts percent rural add- after January 1,
on in CY 2006 and
ending in CY 2007
for a beneficiary
who resides in a
non-MSA area
----------------------------------------------------------------------------------------------------------------
Home Health Aide....................................... $46.24 x 1.05 $48.55
Medical Social Services................................ 163.68 x 1.05 171.86
Occupational Therapy................................... 112.40 x 1.05 118.02
Physical Therapy....................................... 111.65 x 1.05 117.23
Skilled Nursing........................................ 102.11 x 1.05 107.22
Speech-Language Pathology.............................. 121.32 x 1.05 127.39
----------------------------------------------------------------------------------------------------------------
D. Home Health Care Quality Improvement
Section 5201(c)(2) of the DRA added section 1895(b)(3)(B)(v)(II) to
the Act, requiring that ``each home health agency shall submit to the
Secretary such data that the Secretary determines are appropriate for
the measurement of health care quality. Such data shall be submitted in
a form and manner, and at a time, specified by the Secretary for
purposes of this clause.'' In addition, section 1895(b)(3)(B)(v)(I) of
the Act, as also added by section 5201(c)(2) of the DRA, dictates that
``for 2007 and each subsequent year, in the case of a home health
agency that does not submit data to the Secretary in accordance with
subclause (II) with respect to such a year, the home health market
basket percentage increase applicable under such clause for such year
shall be reduced by 2 percentage points.''
The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) required
the use of a standardized assessment instrument for quality oversight
of HHAs. A standardized assessment instrument provides an HHA with a
uniform mechanism to assess the needs of their patients and provide CMS
with a uniform mechanism to assess the HHA's ability to adequately
address those needs. To fulfill the OBRA 87 mandate, CMS required that,
as part of their comprehensive assessment process, HHAs collect and
report Outcome and Assessment Information Set (OASIS) data and later
mandated the submission of this data as a Medicare Condition of
Participation for home health agencies at 42 CFR 484.20 and 484.55.
The OASIS data provide consumers and HHAs with ten publicly-
reported home health quality measures which have been endorsed by the
National Quality Forum (NQF). Reporting this quality data has also
required the development of several supporting mechanisms such as the
HAVEN software used to encode and transmit data using a CMS standard
electronic record layout, edit specifications, and data dictionary. Use
of the HAVEN software, which includes the OASIS, has become a standard
practice within HHA operations. These early investments in data
infrastructure and supporting software that CMS and HHAs have made over
the past several years in order to create this quality reporting
structure, have made quality reporting and measurement an important
component of the HHA industry. The 10 measures are:
(1) Improvement in ambulation/locomotion
(2) Improvement in bathing
(3) Improvement in transferring
(4) Improvement in management of oral medications
(5) Improvement in pain interfering with activity
(6) Acute care hospitalization
(7) Emergent care
(8) Improvement in dyspnea
(9) Improvement in urinary incontinence
(10) Discharge to community
We proposed to use OASIS data and the 10 quality measures based on
those data as the appropriate measure of home health quality for CY
2007. Continuing to use the OASIS instrument minimizes
[[Page 65889]]
the burden to providers and ensures that costs associated with the
development and testing of a new reporting mechanism are not incurred.
We believe that the noted 10 quality measures are the most appropriate
measure of home health quality. Accordingly, for CY 2007, we proposed
to require that the OASIS data, specifically the 10 quality measures,
be submitted by HHAs, to meet the requirement that each HHA submit data
appropriate for the measurement of health care quality, as determined
by the Secretary.
Additionally, section 1895(b)(3)(B)(v)(II) of the Act provides the
Secretary with the discretion to require the submission of the required
data in a form, manner, and time specified by him. For CY 2007, we
proposed to consider OASIS data submitted by HHAs to CMS for episodes
beginning on or after July 1, 2005 and before July 1, 2006 as meeting
the reporting requirement. This proposed reporting time period would
allow a full 12 months of data and provides CMS the time necessary to
analyze and make any necessary payment adjustments to the CY 2007
payment rates for HHAs that fail to meet the reporting requirement.
HHAs that met the reporting requirement would be eligible for the full
home health market basket percentage increase. Using historical data to
determine a prospective update is also used for hospital pay for
reporting.
As discussed in the August 3, 2006 proposed rule, during the next
few years, we noted that we would be pursuing the development of
patient level process measures for home health agencies. We also
proposed to continue to refine the current OASIS tool in response to
recommendations from a Technical Expert Panel conducted to review the
data elements that make up the OASIS tool. These process measures would
refer to specific care practices that are, or are not, followed by the
home health agency for each patient. An example of this type of measure
may be: the percentage of patients at risk of falls for whom prevention
of falls was addressed in the care plan. We expect to introduce these
additional measures over CY 2008 and CY 2009 so as to complement the
existing OASIS outcome measures. During the years leading to CY 2010
payments, we will test and refine these measures to determine if they
can more accurately reflect the level of quality care being provided at
HHAs without being overly burdensome with the data collection
instrument. Some process measures are in the very early stages of
development. To the extent that evidence-based data are available on
which to determine the appropriate measure specifications, and adequate
risk-adjustments are made, we anticipate collecting and reporting these
measures as part of each agency's home health quality plan. We believe
that future modifications to the current OASIS tool including reducing
the number of questions on the tool, refining possible responses, as
well as adding new process measures will be made. In all cases, we
anticipate that any future quality measures should be evidence-based,
clearly linked to improved outcomes, and able to be reliably captured
with the least burden to the provider. We are also beginning work in
order to measure patient experience of care (in the form of a patient
satisfaction survey) in the home health setting.
We recognize, however, that the conditions of participation (42 CFR
part 484) that require OASIS submission also provide for exclusions
from this requirement. Generally, agencies are not subject to the OASIS
submission requirement, and thus do not receive Medicare payments, for
patients that are not Medicare beneficiaries or for patients that are
not receiving Medicare-covered home health services. Under the
conditions of participation, agencies are excluded from the OASIS
reporting requirement on individual patients if:
Those patients are receiving only non-skilled services,
Neither Medicare nor Medicaid is paying for home health
care (patients receiving care under a Medicare or Medicaid Managed Care
Plan are not excluded from the OASIS reporting requirement),
Those patients are receiving pre- or post-partum services,
Those patients are under 18 years of age.
We believe that the rationale behind our proposal to exclude these
agencies from submitting OASIS data on patients excluded from OASIS
submission as a condition of participation is equally applicable to
HHAs for purposes of meeting the DRA quality data reporting
requirement. If an agency is not submitting OASIS for patients excluded
from OASIS submission as a condition of participation, we believe that
the submission of OASIS data for quality measures for Medicare payment
purposes is also not necessary. Accordingly, we proposed that HHAs
would not need to submit quality measures for DRA reporting purposes
for those patients who are excluded from OASIS submission as a
condition of participation.
Additionally, we proposed that agencies that are newly certified
(on or after May 31, 2006 for payments to be made in CY 2007) would be
excluded from the DRA reporting requirement as data submission and
analysis would not be possible for an agency certified this late in the
reporting time period. In future years, agencies that certify on or
after May 31 of the preceding year involved would be excluded from any
payment penalty under the DRA for the following calendar year. For
example, for purposes of determining compliance with the quality data
reporting requirement for CY 2007, if HHA ``X'' were to enroll in the
Medicare Program on or before May 30, 2006, CMS would expect HHA ``X''
to submit the required quality data (unless covered by another
exclusion protocol) on or before June 30, 2006 (the end of the
reporting period for payments effectuated in CY 2007). However, if HHA
``Y'' was to enroll in the Medicare Program on or after May 31, 2006,
CMS would automatically exclude HHA ``Y'' from the DRA quality data
reporting requirements and the agency would be entitled to the full
market basket increase for CY 2007. We note that these proposed
exclusions would only affect reporting requirements under the DRA and
would not otherwise affect the agency's OASIS reporting
responsibilities under the conditions of participation.
We proposed to require that all HHAs, unless covered by these
specific exclusions, meet the reporting requirement, or be subject to a
2 percent reduction in the home health market basket percentage
increase in accordance with section 1895(b)(3)(B)(v)(I) of the Act. The
2 percent reduction would apply to all episodes ending on or before
December 31, 2007. We provide the reduced payment rates in tables 5, 6,
7, and 8 below.
[[Page 65890]]
Table 5.--For HHAs That Do Not Submit the Required Quality Data-- National 60-Day Episode Amount Updated by the
Estimated Home Health Market Basket Update for CY 2007, Minus 2 Percentage Points, Before Case-Mix Adjustment
----------------------------------------------------------------------------------------------------------------
Multiply by the estimated home CY 2007 updated national 60-day
Total CY 2006 prospective payment health market basket update (3.3 episode rate for HHAs that do not
amount per 60-day episode Percent \1\ minus 2 percent) submit required quality data
----------------------------------------------------------------------------------------------------------------
$2,264.28 x 1.013 $2,293.72
----------------------------------------------------------------------------------------------------------------
\1\The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc,
3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.
Table 6--For HHAs That Do Not Submit the Required Quality Data--National Per-Visit Amounts Updated by the
Estimated Home Health Market Basket Update for CY 2007, Minus 2 Percentage Points
----------------------------------------------------------------------------------------------------------------
CY 2007 per-visit
Multiply by the payment amount
Final CY 2006 per- estimated home per discipline
Home health discipline type visit amounts per health market for HHAs that do
60-day episode basket update not submit
(3.3 percent \1\ required quality
minus 2 percent) data
----------------------------------------------------------------------------------------------------------------
Home Health Aide....................................... $44.76 x 1.013 $45.34
Medical Social Services................................ 158.45 x 1.013 160.51
Occupational Therapy................................... 108.81 x 1.013 110.22
Physical Therapy....................................... 108.08 x 1.013 109.49
Skilled Nursing........................................ 98.85 x 1.013 100.14
Speech-Language Pathology.............................. 117.44 x 1.013 118.97
----------------------------------------------------------------------------------------------------------------
\1\The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc,
3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.
Table 7.--For HHAs That Do Not Submit the Required Quality Data-- Payment Amount for 60-Day Episodes Beginning
in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket for CY 2007, Minus 2
Percentage Points, with Rural Add-on, Before Case-Mix Adjustment
----------------------------------------------------------------------------------------------------------------
CY 2007 Payment amount per 60-day
episode beginning in CY 2006 and
CY 2007 Updated national 60-day ending in CY 2007 for a beneficiary
episode rate for HHAs that do not 5 Percent rural add-on who resides in a non-MSA area for
submit required quality data HHAs that do not submit required
quality data
----------------------------------------------------------------------------------------------------------------
$2,293.72 x 1.05 $2,408.41
----------------------------------------------------------------------------------------------------------------
Table 8--For HHAs That Do Not Submit the Required Quality Data-- Per-Visit Payment Amounts for Episodes
Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket for CY 2007, Minus
2 Percentage Points, with Rural Add-on
----------------------------------------------------------------------------------------------------------------
CY 2007 Per-visit
payment amounts
for episodes
beginning in CY
CY 2007 Per-visit 2006 and ending
amounts for HHAs 5 Percent rural in CY 2007 for a
Home health discipline type that do not add-on beneficiary who
submit required resides in a non-
quality data MSA area for HHAs
that do not
submit required
quality data
----------------------------------------------------------------------------------------------------------------
Home Health Aide....................................... $45.34 x 1.05 $47.61
Medical Social Services................................ 160.51 x 1.05 168.54
Occupational Therapy................................... 110.22 x 1.05 115.73
Physical Therapy....................................... 109.49 x 1.05 114.96
Skilled Nursing........................................ 100.14 x 1.05 105.55
Speech-Language Pathology.............................. 118.97 x 1.05 124.92
----------------------------------------------------------------------------------------------------------------
Section 1895(b)(3)(B)(v)(III) of the Act further requires that the
``Secretary shall establish procedures for making data submitted under
subclause (II) available to the public.'' Additionally, the statute
requires that ``such procedures shall ensure that a home health agency
has the opportunity to review the data that is to be made public with
respect to the agency prior to such data being made public.'' To meet
the requirement for making such data public, we proposed
[[Page 65891]]
to continue to use the CMS Home Health Compare Web site whereby HHAs
are listed geographically. Currently the 10 proposed quality measures
are posted on the CMS Home Health Compare Web site. Consumers can
search for all Medicare-approved home health providers that serve their
city or zip code and then find the agencies offering the types of
services they need as well as the required quality measures. See http://www.medicare.gov/HHCompare.
HHAs would continue to have access
(through the Home Health Compare contractor) to its own quality data
(updated periodically) and we would establish a process by which
agencies would receive a report before reporting the data publicly.
Currently, the CMS Home Health Compare Web site does not publicly
report data when agencies have fewer than 20 episodes of care within a
reporting period. In light of the DRA requirements, we recognize the
need to provide the required data to the public and would make these
statistics available through expansion of the CMS Home Health Compare
Web site.
In the July 27, 2005 Medicare Payment Advisory Commission (MedPAC)
testimony before the U.S. Senate Committee on Finance, MedPAC expressed
support for the concept of differential payments for Medicare
providers, which could create incentives to improve quality. To support
this initiative, MedPAC stated that ``outcome measures from CMS'
Outcome-based Quality Indicators'' (currently collected through the
OASIS instrument) ``could form the starter set.'' MedPAC further states
``* * * the Agency for Healthcare Research and Quality concur(s) that a
set of these measures is reliable and adequately risk adjusted.''
The MedPAC testimony recognizes that while the goal of care for
many home health patients is improving health and functioning, for some
patients the goal of the HHA is to simply stabilize their conditions
and prevent further decline. Additionally, the MedPAC testimony
reflects that measures of structure and process could also be
considered.
Various home health outcome measures are now in common use and have
been studied for some time. A number of these measures have been
endorsed by the National Quality Forum (NQF) and are evidence-based,
well accepted, and not unduly burdensome. When determining outcome
measures that will be most appropriate, it is important to measure
aspects of care that providers can control and are adequately risk-
adjusted. Home-based care presents particular difficulties for provider
control because patient conditions are compounded by a variety of home
environment and support system issues.
We are currently pursuing the development of patient-level process
measures for HHAs, as well as refining the current OASIS tool in
response to recommendations from a Technical Expert Panel conducted to
review the data elements that make up the OASIS tool. These additional
measures would complement the existing OASIS outcome measures and would
assist us in identifying processes of care that lead to improvements
for certain populations of patients. These process measures are
currently in the very early stages of development. As we stated
previously, to the extent that evidence-based data are available on
which to determine the appropriate measure specifications, and adequate
risk-adjustments are made, we anticipate collecting and reporting these
measures as part of our home health quality plan. Possible
modifications to the current OASIS tool include reducing the number of
questions on the tool, refining possible responses, as well as adding
new process measures.
We solicited comments on how to make the outcome measures more
useful. We also solicited comments on measures of home health care
processes for which there is evidence of improved care to
beneficiaries. In all cases, we noted that measures should be evidence-
based, clearly linked to improved outcomes, and able to be reliably
captured with the least burden to the provider. We also considered
measures of patient experience of care in the home health setting, as
well as efficiency measures, and solicited comment on the use of these
measures and their importance in the home health setting. In the
proposed rule, we noted that we would address any changes to the HH PPS
quality data submission requirement in future rulemaking.
We also stated our intent to provide guidance on the
specifications, definitions, and reporting requirements of any
additional measures through the standard protocol for measure
development.
We proposed to revise the regulations at Sec. 484.225 to reflect
these proposed payment requirements which would require submission of
quality data. For CY 2007, we will finalize the requirement to use the
10 OASIS measures as meeting the DRA quality data reporting requirement
as discussed in section II.D. of the August 3, 2006 proposed rule and
the regulations at Sec. 484.225.
E. Outliers and Fixed Dollar Loss Ratio
Outlier payments are payments made in addition to regular 60-day
case-mix and wage-adjusted episode payments for episodes that incur
unusually large costs due to patient home health care needs. Outlier
payments are made for episodes for which the estimated cost exceeds a
threshold amount. The episode's estimated cost is the sum of the
national wage-adjusted per-visit payment amounts for all visits
delivered during the episode. The outlier threshold for each case-mix
group, PEP adjustment, or total SCIC adjustment is defined as the 60-
day episode payment amount, PEP adjustment, or total SCIC adjustment
for that group plus a fixed dollar loss amount. Both components of the
outlier threshold are wage-adjusted.
The wage-adjusted fixed dollar loss (FDL) amount represents the
amount of loss that an agency must bear before an episode becomes
eligible for outlier payments. The FDL is computed by multiplying the
wage-adjusted 60-day episode payment amount by the FDL ratio, which is
a proportion expressed in terms of the national standardized episode
payment amount. The outlier payment is defined to be a proportion of
the wage-adjusted estimated costs beyond the wage-adjusted threshold.
The proportion of additional costs paid as outlier payments is referred
to as the loss-sharing ratio.
Section 1895(b)(5) of the Act requires that estimated total outlier
payments are no more than 5 percent of total estimated HH PPS payments.
In response to the concerns about potential financial losses that might
result from unusually expensive cases expressed in comments to the
October 28, 1999 proposed rule (64 FR 58133), the July 2000 final rule
set the target for estimated outlier payments at the 5 percent level.
The FDL ratio and the loss-sharing ratio were then selected so that
estimated total outlier payments would meet the 5 percent target.
For a given level of outlier payments, there is a trade-off between
the values selected for the FDL ratio and the loss-sharing ratio. A
high FDL ratio reduces the number of episodes that can receive outlier
payments, but makes it possible to select a higher loss-sharing ratio
and, therefore, increase outlier payments for outlier episodes.
Alternatively, a lower FDL ratio means that more episodes can qualify
for outlier payments, but outlier payments per episode must be lower.
As a result of public comments on the October 28, 1999 proposed rule,
in our July 2000 final rule, we made the decision to attempt to do the
former.
[[Page 65892]]
In the July 2000 final rule, we chose a value of 0.80 for the loss-
sharing ratio, which preserves incentives for agencies to attempt to
provide care efficiently for outlier cases. A loss-sharing ratio of
0.80 was also consistent with the loss-sharing ratios used in other
Medicare PPS outlier policies. Furthermore, we estimated the value of
the FDL ratio that would yield estimated total outlier payments that
were 5 percent of total home health PPS payments. The resulting value
for the FDL ratio for the July 2000 final rule was 1.13.
Our CY 2005 update to the HH PPS rates (69 FR 62124) changed the
FDL ratio from the original 1.13 to 0.70 to allow more home health
episodes to qualify for outlier payments and to better meet the 5
percent target of outlier payments to total HH PPS payments. We stated
in that CY 2005 update that we planned to continue to monitor the
outlier expenditures on a yearly basis and to make adjustments as
necessary (69 FR 62129). To do so, we planned on using the best
Medicare data available at the time of publication. For the CY 2005
update, we used CY 2003 home health claims data.
Our CY 2006 update to the HH PPS rates (70 FR 68132) changed the
FDL ratio from 0.70 to 0.65 to allow even more home health episodes to
qualify for outlier payments and to better meet the 5 percent target of
outlier payments to total HH PPS payments. For the CY 2006 update, we
used CY 2004 home health claims data.
At the time of publication of the August 3, 2006 proposed rule, we
did not have more recent data, but we noted that we may update the FDL
ratio for CY 2007 depending on the availability of more recent data. We
further noted that if we updated the FDL ratio for the CY 2007 update,
we would use the same methodology performed in updating the current FDL
ratio described in the October 22, 2004 final rule. Subsequent to the
publication of the August 3, 2006 proposed rule, we have now obtained
more recent data, that is, CY 2005 home health claims data.
Accordingly for this final rule, we have used the same methodology
and performed an analysis on the CY 2005 HH PPS analytic data to update
the FDL ratio for CY 2007. The results of this analysis indicate that
an FDL ratio of 0.67 is consistent with the existing loss-sharing ratio
of 0.80 and a projected target percentage of estimated outlier payments
of 5 percent. Therefore, we are updating the FDL ratio from the current
0.65 to 0.67 for CY 2007.
Expressed in terms of a fixed dollar loss amount, an FDL ratio of
0.67 indicates that providers would absorb approximately $1,567 of
their costs (before wage adjustment), in addition to their loss-sharing
portion of the estimated cost in excess of the outlier threshold. This
fixed dollar loss amount of approximately $1,567 is computed by
multiplying the standard 60-day episode payment amount (2,339.00) by
the FDL ratio (0.67). In contrast, using the current FDL ratio (0.65),
the fixed dollar loss amount would be approximately $1,520 ($2,339.00 x
0.65)
F. Hospital Wage Index--Revised OMB Definitions for Geographical
Statistical Areas
Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the
Secretary to establish area wage adjustment factors that reflect the
relative level of wages and wage-related costs applicable to the
furnishing of home health services and to provide appropriate
adjustments to the episode payment amounts under the HH PPS to account
for area wage differences. We apply the appropriate wage index value to
the labor portion (76.775 percent; see 60 FR 62126) of the HH PPS rates
based on the geographic area in which the beneficiary received home
health services as discussed in section II.A of the August 3, 2006
proposed rule. Generally, we determine each HHA's labor market area
based on definitions of Metropolitan Statistical Areas (MSAs) issued by
the Office of Management and Budget (OMB).
We acknowledged in our October 22, 2004 final rule that on June 6,
2003, the OMB issued an OMB Bulletin (No. 03-04) announcing revised
definitions for MSAs, new definitions for Micropolitan Statistical
Areas and Combined Statistical Areas, and guidance on using the
statistical definitions. 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 Core-Based Statistical Areas (CBSAs). In the
November 9, 2005 final rule, we adopted the OMB-revised definitions and
implemented a one-year transition policy consisting of a 50/50 blend of
the MSA-based and the new CBSA-based wage indexes.
As discussed previously and set forth in the July 3, 2000 final
rule, the statute provides that the wage adjustment factors may be the
factors used by the Secretary for purposes of section 1886(d)(3)(E) of
the Act for hospital wage adjustment factors. Again, as discussed in
the July 3, 2000 final rule, we proposed to use the pre-floor and pre-
reclassified hospital wage index data to adjust the labor portion of
the HH PPS rates based on the geographic area in which the beneficiary
receives the home health services. We believe the use of the pre-floor
and pre-reclassified hospital wage index data results in the
appropriate adjustment to the labor portion of the costs as required by
statute. For the CY 2007 update to the home health payment rates, we
proposed to continue using the most recent pre-floor and pre-
reclassified hospital wage index available at the time of publication.
See Addenda A and B of this final rule, respectively, for the rural and
urban hospital wage indexes using the CBSA designations. For the HH PPS
rates addressed in the August 3, 2006 proposed rule, we used
preliminary 2007 pre-floor and pre-reclassified hospital wage index
data. We incorporated updated hospital wage index data for the 2007
pre-floor and pre-reclassified hospital wage index to be used in this
final rule (not including any reclassifications under section
1886(d)(8)(B) of the Act).
As implemented under the HH PPS in the July 3, 2000 HH PPS final
rule, each HHA's labor market is determined based on definitions of
MSAs issued by OMB. In general, an urban area is defined as an MSA or
New England County Metropolitan Area (NECMA) as defined by OMB. Under
Sec. 412.62(f)(1)(iii), a rural area is defined as any area outside of
an urban area. The urban and rural area geographic classifications are
defined in Sec. 412.62(f)(1)(ii) and Sec. 412.62(f)(1)(iii),
respectively, and have been used under the HH PPS since it was
implemented.
Under the HH PPS, the wage index value is based upon the site of
service for the beneficiary (defined by section 1861(m) of the Act as
the beneficiary's place of residence). As has been our longstanding
practice, any area not included in an MSA (urban area) is considered to
be nonurban (Sec. 412.64(b)(1)(ii)(C)) and receives the statewide
rural wage index value (see, for example, 65 FR 41173).
For CY 2007, we proposed using 100 percent of the CBSA-based wage
area designations for purposes of determining the HH PPS wage index
adjustment.
In adopting the CBSA designations, we identified some geographic
areas where there were no hospitals, and thus no hospital wage data on
which to base the calculation of the CY 2007 home health wage index.
For CY 2006, we adopted a policy in the HH PPS final rule (70 FR 68132)
of using the CY 2005 pre-floor, pre-reclassified hospital wage index
value for rural areas when no rural hospital wage data are available.
We also adopted a policy that for urban labor markets without an urban
hospital
[[Page 65893]]
from which a hospital wage index can be derived, all of the CBSAs
within the State would be used to calculate a statewide urban average
wage index to use as a reasonable proxy for these areas. We have not
received any concerns from the industry regarding our policy to
calculate an urban wage index, using an average of all of the urban
CBSAs wage index values within the State, for urban labor markets
without an urban hospital from which a hospital wage index can be
derived. Consequently, in the August 3, 2006 proposed rule, we proposed
to continue to apply the average wage index from all urban areas in the
state to any urban areas lacking hospital wage data in that state.
Currently, the only CBSA that would be affected by this is CBSA 25980
Hinesville, Georgia.
In the August 3, 2006 proposed rule, we again proposed to apply the
CY 2005 pre-floor/pre-reclassified hospital wage index to rural areas
where no hospital wage data is available. Currently, the only rural
areas that would be affected by this are Massachusetts and Puerto Rico.
Since publication of the CY 2006 HH PPS final rule, representatives of
the home health industry have expressed concerns with this policy,
specifically as it applies to Massachusetts. In response to these
concerns and in recognition that, in the future, there may be
additional rural areas impacted by a lack of hospital wage data from
which to derive a wage index, we considered alternative methodologies
for imputing a rural wage index for areas where no hospital wage data
are available.
We specifically considered imputing a rural wage index by computing
a simple average of all of the statewide (rural) wage indexes at the
Census Division level. Census Divisions are defined by the U.S. Census
Bureau and may be found at http://www.census.gov/geo/www/us_regdiv.pdf.
Massachusetts is located in Census Division I, along with Connecticut,
Maine, New Hampshire, Vermont and Rhode Island. The Census Bureau
states, ``Puerto Rico and the Island Areas are not part of any census
region or census division.'' Therefore, we could not compute a rural
wage index for Puerto Rico using this alternative methodology.
In the August 3, 2006 proposed rule, we solicited comments on the
current methodology and alternative methodologies for determining a
wage index for areas without the necessary hospital wage data. Since
publication of the August 3, 2006 proposed rule, we have received
numerous comments regarding our policy for determining a wage index for
rural areas without the necessary hospital wage data. In direct
response to these comments, we have decided to revise the methodology
for imputing a rural wage index. We discuss the change to the
methodology for imputing a rural wage index in section III of this
final rule.
G. Payment for Oxygen, Oxygen Equipment and Capped Rental DME Items
As discussed in the August 3, 2006 proposed rule, we would amend
our regulations at Sec. 414.226 by revising the payment rules for
oxygen and oxygen equipment in paragraph (a), adding a new paragraph
(f) that provides that the beneficiary assumes ownership of oxygen
equipment on the first day that begins after the 36th continuous month
in which rental payments are made, and adding a new paragraph (g) that
contains new supplier requirements that we believe are necessary in
light of the amendments made to section 1834(a)(5) of the Act by
section 5101(b) of the DRA. As discussed in the August 3, 2006 proposed
rule, we would amend our regulations at Sec. 414.226 by adding a new
paragraph (c) that establishes new classes and national payment amounts
for oxygen and oxygen equipment based on our authority in section
1834(a)(9)(D) of the Act. We also proposed to revise paragraph (b) of
this section to incorporate the special payment rules for oxygen
equipment mandated by section 1834(a)(21) of the Act. The provisions of
section 1834(a)(21), which we believe are self-implementing, resulted
in adjustments to Medicare payment amounts for oxygen contents and
stationary oxygen equipment as well as portable oxygen equipment in
2005, which were implemented through program instructions. We are now
seeking to codify these changes to make our regulations consistent with
the payment methodology for these items in 2005 and 2006, and because
the payment reductions mandated by section 1834(a)(21) are incorporated
into our proposal, as more fully discussed in section I of the August
3, 2006 proposed rule, to create new payment classes for oxygen and
oxygen equipment. The August 3, 2006 proposed rule indicated that we
would redesignate old paragraph (c) of this section as paragraph (d)
and would amend this paragraph to indicate under what situations
payments would be made for the items and services described in new
paragraph (c). Finally, the August 3, 2006 proposed rule indicated that
we would redesignate old paragraph (d) of this section as paragraph (e)
and would make technical changes to this paragraph so that the cross-
references are accurate in light of the other changes we proposed to
make to Sec. 414.226.
The August 3, 2006 proposed rule would also amend our regulations
at Sec. 414.229 by revising the payment rules for capped rental
durable medical equipment (DME) items (also called capped rental items)
in paragraph (a), revising paragraph (f) to provide for new payment
rules for capped rental items furnished beginning on or after January
1, 2006, revising paragraph (g) to provide for supplier requirements
that we believe are necessary in light of the amendments made to
section 1834(a)(7)(A) of the Act by section 5101(a) of the DRA, and
adding a new paragraph (h) to address the lump-sum purchase option for
power-driven wheelchairs furnished on or after January 1, 2006. The
language in current paragraphs (f) and (g) of this section is obsolete,
and therefore, we proposed to delete this language.
The August 3, 2006 proposed rule indicated that we would amend our
regulations at Sec. 414.210 by revising the maintenance and servicing
rules in paragraph (e) and the replacement of equipment rules in
paragraph (f) to further implement the new supplier requirements that
we proposed below.
Finally, we proposed to revise Sec. 414.230(b) to incorporate
section 5101(b)(2)(B) of the DRA, which provides that for all
beneficiaries receiving oxygen equipment paid for under section 1834(a)
on December 31, 2005, the period of continuous use begins on January 1,
2006. We also proposed to revise Sec. 414.230(f), which governs when a
new period of continuous use begins if a beneficiary receives new
equipment, to account for the fact that oxygen equipment is paid on a
modality neutral basis.
Section 5101(a) of the DRA changes the Medicare payment methodology
for capped rental equipment to beneficiary ownership after 13 months of
continuous use, for those beneficiaries who need the equipment for more
than 13 months. This section also makes the transfer of title for the
capped rental items a requirement rather than a beneficiary option
after 13 months of continuous use. The changes made by this section of
the DRA apply to capped rental items, including rented power-driven
wheelchairs, for which the first rental month occurs on or after
January 1, 2006. We proposed to update Sec. 414.229 of our regulations
to reflect these new statutory requirements. However, for capped rental
items and rented power-driven wheelchairs for which the first rental
month occurred before January 1, 2006, the existing rules in Sec.
414.229 would continue to apply. In
[[Page 65894]]
addition, as was the case before enactment of the DRA, beneficiaries
may elect to obtain power-driven wheelchairs furnished on or after
January 1, 2006, on a lump-sum purchase basis.
Section 5101(b) of the DRA changes the Medicare payment methodology
for oxygen equipment from continuous rental to beneficiary ownership
after 36 months of continuous use, for those beneficiaries who
medically need the oxygen equipment for more than 36 months. For
beneficiaries who were receiving oxygen equipment on December 31, 2005
for which payment was made under section 1834(a) of the Act, the 36-
month rental period began on January 1, 2006. For beneficiaries who
begin to rent oxygen equipment on or after January 1, 2006, the 36-
month rental period commences at the time they begin to rent the
equipment. We proposed to update Sec. 414.226 of our regulations to
incorporate these new requirements.
In light of the changes made by sections 5101(a) and (b) of the
DRA, we believe it was necessary to propose additional supplier
requirements in order to maintain beneficiary protections and access to
oxygen, oxygen equipment, and capped rental DME items under section
1834(a) of the Act. For both capped rental DME items and oxygen
equipment, the DRA amendments make the transfer of title from the
supplier to the beneficiary a requirement rather than an option after
the statutorily-prescribed rental period ends for each category of
items. Therefore, suppliers and beneficiaries should be aware that
title to these items will automatically transfer to the beneficiary if
the medical need for the equipment continues for a period of continuous
use that is longer than 36 months for oxygen equipment and 13 months
for capped rental items. We are concerned that there may be incentives
for suppliers to avoid having to transfer title to equipment to
beneficiaries as required by the DRA. For example, we are aware of
cases where a supplier has informed beneficiaries that it would decline
to accept assignment for capped rental items and would charge
beneficiaries who elected the purchase option the full retail price for
the item during the 13th rental month (which was right before the
supplier would be required to transfer title under the purchase
option). In these cases, the beneficiary would become financially
liable for the total retail price for the equipment in the 13th month
if they elected the purchase option. In our August 3, 2006 proposed
rule, we made several proposals relating to the furnishing of oxygen
equipment and capped rental items which we believe protect
beneficiaries from these types of abusive practices and which we
believe are reasonable for a supplier to comply with. Our authority to
promulgate these requirements stems from our authority to administer
the payment rules at section 1834(a)(5) of the Act for oxygen equipment
and section 1834(a)(7) of the Act for capped rental items, as well as
the general authority provided in section 1871 of the Act for
prescribing regulations necessary for administering the Medicare
program. Other than the length of the rental periods, which the DRA
made effective beginning on January 1, 2006 for all oxygen equipment
and for capped rental items for which the first rental period began on
or after that date, we proposed that the requirements presented in this
section of the regulations would be effective on January 1, 2007, and
would apply to suppliers that furnish oxygen equipment or capped rental
items on a rental basis.
We believe that a supplier of an item that is subject to these new
payment rules that furnishes the item in the first month for which a
rental payment is made has an obligation to continue furnishing the
item to the beneficiary for the entire period of medical need in which
payments are made, up to and including the time when title to the
equipment transfers to the beneficiary. We believe it is reasonable for
the beneficiary to have an expectation that he or she will not be
forced to change equipment or suppliers during the period of medical
need unless he or she wants to. Therefore, we proposed that unless an
exception applies, the supplier that furnishes oxygen equipment or a
capped rental item for the first month of the statutorily prescribed
rental period must continue to furnish the oxygen equipment or the
capped rental item for as long as the equipment remains medically
necessary, up to and including the last month for which a rental
payment is made by Medicare. We believe that this proposal was
necessary to ensure beneficiary access to equipment during a period of
medical need, which we believe could be jeopardized if suppliers have
the option to take back the rented equipment just before the rental
period expires in order to retain title to that equipment. We proposed
that this requirement would be subject to the following exceptions: (1)
Cases where the item becomes subject to a competitive acquisition
program implemented in accordance with section 1847(a) of the Act; (2)
cases where a beneficiary relocates on either a temporary or permanent
basis to an area that is outside the normal service area of the initial
supplier; (3) cases where the beneficiary chooses to obtain equipment
from a different supplier; and (4) other cases where CMS or the carrier
determine that an exception is warranted. We have proposed rules in
connection with the first exception in our Notice of Proposed
Rulemaking for Competitive Acquisition for Certain Durable Medical
Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Other
Issues. These proposed rules are addressed beginning on page 25662 of
the May 1, 2006 proposed rule (71 FR 25654). If the second exception
applies, we proposed that the supplier or beneficiary would need to
arrange for another supplier in the new area to furnish the item on
either a temporary or permanent basis. This proposed exception is
consistent with what currently happens when beneficiaries move outside
a supplier's service area on either a temporary or permanent basis. The
third exception is intended to protect a beneficiary's right to obtain
the equipment from the supplier of his or her choice. Finally, we
proposed to allow other exceptions to this proposed requirement on a
case-by-case basis at the discretion of CMS or the Medicare contractor.
CMS will be monitoring the case-by-case determinations made by the
Medicare contractor.
We are concerned that there might be potential incentives for a
supplier to replace more valuable or newer equipment used by the
beneficiary with less valuable or older equipment from its inventory at
some point before the 36th rental month for oxygen equipment or 13th
rental month for capped rental DME expires in order to avoid losing
title to the more valuable equipment. In order to avoid such potential
situations, we proposed that the supplier may not provide different
equipment from that which was initially furnished to the beneficiary at
any time during the 36-month period for oxygen equipment or 13th rental
month for capped rental DME unless one of the following exceptions
applies: (1) The equipment is lost, stolen, or irreparably damaged; (2)
the equipment is being repaired while loaner equipment is in use; (3)
there is a change in the beneficiary's medical condition such that the
equipment initially furnished is no longer appropriate or medically
necessary; or (4) the carrier determines that a change in equipment is
warranted. However, we proposed that a change from one oxygen equipment
modality to another
[[Page 65895]]
without physician documentation that such a change is medically
necessary for the individual would not be considered a change in
equipment that is warranted under the fourth exception stated above
since there is no medical basis for the change. In those cases where
the equipment is replaced, we proposed that the replacement item must
be equipment that is, at minimum, in the same condition as the
equipment being replaced. That proposal was intended to safeguard
beneficiary access to quality oxygen equipment and capped rental items
throughout the duration of the rental period.
Under Medicare, suppliers who furnish items of DME can accept
assignment on all claims for Medicare services or on a claim-by-claim
basis. Assignment is an agreement between the supplier and the
beneficiary under which the supplier agrees to request direct payment
from Medicare for the item, to accept 80 percent of the Medicare
allowed payment amount for the item from the carrier, and to charge the
beneficiary not more than the remaining 20 percent of the Medicare
approved payment amount, plus any unmet deductible. If a supplier
elects not to accept assignment, Medicare pays the beneficiary 80
percent of the Medicare allowed payment amount, after subtracting any
unmet deductible, and there is no limit under Title XVIII of the Act on
the amount the supplier can charge the beneficiary for rental of the
DME item. The beneficiary, in these situations, is financially
responsible for the difference between 80 percent of the Medicare
allowed payment amount and the amount the supplier charges for the
rental of the DME item.
Section 1842(h) allows suppliers to sign a participation agreement
where the supplier agrees voluntarily, before a calendar year, to
accept assignment for all Medicare items and services furnished to a
beneficiary for the following calendar year. Current supplier
participation agreements are renewable annually. However, the
agreements do not apply for a full period of medical need for specific
beneficiaries in cases where such need extends for more than a calendar
year. Nor do current participation agreements apply to periods of
medical need where such a period overlaps calendar years. In the latter
case, while a supplier may renew its participation agreement annually,
a beneficiary would not know before choosing a supplier whether the
supplier would be willing to accept assignment of all claims during the
13-month or 36-month rental period.
In order for the beneficiary to make an informed choice, we
proposed that before furnishing the oxygen equipment or a capped rental
item, the supplier must disclose to the beneficiary its intentions
regarding whether it will accept assignment of all monthly rental
claims for the equipment during the period of medical necessity, up to
and including the 36th month of continuous use for oxygen equipment or
the 13th rental month of continuous use for capped rental DME in which
rental payments could potentially be made. We believe that it is
reasonable for the supplier to disclose to each beneficiary its
intentions regarding assignment of claims for all months during a
rental period as this decision has a direct financial effect on the
beneficiary. A supplier's intentions could be expressed in the form of
a written agreement between the supplier and a beneficiary. This
proposal would require suppliers to give beneficiaries advance notice
of the possible extent of their financial liability during the period
of medical need in which monthly rental payments are made for the
equipment, so that they can use this information to help select a
supplier. Additionally, to promote informed beneficiary choices, we
plan to post information on a CMS and/or CMS contractor Web site(s)
indicating supplier specific information on oxygen equipment and capped
rental items such as (1) the percentage of beneficiaries for whom each
supplier accepted assignment during a prior period of time (for
example, a quarter), and/or (2) the percentage of cases in which the
supplier accepted assignment during the beneficiary's entire rental
period. We believe that those proposals create reasonable rules for
suppliers that furnish oxygen equipment and capped rental items and
ensure that beneficiaries have information necessary to make informed
choices that could have significant financial consequences for them.
H. Payment for Oxygen Contents for Beneficiary-Owned Oxygen Equipment
Section 1834(a)(5) of the Act, as amended by section 5101(b)(1) of
the DRA, requires that Medicare continue to make monthly payments for
the delivery and refilling of oxygen contents for the period of medical
need after beneficiaries own their own gaseous or liquid oxygen
stationary or portable equipment. Before the enactment of the DRA,
Medicare made monthly payments for the delivery and refilling of oxygen
contents for beneficiaries who own their own stationary and/or portable
equipment (equipment they obtained on a purchase basis before June 1,
1989, out-of-pocket, or before they enrolled in Medicare Part B). In
accordance with the DRA, we proposed that after the supplier transfers
title to the stationary and/or portable oxygen equipment to the
beneficiary, Medicare would continue to make separate monthly payments
for gaseous or liquid oxygen contents until medical necessity ends. We
also proposed that if the beneficiary-owned equipment is replaced, and
Medicare pays for the replacement in accordance with proposed revised
Sec. 414.210(f) (see section K of this final rule for a more complete
discussion of our proposed oxygen equipment replacement policies), a
new 36-month rental period start and the payment for oxygen contents
would be included in the monthly rental payments. We proposed that all
oxygen content payment amounts would be based on new rates developed in
accordance with our proposal to establish new payment classes, as
discussed in section I below.
In transferring title to gaseous or liquid oxygen equipment used
during the 36-month rental period, we proposed that suppliers must
transfer title for all equipment that will meet the beneficiary's
continued medical need, including those oxygen cylinders or vessels
that are refilled at the supplier's place of business. Customary
practice by suppliers for refilling oxygen contents is to deliver to
the beneficiary cylinders filled with contents and take back the empty
cylinders to the supplier's place of business to refill the oxygen
contents. Under our proposal, title would transfer for both sets of
cylinders, meaning the ones that are being used by the beneficiary for
the month and the ones that the supplier refills in its business
location and delivers for use during the next subsequent month. This
policy would apply to both gaseous and liquid oxygen stationary
equipment and portable systems. Similarly, in those cases where the
beneficiary uses an oxygen equipment system which includes a compressor
which fills portable gaseous cylinders in the beneficiary's home, we
proposed that suppliers must transfer title for this equipment to the
beneficiary.
Concerns have been raised regarding beneficiary access to, and
safety issues associated with, the delivery of oxygen contents for
beneficiary-owned stationary and portable gaseous or liquid equipment.
We believe that these concerns are based on the misconception that
beneficiaries become responsible for filling their own cylinders. To
the contrary, there are numerous State and Federal regulations
governing the safe handling, filling, and transport of oxygen and those
regulations are unaffected by the DRA oxygen provisions. We expect that
[[Page 65896]]
suppliers will continue to furnish replacement contents for
beneficiary-owned gaseous and liquid systems in the same way that they
have furnished replacement contents for beneficiary-owned equipment in
the past. For example, suppliers that deliver a 1 month supply of
gaseous cylinders to a beneficiary's home at the same time that they
are picking up empty cylinders that the beneficiary used during the
previous month could continue this practice under section 5101(b) of
the DRA.
I. Classes of Oxygen and Oxygen Equipment
Based on information from paid Medicare claims with dates of
service in calendar year 2004, distribution of usage among the four
general categories of oxygen systems was: (a) 69 percent of
beneficiaries used both a stationary concentrator (which does not
require delivery of oxygen contents) and a portable system that
requires delivery of gaseous or liquid oxygen, (b) 5 percent of
beneficiaries used a stationary system that requires delivery of
gaseous or liquid oxygen and a portable system that requires delivery
of gaseous or liquid oxygen, (c) 24 percent of beneficiaries used a
stationary concentrator system only, and (d) 2 percent of beneficiaries
used only a stationary system that requires delivery of liquid or
gaseous oxygen. The prevalent use of stationary concentrator systems is
due, in part, to the fact that this system is the most cost-effective
and dependable of the stationary oxygen modalities. The main reason
that the concentrator system is the most cost-effective system is that
the oxygen is concentrated from room air, and therefore, the high cost
of delivering contents to the beneficiary's residence is removed when
this system is used. Medicare's current payment structure results in
two separate payments for beneficiaries using both stationary and
portable systems, both of which are modality neutral, meaning that the
payment amount does not differ depending on the type of oxygen delivery
system (gaseous, liquid, or concentrator) that is furnished. One
payment, hereinto referred to as the ``stationary payment,'' includes
payment for the rental of stationary equipment, delivery of stationary
oxygen contents (for gaseous or liquid systems), and delivery of
portable oxygen contents (for gaseous or liquid systems). A separate
add-on payment, hereinto referred to as the ``portable add-on,'' is
also made in cases where the beneficiary is renting portable oxygen
equipment. As a result of this payment methodology which has been in
place since 1989, suppliers have a financial incentive to furnish low
cost concentrator systems as opposed to more expensive gaseous or
liquid systems because the monthly payment is the same regardless of
which system is used. Finally, in implementing section 1834(a)(5) and
(9) of the Act, monthly payment amounts were established through
regulations at Sec. 414.226 for (1) stationary and portable oxygen
contents (for beneficiaries who use stationary and, if applicable,
portable equipment), and (2) portable oxygen contents only (for
beneficiaries who only use portable oxygen equipment). The current
average statewide monthly payment amounts are:
------------------------------------------------------------------------
------------------------------------------------------------------------
Equipment & Contents Oxygen Contents Only
------------------------------------------------------------------------
Stationary Pmt.................. $199 Stationary & Portable... $156
Portable Add-on................. 32 Portable Only........... 21
------------------------------------------------------------------------
Based on our data, 36 percent of Medicare beneficiaries continue
using oxygen equipment for more than 3 years, that is, beyond the 36th
month after which title for the equipment would transfer to the
beneficiary in accordance with the DRA.
We have heard concerns about the appropriateness of the current
payment structure for oxygen and oxygen equipment in light of changes
in the technologies for oxygen delivery systems that have occurred
since 1989, and these concerns have been amplified in light of the
recent changes made by the DRA. The specific concerns pertain to
beneficiary access to (1) portable oxygen contents after title to the
equipment transfers to the beneficiary, (2) devices that allow a
beneficiary to fill portable tanks at home (otherwise referred to in
the oxygen equipment industry as transfilling systems), and (3)
portable oxygen concentrators. As we implement the DRA provisions for
oxygen equipment and promulgate additional supplier requirements, we
want to ensure that the Medicare payment methodology results in
payments for oxygen and oxygen equipment that are accurate, do not
impede beneficiary access to innovations in technology, and do not
create inappropriate incentives for suppliers.
Some believe that Medicare's stationary payment for equipment and
contents (average of $199) is ``too high'' and that Medicare's payment
for portable oxygen contents only for beneficiary-owned portable
equipment (average of $21) is ``too low''. While some contend that the
overall payment (stationary payment plus portable add-on) for oxygen
and oxygen equipment is adequate as long as the beneficiary continues
to rent the equipment, they are concerned about the adequacy of
Medicare's $21 monthly payment for furnishing oxygen contents for
beneficiary-owned portable equipment. Some believe that Medicare's
current average monthly payment of $156 for oxygen contents, which
includes payment for both stationary and portable systems, is high
enough to create an incentive for suppliers to furnish stationary
oxygen systems that require the ongoing delivery of oxygen contents,
rather than stationary concentrator systems that do not require
delivery of oxygen contents.
Some technologies provide an attachment to a stationary oxygen
concentrator that allows beneficiaries to fill their own portable tanks
at home. Delivery of portable oxygen contents to the beneficiary's home
is, therefore, not necessary since this equipment refills the
beneficiary's rented or owned portable oxygen tanks. This transfilling
technology eliminates the need for frequent and costly trips by a
supplier to a beneficiary's home to refill portable oxygen tanks and
would save the Medicare program and beneficiaries who use portable
equipment the expense of paying for delivery of portable oxygen
contents. We note that we are not aware that a similar ``transfilling''
technology has been developed that would be capable of filling
stationary tanks in the beneficiary's home. Therefore, there remains a
need for ongoing delivery of gaseous or liquid oxygen contents for
stationary equipment. In accordance with the DRA, after 36 months of
continuous use, title for the transfilling equipment and accompanying
portable oxygen tanks would transfer to the beneficiary who would then
own a portable equipment system that self-generates oxygen in their
home. However, some are concerned that current Medicare payment rules
that
[[Page 65897]]
allow payment for oxygen contents for stationary equipment creates an
incentive for suppliers to furnish stationary oxygen equipment that
require liquid or gaseous oxygen deliveries, rather than concentrators
and transfilling equipment that self-generate oxygen in the
beneficiary's home. In addition, portable oxygen concentrators are now
available that meet both the beneficiary's stationary and portable
oxygen needs. Some have raised concern about whether the combination of
the Medicare stationary payment and portable add-on payment
(approximately $231 per month), which is what is currently paid for
portable oxygen concentrators, is sufficient to facilitate use of this
new technology which, like a transfilling system, eliminates the need
for delivery of oxygen contents, but is more expensive than a
``standard'' or ``non-portable'' concentrator.
In light of these concerns, we proposed regulatory changes to
address the Medicare payment rates for oxygen and oxygen equipment. We
proposed to address these issues by using our authority under section
1834(a)(9)(D) of the Act to establish separate classes and monthly
payment rates for items of oxygen and oxygen equipment. Specifically,
there are two changes we proposed for oxygen and oxygen equipment:
1. We proposed to establish a new class and monthly payment amount
for oxygen generating portable oxygen equipment (for example, portable
concentrators and transfilling systems).
2. We proposed to establish separate classes and monthly payment
amounts for gaseous and liquid oxygen contents that must be delivered
for beneficiary-owned stationary and portable oxygen equipment.
The first change involves creating a new separate class for
portable oxygen systems that generate their own oxygen and therefore
eliminate the need for delivery of oxygen contents (for example,
portable concentrator systems or transfilling systems). A higher
monthly payment amount would be allowed, as described below, for these
systems to account for the increased, up-front costs to the supplier of
furnishing these more expensive concentrator or transfilling systems,
which would be partially offset by the reduced payments that the
supplier would receive from the Medicare program and beneficiaries due
to the fact that these systems do not require the delivery of oxygen
contents.
The second change involves creating two separate classes
(stationary contents only and portable contents only) and monthly
payment rates for furnishing oxygen contents for beneficiary-owned
stationary and portable systems. Currently, the combined average
monthly payment amount of $156 for furnishing oxygen contents for
beneficiary-owned stationary and portable systems includes payment for
both stationary contents and portable contents. The current fee
schedule amounts for oxygen contents are based on calendar year data
from 1986 for the combined average Medicare monthly payment for both
stationary and portable contents divided by number of rental months for
stationary liquid and gaseous oxygen equipment. As a result, the
current combined stationary/portable contents payment results in
Medicare payments for portable contents even in those cases where the
beneficiary does not use portable oxygen equipment. Under our proposal
to create one payment class for oxygen contents used for stationary
equipment, and a separate class for oxygen contents used for portable
equipment, new national monthly payment amounts for stationary contents
delivery and portable contents delivery would be established by
splitting the combined payment of $156 into two new payments as
explained below. This change would increase the monthly payment for
furnishing portable oxygen contents and would address the concerns that
the monthly payment rate of $21 is too low for the delivery and filling
of portable tanks after the beneficiary assumes ownership of the
equipment in accordance with the DRA.
In order to achieve budget neutrality for the new classes of oxygen
and increase payment amounts for furnishing portable contents, we would
need to reduce other Medicare oxygen payment rates. Budget neutrality
would require that Medicare's total spending for all modalities of
stationary and portable systems, including contents, be the same under
the proposed change as they would be without the change.
We proposed to achieve budget neutrality by reducing the current
monthly payment amounts (the stationary payment) for stationary oxygen
equipment and oxygen contents (for stationary or portable equipment)
made during the rental period. This reduction in payment is necessary
to offset increased payments for the changes identified above and to
meet the requirement in section 1834(a)(9)(D)(ii) that the classes and
payments be established in a budget neutral fashion. In most cases,
suppliers furnish Medicare beneficiaries with stationary oxygen
concentrators. These devices can be purchased for $1,000 or less and
the current, average Medicare payment of $199 pays suppliers $1,990
over 10 months. We believe that these facts indicate that making a
reduction (from $199 on average to $177) in Medicare payment for this
relatively inexpensive oxygen equipment in order to pay oxygen
suppliers adequately for furnishing portable oxygen contents and more
expensive portable oxygen equipment technologies is warranted. With
this approach, the proposed new classes, as well as proposed new
national monthly payment rates, would be as follows:
1. Stationary Payment: $177.
2. Portable Add-On: $32.
3. Oxygen Generating Portable Equipment Add-On (portable
concentrators or transfilling systems): $64.
4. Stationary Contents Delivery: $101.
5. Portable Contents Delivery: $55.
We provide a detailed discussion of the payment rate calculations/
adjustments in the paragraphs that follow. Under the proposed new
oxygen and oxygen equipment class structure described above, in those
cases where the beneficiary needs both stationary and portable oxygen,
monthly payments of $241 or $209 (proposed revised stationary payment
of $177 plus one of two proposed portable equipment payments, $32 or
$64) would be made during rental months 1 through 36. The stationary
payment (which includes payment for stationary equipment, as well as
oxygen contents for stationary and portable systems) of $177 would be
made during rental months 1 through 36 for beneficiaries who only need
stationary oxygen and oxygen equipment. Monthly payments of $101 for
stationary oxygen contents and/or $55 for portable oxygen contents
would be made in cases where beneficiaries own their stationary and/or
portable oxygen equipment. As explained in more detail in the
paragraphs that follow, the $101 payment is for stationary oxygen
contents only and is derived from the current payment of $156, which is
made for both stationary and portable oxygen contents. The $55 payment
for portable oxygen contents only is also derived from the current
payment of $156 that is made for both stationary and portable oxygen
contents and would replace the current statewide portable oxygen
contents fees (average of $21), which was based on a relatively small
number of claims and allowed services compared to the number of claims
and allowed services that were used in computing the statewide fees
(average of $156) for a combination of stationary and portable oxygen
contents.
[[Page 65898]]
As noted above, the proposed national payment rates for delivery of
oxygen contents for beneficiary-owned gaseous/liquid equipment were
derived from the current average payment for a combined oxygen contents
delivery of $156. We proposed to establish $101, or 65 percent of $156,
as the monthly payment rate for delivery of larger, heavier,
beneficiary-owned stationary gaseous oxygen cylinders or liquid oxygen
vessels and $55, or 35 percent of $156, as the monthly payment rate for
delivery of smaller, lighter, beneficiary-owned portable gaseous oxygen
cylinders or liquid oxygen vessels. The 65/35 split is based on our
understanding that there are higher costs associated with delivering
stationary tanks (cylinders of gaseous oxygen and vessels of liquid
oxygen) which are approximately twice as large as the portable tanks.
Such costs include supplier overhead costs, including the costs to
purchase, maintain, and dispatch trucks, obtain insurance, and purchase
fuel. The 65/35 split is intended to account for the difference in
costs associated with the size of the tanks. Larger tanks take up more
space on the trucks, take longer to fill, are harder to move, and
result in increased fuel costs.
We estimate that the increase from $21 to $55 in the monthly
payment rate for delivery of oxygen contents for beneficiary-owned
portable equipment will result in increased expenditures of
approximately $22 million over a 24 month period, or $11 million
annually. This figure is based on current data on utilization of
portable oxygen by Medicare beneficiaries.
The add-on payment amount of $64 for the oxygen generating portable
equipment class was calculated based on data indicating long term
savings generated from use of equipment that eliminated the need for
payment of $55 per month for portable oxygen contents. The first step
in calculating the proposed $64 payment for oxygen generating portable
equipment involves the computation of a national, enhanced, modality
neutral monthly payment amount of $241 for new technology systems
(stationary concentrators and transfilling systems, as well as portable
concentrators), which was derived from the sum of the current average
stationary payment ($199), the current average portable add-on payment
($32), and an additional $10 to pay suppliers for furnishing more
expensive equipment that eliminates the need for delivery of portable
oxygen contents. Specifically, we calculated the modality neutral
increased payment (that is, $10 above the current combination of the
stationary payment and portable add-on payment) by estimating potential
savings that the Medicare program would realize as a result of not
having to pay for delivery of oxygen contents for beneficiary-owned
portable oxygen systems in the fourth and fifth years of use. We
calculated the increased payment to be equal to potential savings from
not delivering oxygen contents. In calculating this increased payment,
we were only factoring in savings from the fourth and fifth years of
use since we assume that most beneficiaries will elect to obtain
replacement equipment after the 5-year reasonable useful lifetime for
their equipment has expired. Since our data indicate that 35.8 percent
of beneficiaries will use oxygen equipment for more than 3 years, and
that approximately 74 percent of these beneficiaries use portable
equipment, the $10 amount is calculated based on the following formula,
and is rounded to the nearest dollar:
[GRAPHIC] [TIFF OMITTED] TR09NO06.000
We estimate that the additional $10 payment per month for oxygen
generating portable equipment (transfilling units and portable
concentrators) will result in increased expenditures of approximately
$15 million over a 36 month period, or $5 million annually. This figure
is based on current data on utilization of stationary and portable
oxygen by Medicare beneficiaries over 36 months.
The second step in calculating the proposed $64 add-on payment for
the proposed new class of oxygen generating portable equipment involves
subtracting the proposed new stationary payment. Therefore, the
national monthly payment of $241 computed in the first step above would
be reduced by $177, the proposed new adjusted stationary payment
amount, to arrive at the proposed add-on payment of $64 for just the
oxygen generating portable equipment. In addition, to offset the
increased annual payments of approximately $16 million that will result
from increased payments for portable oxygen contents ($11 million) and
newer technology oxygen generating portable equipment ($5 million), we
proposed to decrease the current stationary payment by $22 ($199-$177).
We estimated that this offset would result in annual Medicare savings
of approximately $16 million, and would therefore offset the increased
payments for new technology oxygen generating portable equipment and
delivery of oxygen contents for other beneficiary-owned portable
equipment. We proposed that these fees be established on a nationwide
basis due to the fact that the variation in the current statewide fee
schedule amounts for oxygen and oxygen equipment, as well as the
portable equipment add-on payment, are currently only 3 percent and 5
percent, respectively.
We proposed that the $64 add-on payment would be made for oxygen
generating portable equipment only if the equipment eliminates the need
for delivery or portable oxygen contents. However, if transfilling
equipment is used in connection with a stationary oxygen concentrator
(whether as an integrated system component or as a separate part) to
both deliver stationary oxygen and fill portable oxygen tanks, Medicare
would make both a $177 stationary payment for the stationary oxygen
concentrator and stationary oxygen contents, and a separate $64 oxygen
generating portable equipment payment for the portable oxygen
transfilling equipment.
There are also portable oxygen transfilling products that are not
part of or used in conjunction with a stationary oxygen concentrator.
These products are only used to fill portable oxygen tanks in the
beneficiary's home. If the beneficiary is using one of these products,
Medicare would make a $64 oxygen generating portable equipment payment.
If the patient is also renting any type of stationary oxygen equipment
(gaseous, liquid, or concentrator), Medicare would make a separate,
additional $177 stationary equipment payment for that equipment.
If a portable oxygen concentrator is furnished, Medicare would make
the $64 oxygen generating portable equipment add-on payment if the
portable oxygen concentrator is used as both the beneficiary's
stationary oxygen equipment and portable oxygen equipment. In this
case, the portable oxygen concentrator equipment would fall under both
the stationary oxygen equipment class and the oxygen generating
portable equipment class. Therefore, the $177 stationary payment would
also be made in this situation, since the equipment being furnished
meets the beneficiary's needs for both stationary and portable oxygen
equipment. In this case, it would be necessary for the supplier to use
two HCPCS codes to bill for this device since it is being used as both
the stationary and portable oxygen equipment for the beneficiary. If
the beneficiary owns any type of stationary equipment (concentrator,
liquid, or gaseous), and is also furnished with a portable oxygen
concentrator, only the
[[Page 65899]]
oxygen generating payment of $64 would be made (that is, the supplier
would not also receive the $177 payment) and the portable oxygen
concentrator equipment would fall under the oxygen generating portable
equipment class because it is only being used to meet the beneficiary's
need for portable oxygen equipment. Finally, if, the beneficiary is
renting any type of stationary equipment (concentrator, liquid, or
gaseous), and is also furnished with a portable oxygen concentrator,
the oxygen generating add-on payment of $64 would be paid for the
portable oxygen concentrator and the stationary payment of $177 would
be paid separately for the stationary oxygen equipment and contents.
In summary, we proposed new payment classes for oxygen contents for
beneficiary-owned stationary equipment, oxygen contents for
beneficiary-owned portable equipment, and oxygen generating portable
equipment. Payments for oxygen contents for beneficiary-owned portable
equipment and oxygen generating portable equipment would exceed what is
currently paid for these items to ensure access to portable oxygen
regardless of the type of equipment used. These increased payments
would be offset by a reduction in the stationary payment. The six broad
categories of oxygen equipment used by beneficiaries are as follows:
A. Concentrator and liquid or gaseous portable equipment.
B. Concentrator and/or oxygen generating portable equipment.
C. Liquid or gaseous stationary equipment and liquid or gaseous
portable equipment.
D. Liquid or gaseous stationary equipment and oxygen generating
portable equipment.
E. Concentrator only.
F. Liquid or gaseous stationary equipment only.
Based on our proposed new payment classes, Medicare payment under
these six categories would be as follows:
----------------------------------------------------------------------------------------------------------------
Contents for beneficiary-owned
Category Equipment rental and contents equipment
----------------------------------------------------------------------------------------------------------------
A............................... $209 ($177 + $32) $55
B............................... $241 ($177 + $64) $0
C............................... $209 ($177 + $32) $156 ($101 + $55)
D............................... $241 ($177 + $64) $101
E............................... $177 $0
F............................... $177 $101
----------------------------------------------------------------------------------------------------------------
We proposed to revise our regulations in order to implement these
new payment classes and payment amounts, effective for claims with
dates of service on or after January 1, 2007.
J. Payment for Maintenance and Servicing of Oxygen and Oxygen Equipment
and Capped Rental Items
Immediately following passage of the DRA, concerns were raised
regarding the ability of a beneficiary to obtain maintenance and
servicing of his or her DME once he or she has taken title to it. We
believe that these concerns are largely based on misconceptions that
the beneficiary will ``be on his or her own'' in terms of maintenance
and servicing of equipment and submission of claims for payment for
these services. We believe that these concerns are unfounded because
Medicare payment has traditionally been made for reasonable and
necessary repair and maintenance of beneficiary-owned DME. In addition,
section 1834(a)(5)(F)(ii)(II)(bb) of the Act, as amended by section
5101(b)(1)(B) of the DRA, and Section 1834(a)(7)(A)(iv) of the Act, as
amended by Section 5101(A)(1) of the DRA, require that Medicare
continue to pay for reasonable and necessary maintenance and servicing
for parts and labor not covered under a manufacturer's or supplier's
warranty in amounts determined to be appropriate by the Secretary.
Medicare has also traditionally paid for loaner equipment used
while the beneficiary's equipment is being repaired, or in some cases,
when the beneficiary does not have access to the equipment (for
example, in cases when a natural disaster such as a hurricane forces
the beneficiary to be evacuated from his or her home). We proposed to
continue Medicare payment for such loaner equipment.
We are not aware of instances where beneficiaries have encountered
problems in finding suppliers to provide maintenance and servicing of
beneficiary-owned DME. Section 414.210(e) of our regulations currently
provides that reasonable and necessary charges for maintenance and
servicing of DME are those charges made for parts and labor not
otherwise covered under a manufacturer's or supplier's warranty. This
definition has been applied in paying claims for maintenance and
servicing of beneficiary-owned DME for several years, and the wording
of this regulatory definition is parallel to that used in amended
sections 1834(a)(7)(A)(iv) and (a)(5)(F)(ii)(II)(bb) of the Act in
describing the ``maintenance and servicing'' payments that are
permitted for capped rental DME and oxygen equipment after title has
transferred to the beneficiary. We proposed to continue use of this
existing regulatory definition to define ``maintenance and servicing''
in section 5101 of the DRA. We, however, also proposed to apply our
existing policy of not covering certain routine maintenance or periodic
servicing of purchased equipment, such as testing, cleaning,
regulating, changing filters, and general inspection of beneficiary-
owned DME that can be done by the beneficiary or caregiver, to
beneficiary-owned oxygen equipment and to continue that policy for
beneficiary-owned capped rental equipment. As specified in current
program instructions at section 110.2.B of chapter 15 of the Medicare
Benefit Policy Manual (Pub 100-02), ``the owner [of the equipment] is
expected to perform such routine maintenance rather than a retailer or
some other person who charges the beneficiary.'' We expect that the
supplier, when transferring title to the equipment to the beneficiary,
would also provide to the beneficiary any operating manuals published
by the manufacturer which describe the servicing an owner may perform
to properly maintain the equipment. We also believe that these owner
manuals are commonly available at the various manufacturer Web sites.
In addition, the Durable Medical Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) supplier standards at Sec. 424.57(c)(12) require
suppliers to provide the beneficiary with necessary information and
instructions on how to use DME items safely and effectively. We believe
that after receiving this information, and after becoming familiar with
the equipment during the 13 or 36 month rental period, the beneficiary
and/or caregiver should be very knowledgeable regarding the routine
[[Page 65900]]
maintenance required for the item. All non-routine maintenance of
beneficiary-owned oxygen equipment and capped rental items which would
need to be performed by authorized technicians would be covered as
reasonable and necessary maintenance and servicing. Examples of the
types of maintenance that would be covered are currently listed in
program instructions at section 110.2.B of chapter 15 of the Medicare
Benefit Policy Manual (Pub 100-02) and include ``breaking down sealed
components and performing tests which require specialized testing
equipment not available to the beneficiary.''
We proposed that maintenance and servicing of beneficiary-owned
oxygen equipment and capped rental items would be reasonable and
necessary if it is non-routine maintenance and servicing necessary to
make the equipment serviceable. Payment is currently made under the
Medicare program for parts and labor associated with repairing
beneficiary-owned DME. Medicare allowed payment amounts for replacement
parts are currently paid based on the carrier's individual
consideration of the item. With regard to replacement parts for
beneficiary-owned oxygen equipment or capped rental equipment, we
proposed that the carrier pay for the parts in a lump sum amount based
on its consideration of the cost of the item, as is consistent with
what our carriers currently do when evaluating maintenance and
servicing claims for other beneficiary-owned DME. Currently, payment
for labor is based on 15-minute increments in amounts that are
established by the carriers and updated on an annual basis by the same
factor specified in section 1834(a)(14) of the Act, which is used to
update fee schedule amounts for DME. We proposed that the carriers use
the same fee for labor that is currently used in paying for labor
associated with repairing, maintaining, and servicing other
beneficiary-owned DME, as we are not aware of any past problems
associated with access to these services paid at these rates. We
believe that the current methods and fees used by carriers in paying
for maintenance and servicing of beneficiary-owned DME are reasonable
given that we are not aware of any past problems associated with access
to these services paid at these rates. In most cases, neither the
Medicare program nor the beneficiary actually pays the full amount for
repairing or maintaining an item since manufacturer warranties that
cover all or part of these costs are widespread. For example, some
manufacturers of commonly used oxygen concentrators offer full
warranties that cover all parts and labor for 5 years. Rules in Sec.
414.210(f) regarding replacement of DME that has been in continuous use
for the equipment's reasonable useful lifetime provide that the
beneficiary can elect to obtain replacement equipment after the
reasonable useful lifetime for the equipment has expired. Therefore, we
believe that the beneficiary should incur little, if any, expense for
repair or maintenance of necessary equipment in cases where
manufacturer warranties exist that cover parts and labor necessary to
repair a new item during a 5-year period.
K. Payment for Replacement of Beneficiary-Owned Oxygen Equipment,
Capped Rental Items, and Associated Supplies and Accessories
Medicare has traditionally paid for replacement beneficiary-owned
DME after the expiration of the equipment's useful lifetime (see Sec.
414.210(f) and Sec. 414.229(g) of our regulations), and for
replacement supplies and accessories used in conjunction with
beneficiary-owned DME when these supplies and accessories are necessary
for the effective use of the DME (see Sec. 110.3 of Chapter 15 of the
Medicare Benefit Policy Manual (pub. 100-02)). Examples of supplies
include drugs and administration sets used with infusion pumps.
Examples of accessories include masks and tubing used with respiratory
equipment. We proposed to apply these policies to beneficiary-owned
oxygen equipment, as well as the supplies and accessories used in
conjunction with this equipment, and to continue to apply these
policies to beneficiary-owned capped rental items, as well as the
supplies and accessories used in conjunction with these items.
Specifically, we proposed to update Sec. 414.210(f) and Sec.
414.229(g) of our regulations to reflect that payment may be made for
the replacement of beneficiary-owned oxygen equipment and capped rental
DME in cases where the item is lost, stolen, or irreparably damaged, or
in cases where the item has been in continuous use for its reasonable
useful lifetime. We proposed that payment for the replacement be made
on a rental basis in accordance with the payment rules in Sec. 414.226
for oxygen equipment and Sec. 414.229 for capped rental items. We also
proposed to revise Sec. 414.229 to reflect that these proposed changes
to the replacement policy for beneficiary-owned capped rental items
only apply to those items for which the first rental month occurs on or
after January 1, 2007 since the DRA does not apply to capped rental
items for which the first rental month occurs before January 1, 2006.
The current rules will remain in place for capped rental items to which
the DRA does not apply.
We are aware that some manufacturer warranties may cover
replacement of oxygen or capped rental equipment within a certain time
period after the item is furnished. As was our policy before the
enactment of DRA (see Sec. 110.2.C of Chapter 15 of the Medicare
Benefit Policy Manual (pub. 100-02)), we proposed that Medicare not pay
for the replacement of beneficiary-owned oxygen equipment or capped
rental items covered by a manufacturer's or supplier's warranty. In
cases where equipment replacement is not covered by a manufacturer's or
supplier's warranty, we proposed that the supplier must still replace
beneficiary-owned oxygen equipment or beneficiary-owned capped rental
items at no cost to the beneficiary or to the Medicare program if: (1)
The total accumulated costs, as illustrated in the example below, to
repair the item after transfer of title to the beneficiary exceed 60
percent of the replacement cost; and (2) the item has been in
continuous use for less than its reasonable useful lifetime, as
established in accordance with the procedures set forth in proposed
revised Sec. 414.210(f). For example, a capped rental item that can be
replaced for $1,000 (total of fee schedule payments after 13 rental
months) and for which title has transferred to the beneficiary in
accordance with section 1834(a)(7)(A)(ii) of the Act can be used to
illustrate what we mean when we use the term ``accumulated costs''
above. In this example, if Medicare has paid a total of $500 for 3
repairs necessary to make the item functional, and a fourth repair
costing $200 is needed in order to make the item functional, the
accumulated costs for repair in this case will equal $700, which
exceeds $600 or 60 percent of the $1,000 cost to replace the item. In
this case, the supplier would be required to furnish a replacement
item. The greater than 60 percent of cost threshold for replacement is
consistent with the threshold repair costs that can result in the
replacement of prosthetics (artificial limbs) in accordance with
section 1834(h)(1)(G) of the Act. We believe this threshold should
apply to oxygen equipment and capped rental items as well, because
artificial limbs, like these items, are built to withstand repeated
use.
We proposed that the supplier be responsible for the cost of the
replacement equipment because we believe that the item in this case did
not last for the entire reasonable useful
[[Page 65901]]
lifetime. After the beneficiary acquires title to the item, the
supplier that transferred title would be responsible for furnishing the
replacement item. We proposed this provision to safeguard the
beneficiary from receiving, and the Medicare program from paying for,
substandard equipment, and to avoid creating an incentive for suppliers
to increase the number of claims submitted for repairs in an effort to
recover revenue lost as a result of DRA section 5101. We believe that
this requirement is not unreasonable since suppliers should be
furnishing items in good working order and are otherwise bound by
regulations at Sec. 424.57(c)(15) to accept returns from beneficiaries
of substandard items. Exceptions to this rule may be granted by CMS or
the carrier as appropriate (for example, the supplier would not be
responsible for replacing an item in need of repair due to beneficiary
neglect or abuse).
L. Periods of Continuous Use
Rules that apply in determining a period of continuous use for
rental of DME are found at Sec. 414.230 of our regulations. We
proposed that these rules would continue to apply in implementing
section 5101 of the DRA, with one exception. The rules in Sec.
414.230(f) provide that a new period of continuous use begins for new
or additional equipment prescribed by a physician and found to be
medically necessary, even if the new or additional equipment is similar
to the old equipment.
Medicare payments for stationary and portable oxygen and oxygen
equipment are currently modality neutral, which means that the same
payment amounts apply to the different types of oxygen equipment
furnished to Medicare beneficiaries. Since there is no distinction made
between oxygen equipment modalities for payment purposes under the
Medicare program, we do not believe that it is necessary or appropriate
to begin a new period of continuous use when the beneficiary changes
from one oxygen equipment modality to another. We proposed to revise
Sec. 414.230(f) of our regulations to designate the existing language
in this section as paragraph (f)(1) and to add a new paragraph (f)(2)
to reflect this exception, effective for oxygen equipment furnished on
or after January 1, 2007. We also proposed to revise Sec. 414.230(b)
to incorporate section 5101(b)(2)(B) of the DRA, which provides that
for all beneficiaries receiving oxygen equipment paid for under section
1834(a) on December 31, 2005, the period of continuous use begins on
January 1, 2006.
M. Other Issues: Health Care Information Transparency, Health
Information Technology, and Medicare Payment Structures
Both Medicare's payment structures and the actual delivery of post
acute care have evolved significantly over the past decade. Before the
BBA, HHAs and other post-acute settings such as inpatient
rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs)
were paid on the basis of cost. Since that time, we have implemented
various legislative mandates that established prospective payment
systems in these settings. The PPS methodologies used in these settings
rely on patient-level clinical information to provide pricing, support
the provision of high quality services, and encourage the efficient
delivery of care. CMS is exploring refinements to the existing
provider-oriented ``silos'' to create a more seamless system for
payment and delivery of post-acute care (PAC) under Medicare. This new
model could feature more consistent payments for the same type of care
across different sites of service, value based purchasing incentives,
and the collection of uniform clinical assessment information to
support quality and discharge planning functions.
CMS is considering a demonstration to determine whether incentive
payments to HHAs impact improvements in the quality of care of Medicare
beneficiaries.
Section 5008 of the Deficit Reduction Act of 2005 (DRA) provides
for a demonstration on uniform assessment and data collection across
different sites of service. This 3-year demonstration project is to be
established by January 1, 2008. We are in the early stages of
developing a standard, comprehensive assessment instrument to be
completed at hospital discharge and ultimately integrated with PAC
assessments. The demonstration will enable us to test the usefulness of
this instrument, and analyze cost and outcomes across different PAC
sites. The lessons learned from this demonstration will inform efforts
to improve the post-acute payment systems.
We have evaluated the existing assessment instruments that managed
care and other insurers use. These instruments will form the basis of
our efforts to create a discharge assessment tool that can serve to
facilitate post-hospital placement decisions; enhance the safety and
quality of care during patient transfers through transmission of core
information to a receiving provider; and provide baseline information
for longitudinal follow-up of health and function.
In the April 25, 2006 Inpatient Prospective Payment System proposed
rule (71 FR 23996), we discussed in detail the Health Care Information
Transparency Initiative and our efforts to promote effective use of
Health Information Technology (HIT) as a means to help improve health
care quality and improve efficiency. Specifically, with regard to the
transparency initiative, we discussed several potential options for
making pricing and quality information available to the public (71 FR
24120 through 24121). We solicited comments on ways the Department can
encourage transparency in health care quality and pricing whether
through its leadership on voluntary initiatives or through regulatory
requirements. We also sought comments on the Department's statutory
authority to impose such requirements. In addition, we discussed the
potential for HIT to facilitate improvements in the quality and
efficiency of health care services (71 FR 24100 through 24101). We
solicited comments on our statutory authority to encourage the adoption
and use of HIT. The 2007 Budget states that ``the Administration
supports the adoption of Health Information Technology (HIT) as a
normal cost of doing business to ensure patients receive high quality
care.'' We also sought comments on the appropriate role of HIT in
potential value-based purchasing programs, beyond the intrinsic
incentives of a PPS to provide efficient care, encourage the avoidance
of unnecessary costs, and increase quality of care. In addition, we
sought comments on promotion of the use of effective HIT and how CMS
can encourage its use in HHAs.
We intend to consider both the health care information transparency
initiative and the use of HIT as we refine and update all Medicare
payment systems. Therefore, we sought comments on these initiatives as
applied to the HH PPS in the August 3, 2006 proposed rule, including
the Department's statutory authority to impose any such requirements.
We stated that we may address these initiatives in the final HH PPS
rule. For example, a HIT proposal could include adding a requirement
that HHAs use HIT that is compliant with and certified by the
Certification Commission for Health Information Technology (CCHIT) in
the areas in which the technology is available. As noted previously,
the CMS Home Health Compare Web site contains home health quality
information. We note that we are in the process of seeking input on
these initiatives in various proposed Medicare
[[Page 65902]]
payment rules being issued this year. In particular, we intend to
consider both the health care information initiative and the use of HIT
as we refine and update all Medicare payment systems.
III. Analysis of and Responses to Public Comments
We received approximately 106 comments on the August 3, 2006
proposed rule.
General
Comment: Several commenters raised concerns about combining several
unrelated matters into a single public notice. The commenters believed
the style to be confusing and counter to CMS' initiatives for better
public communication.
Response: We recognize the commenters concern and note that we make
every attempt to provide sufficient information in the Federal Register
document to clearly and specifically state the contents of the Federal
Register document. We note that we targeted a similarly situated
audience in that suppliers of oxygen equipment, DME suppliers, and HHAs
all provide services in the post-acute care setting.
Comment: Several commenters requested that telehealth services be
directly funded. These commenters believe that utilization of
telehealth services would save Medicare money by reducing
hospitalization and decreasing the use of multiple medical services.
Response: Telehealth services are not a recognized visit or service
under the HH PPS. Specifically, in section 1895(e)(1)(B) of the Act,
telecommunications services are not considered a home health visit for
the purposes of eligibility or payment under this title.
Comment: A commenter stated that CMS should indefinitely retain the
5 percent rural add-on. Other commenters recognized that it would take
congressional action to extend the 5 percent rural add-on for rural
providers. Nonetheless, these commenters supported an extension of the
rural add-on period. In addition, commenters recommended that CMS
examine the differences between the cost of providing home health
services in a rural setting and those costs of providing home health
services in an urban area.
Response: The rural add-on was a temporary add-on established by
the DRA. Specifically, section 5201 of the DRA required, for home
health services furnished in a rural area with respect to episodes and
visits beginning on or after January 1, 2006 and before January 1,
2007, that we increase by 5 percent the payment amount that otherwise
would be made for the services. The statute does not provide for a
continuation of the rural add-on. We will continue to monitor the HH
PPS to help ensure that home health providers continue to receive
appropriate reimbursement for the services they provide.
Market Basket
Comment: Several commenters believe that the proposed market basket
update falls short of increased costs in the delivery of home health
services. Specifically, they state that labor costs have risen
significantly with the continuing shortage of nursing and therapy
staff, transportation costs skyrocketed in 2005-2006 at a rate far
greater than the estimated 2.2 percent that was set out in the 2006
rate setting rule, technology costs, and costs associated with
regulatory compliance have grown. Some of these commenters believe the
problem with the estimated market basket increase appears to stem from
two weaknesses in the calculation formula: The use of FY 2000 cost
reports and the accuracy of the projection. These commenters believe
the FY 2000 cost reports are inaccurate because they only contained a
portion of the operational changes that have occurred since the onset
of the prospective payment system.
Response: The home health market basket is a fixed-weight
Laspeyres-type price index, which measures the average change in the
price of goods and services purchased by HHAs in providing an efficient
level of home health care services. Furthermore, the projected
estimated HH market basket has been fairly consistent with the actual
market basket determination. Since the inception of the PPS in FY 2001
including years through CY 2005, the forecasted average annual increase
of the home health market basket has been 3.3 percent while the actual
average annual increase of the home health market basket has been 3.2
percent.
With respect to the use of the FY 2000 cost reports, they represent
the most recent and complete cost reports available at the time of the
most recent rebasing of the home health market basket presented in the
CY 2005 proposed rule. Our recent analysis of Medicare cost report data
for 2001 through 2003 shows very similar cost weights, including those
associated with compensation, to the FY 2000 based market basket.
Therefore, we believe the use of the FY 2000 cost reports continue to
accurately reflect a proxy of home health weights.
We further note that for the final rule, we are using the 2006 3rd
quarter forecast with historical data through 2006, 2nd quarter, which
results in a forecast for the home health market basket for CY 2007 of
3.3 percent. This projection includes a higher forecast for the CPI for
private transportation (2.2 percent) and higher forecast for the price
of compensation (3.5 percent) compared to the forecast in the proposed
rule of 0.3 percent and 3.4 percent, respectively.
Comment: One commenter suggested that CMS move away from using the
CPI for private transportation to proxy price changes associated with
transportation costs and substitute it with a more accurate reflection
of home health care transportation experience.
Response: We believe the CPI for private transportation is an
accurate proxy for the price changes associated with home health care
agencies' transportation costs. This CPI measures the price changes of
new and used motor vehicles, motor fuels, motor vehicle parts and
equipment, maintenance and repair, and insurance costs. We believe that
home health agencies incur all of these transportation costs.
Comment: One commenter suggested that the market basket weights
assigned to each input should be re-examined every 2 years using cost
report data that are less than 2 years old. The commenter also suggests
that the validity of the weights should be periodically tested using
audited cost report data.
Response: We rebase the home health market basket on a periodic
basis. When we rebase a market basket, we examine the costs for each
year since the most recent rebasing. In general, cost weights remain
stable from year to year and become less so over a longer time period,
such as 5 or more years. Additionally, we always use the most recent
and complete cost report data at the time of rebasing. For the CY 2005
proposed rule, the most recent and complete cost report data available
was for the year 2000. We are also confident in the validity of the
Medicare cost report data received by the industry. Thus, we believe a
formal audit is not required. However, as part of the standard rebasing
methodology in calculating the cost report weights, we trim the data to
remove the impact of outliers.
Comment: One commenter recommended that the shortfalls in annual
cost increase projections be added to succeeding year inflation
updates. The commenter stated, for example, the under-projection in
[[Page 65903]]
transportation cost increases in 2006 should be reflected in 2007 and
2008.
Response: We believe that the accuracy of the market basket updates
has been reasonable, as evidenced by the last several years which
contained average forecasted updates of 3.3 percent while actual
average annual increase of the home health market basket has been 3.2
percent.
Comment: One commenter suggested that projections should be
thoroughly evaluated and validated. The commenter is aware that CMS
uses a proprietary system, Global Insights, Inc. (GII), in determining
its projections and believes this system should be examined by a CMS
Technical Expert Panel in the immediate future.
Response: GII is an independent firm that forecasts price proxies
and other economic indicators. We believe that the projections we use
are unbiased and consistent across all GII customers, both private and
government. Moreover, we continue to work closely with GII to
continually monitor the reasonableness of its projections.
Comment: Other commenters expressed support for a market basket
update of 3.1 percent and a 15 percent adjustment to the standardized
rates for dually eligible beneficiaries.
Response: We appreciate the support for the proposed market basket
increase. Section 1895(b)(3)(B) of the Act requires the unadjusted
national rate for CY 2007 to be increased by the applicable home health
market basket index amount. The home health market basket for CY 2007
is forecasted to be 3.3 percent. We do not, however, have the statutory
authority to establish a 15 percent adjustment to the standardized
rates for dually eligible beneficiaries.
Comment: One commenter stated that home care providers should
receive their full Medicare market basket update for 2007 and each
subsequent year.
Response: HHAs will receive payments based on a full market basket
update for services provided to Medicare beneficiaries for CY 2007 and
subsequent years as provided at section 1895(b)(3)(B)(v) of the Act,
subject to submitting the required quality measures and other possible
legislative mandates.
Quality/Pay for Reporting
Comment: A commenter recommended that CMS make the penalty for not
submitting the required quality data budget neutral and thus increase
the national standardized episode amount. This would provide a small
reward for the majority of agencies that already comply with the data
submission requirement.
Response: Section 1895(b)(3)(B)(V)(I) of the Act, added by section
5201(c)(2) of the DRA, stipulates that the market basket percentage
increase be reduced by 2 percentage points for HHAs who fail to submit
required data. The statute does not provide that the reduction in the
market basket percentage increase be budget neutral.
Comment: Several commenters supported CMS' proposed and continued
use of the OASIS instrument and reporting infrastructure in response to
the DRA requirements.
Response: We appreciate the commenters' support for this decision.
One of our goals is to allow HHAs to fulfill the DRA's quality data
reporting requirements in the most efficient and least burdensome way
possible.
Comment: Several commenters believe that CMS needs to continue to
refine and enhance the OASIS assessment instrument and associated
quality measures.
Response: As we stated previously, we intend to refine the current
OASIS instrument and associated quality measures. We will also continue
improving the assessment instrument's accuracy in reflecting both the
health status and improvements in condition of our beneficiaries.
Comment: Several commenters confused the various HH Conditions of
Participation requirements, that is, the completion, completeness, and
accuracy of the OASIS assessment, with the reporting requirements
established by the DRA.
Response: The proposed rule dealt solely with the requirements of
section 5201(c)(2) of the DRA to specify the health quality data needed
for quality measurements under the HH PPS. To meet the requirements
established in the DRA, we proposed to rely on the data submitted by
home health providers through the OASIS instrument. The regulations
surrounding completion, completeness, timeliness or other rules
associated with the OASIS were not affected by the HH PPS proposed
rule.
Comment: A few commenters were concerned that the reporting
timeframe established in the proposed rule is over before publication
of the final rule. The commenters noted that prior notification of
payment penalties associated with the DRA quality measures requirement
could not be known before the reporting period commenced.
Response: We acknowledge the commenters' concern, but we believe
our proposed approach adequately addresses these issues. Section
5201(c)(2) of the DRA amends the Act to such that ``each home health
agency shall submit to the Secretary such data that the Secretary
determines are appropriate for the measurement of health care quality.
Such data shall be submitted in a form and manner, and at a time,
specified by the Secretary.'' In considering how to best implement this
provision while still obtaining the needed quality measures, our
approach was to use processes and mechanisms that were already in place
and functioning, as the most efficient and appropriate way to meet the
statutory requirements. Using historical data to determine the
prospective update is similar to the methodology used for hospital pay
for reporting. In this manner, by utilizing an existing system, we were
able to provide the least burdensome measures on the providers, and
would penalize only those providers who were not otherwise meeting the
OASIS submission requirement under the home health Conditions of
Participation.
Comment: One commenter supported CMS' initiative to refine the home
health quality measures and to complement those measures with health
information technology. This commenter stated that the proper use of
new quality measures in certain areas coupled with the appropriate use
of health information technology will help to promote quality care,
efficiency, save Federal dollars, and satisfy the needs of our
beneficiaries.
Response: We appreciate the commenter's support and will continue
to pursue using health information technology to further the goals of
providing appropriate payments for quality services under the HH PPS.
Outlier Payments and Fixed Dollar Loss Ratio
Comment: A commenter expressed concerns with CMS' proposal to
update the fixed dollar loss ratio in the final rule if current data
become available. The commenter believes that CMS has an obligation to
modify PPS outlier criteria each year until the 5 percent set aside is
realized. Commenters urged CMS to ensure that data is available before
the final rule is published. The commenter recommended that CMS provide
an opportunity for review and comment before implementation of any
change that reduces the likely number of episodes qualifying for
outlier payments. Another commenter urged CMS to retain or increase the
current outlier payment structure.
Response: Section 1895(b)(5) of the Act states that the ``Secretary
may provide for an addition or adjustment to the payment amount
otherwise made in the case of outliers * * * [t]he total
[[Page 65904]]
amount * * * may not exceed 5 percent of the total payments projected
or estimated to be made based on the'' HH PPS. The statute makes clear
that to the extent the Secretary chooses to provide for an outlier
adjustment in HH PPS, such adjustment may not be more than 5 percent of
the projected or estimated HH PPS payments. The statute does not
provide for an outlier adjustment of 5 percent.
At the time of publication of the August 3, 2006 proposed rule, we
did not have more recent data, but noted that we may update the FDL
ratio for CY 2007 depending on the availability of more recent data. We
stated that depending on the availability of more recent data at the
time of publication of the HH PPS final rule for CY 2007, we may, if
necessary, implement an update to the FDL ratio for the CY 2007 update
to the HH PPS rates. Subsequent to the publication of the August 3,
2006 proposed rule, we have now obtained more recent data, that is, CY
2005 home health claims data. Accordingly, for this final rule, we have
used the same methodology and performed analysis using the CY 2005 data
to update the FDL ratio for CY 2007. For CY 2007, we are not only
retaining the current outlier payment structure but also increasing the
FDL ratio to allow more episodes to qualify for outlier payments. This
new FDL ratio is 0.67.
Home Health Wage Index
Comment: Several commenters expressed serious concerns about the
use of the pre-floor, pre-reclassified hospital wage index for
adjusting for geographic variation in wages. These commenters believe
that CMS has the regulatory authority to take immediate steps to
implement a wage index that secures a reasonable level of parity with
hospitals in the geographic areas served by HHAs. Specific
recommendations include applying the State-specific rural floor to all
urban areas and implementing a reclassification value proxy for HHAs
operating in areas where hospitals have been reclassified. Commenters
also made recommendations that CMS consider a wholesale revision and
reform of the home health wage index.
Response: These commenters are referring to the rural floor and
geographic reclassification applicable to hospital payments. The rural
floor provision is provided at section 4410 of Public Law 105-33 and is
specific to hospitals. The reclassification provision provided at
section 1886(d)(10) of the Act is also specific to hospitals. Because
these floors and reclassifications apply only to hospitals, and not to
HHAs, we believe the use of the most recent available pre-floor and
pre-reclassified hospital wage index data results in the appropriate
adjustment to the labor portion of home health costs as required at
1895(b)(4)(C). As to the revision and reform of the home health wage
index, we further note that CMS has, along with the industry, explored
the feasibility of developing a home health specific wage index.
Because of the volatility of the home health wage data and the
significant amount of resources that would be required to improve the
quality of those data, we do not expect to propose a home health
specific wage index until we can demonstrate that a home health
specific wage index would be more reflective of the wages and salaries
paid in a specific area, that it would significantly improve our
ability to determine payment for HHAs, and that we can justify the
resources required to collect the data, as well as the increased burden
on providers.
Comment: One commenter was concerned about the wage index for CBSA
12940 ``East Baton Rouge, Ascension, Livingston, West Baton Rouge,
Louisiana.'' The commenter stated that the proposed ``wage index
reflects a decrease from .8593 in CY 2006 to .8099 in CY 2007, a
decrease of nearly 6%.'' The commenter believes this must be the result
of an error and that this wage index should be reviewed for accuracy.
Response: First, the wage index that is applied to payments for
services furnished to home health patients in CY 2006 in CBSA 12940 is
not 0.8593. In CY 2006, we apply a transition wage index of either
0.7967 or 0.8618 (depending on the State and county code where the
beneficiary resides) to payments for home health services provided in
CBSA 12940. This is clearly noted in Addendum A of the CY 2006 HH PPS
final rule (70 FR 68161). The wage index value of 0.8593 would have
been applied to payments for home health services rendered in CBSA
12940 had we not implemented a transition policy for CY 2006. As noted
in the CY 2006 final rule (70 FR 68138), we implemented a transition
policy based on the concern about the potential negative financial
impact of moving to a CBSA-based wage index. The final wage index value
for CBSA 12940 will be 0.8084 for CY 2007.
Second, the change in the wage index value for CBSA 12940 is also
due in part to the inclusion of wage data from the following counties:
East and West Feliciana Counties, Iberville County, Pointe Coupee
County, and St. Helena County. These five counties were previously
classified as rural. However, under the CBSA designations, which we
implemented beginning in CY 2006, they are now part of CBSA 12940.
We further note that we employ processes to review the accuracy of
the wage index. The home health wage index is derived from the pre-
floor, pre-reclassified hospital wage index which is calculated based
on cost report data from hospitals paid under the hospital inpatient
prospective payment system (IPPS). All IPPS hospitals must complete the
wage index survey (Worksheet S-3, Parts II and III) as part of their
Medicare cost reports. Cost reports will be rejected if Worksheet S-3
is not completed. Additionally, intermediaries perform desk reviews on
all hospitals' Worksheet S-3 wage data, and we run edits on the wage
data to further ensure the accuracy and validity of the wage data. In
addition, HHAs have the opportunity to submit comments on the hospital
wage index data during the annual IPPS rulemaking period. Therefore, we
believe our review processes result in an accurate reflection of the
applicable wages for the areas given.
Comment: A commenter expressed concern because implementation of a
CBSA-based wage index places Lake County, Illinois in the same CBSA as
Racine, Wisconsin rather than in the CBSA-based wage index that
includes Chicago. The commenter states that Lake County, Illinois draws
from the same employment pool as does the Chicago metro area. The
commenter further states that this situation requires dual licensure in
order for HHAs in Illinois to hire nurses from Wisconsin.
Response: Lake County, Illinois is not included in the same CBSA
with Racine, Wisconsin. Racine County is in CBSA 39540 and has a CY
2007 wage index of 0.9356. Lake County, Illinois is included with
Kenosha County, Wisconsin in CBSA 29404. Lake County and Kenosha County
are adjacent counties in the States of Illinois and Wisconsin,
respectively. The CY 2007 wage index for CBSA 29404 is 1.0570. OMB
considers Lake County and Kenosha County to be part of the same
Metropolitan Division. OMB defines a ``metropolitan division'' as ``a
county or group of counties within a core-based statistical area that
contains a core with a population of at least 2.5 million. A
metropolitan division consists of one or more main counties that
represent an employment center or centers, plus adjacent counties
associated with the main county or counties through commuting ties.''
This information is available at the following Web address: http://www.whitehouse.gov/omb/bulletins/b03-04.html.
We believe that
[[Page 65905]]
the OMB geographic designations generally reflect the general labor
market.
State participation in the Nurse Licensure Compact alleviates the
need for nurses to be licensed in multiple states. The state of
Wisconsin participates in the Nurse Licensure Compact but Illinois does
not. Illinois' participation in the Nurse Licensure Compact would
alleviate the need for nurses to be licensed in both states.
Comment: Other commenters had issues with the decreases in wage
index that they will experience in the move to a full CBSA-based wage
index in CY 2007.
Response: We appreciate the detailed concerns sent by the
commenters regarding the impact of the wage index update for their
specific areas. We note that there will always be some areas that
experience an increase in wage index values while others experience a
decrease in wage index values. Variability in wage index values occurs
each year as wage index values fluctuate from year to year based on the
changes to the hospital wage data. As a result, wage index values
within the system increase or decrease. We are aware of the changes to
wage index values may be due in part to the adoption of the revised OMB
designations, and in light of these concerns, we provided a one-year
transition period for CY 2006. As to the appropriateness of what CBSA a
particular area has been designated into, CBSA designations are
determined by the Office of Management and Budget (OMB). We continue to
believe that OMB's CBSA designations reflect the most recent available
geographic classifications and are a reasonable and appropriate way to
define geographic areas for purposes of determining wage index values.
Comment: One commenter recommended that CMS apply a transition
policy that would phase in large and unexpected wage index reductions
over a two-year period, similar to the transition CMS applied for the
IPPS conversion to CBSAs.
Response: As noted previously, we implemented a one-year transition
policy as a means to gradually introduce the changes and impact of a
CBSA-based wage index to the HH PPS. We believe that the transitional
one-year period was appropriate and do not agree that a longer
transition period is necessary or appropriate. We again note that
fluctuations in each wage index would be expected even if we did not
adopt the revised OMB designations.
Comment: Commenters raised concerns with CMS' proposal to continue
to use the CY 2005 rural wage index for areas where there is no rural
hospital data to compute a wage index.
Commenters also raised concerns with the alternative methodology
that we discussed, that is, basing the imputed rural wage index on data
from the state's Census Division. Commenters believe that this type of
situation highlights the need to move away from using pre-floor, pre-
reclassified hospital wage data for the home health wage index.
Commenters recommended a number of alternative methodologies for
imputing a wage index value for areas where there are no rural hospital
data to compute a wage index value. The commenters all believe that an
imputed proxy should be reflective of the most local data available.
Almost all of these comments specifically refer to the wage index for
rural Massachusetts.
Response: As noted above, several commenters recommended
alternative methodologies for imputing a rural wage index. One
recommended alternative was to use CAH data to impute a wage index for
rural Massachusetts. However, CAHs are not required to submit the cost
reporting worksheets that we use to compute the hospital wage index.
Requiring CAHs to do so would impose an additional data collection
burden on them. Additionally, those data would then need to be
collected and audited. Therefore, we believe this option would be
unduly burdensome and inefficient.
Another alternative that was recommended was to use the rural wage
index from the single state closest to the Massachusetts rural area.
Rhode Island is the closest State to the Massachusetts rural area, but
Rhode Island has no rural areas. The commenter acknowledged this and
proposed using the wage index for Connecticut. We do not believe that
using the rural wage index from the closest State is appropriate
because this methodology is not easy to apply to other states where
this situation could arise.
Another alternative that was recommended was to use the same
methodology that we use to calculate an ``imputed rural floor'' for PPS
hospitals with no rural areas (69 FR 49111). This methodology compares
the three States that lack rural hospital wage data (Rhode Island, New
Jersey, and Massachusetts) to those three States as a class. As the
commenter recognized, this approach does not match the criterion for
using rural data. The commenter also recognized that since it uses data
from hospitals in New Jersey, it does not meet the criterion of using
the most local data available. We agree with the commenter that this is
not the optimum alternative for imputing a rural wage index for the HH
PPS.
A fourth alternative that was recommended was to use the average
wage index from contiguous CBSAs as an acceptable proxy for a rural
wage index.
A fifth alternative that was suggested was to use BLS wage data to
derive a ratio of rural wages to wages in an urban MSA within the
State. That ratio could then be multiplied by the wage index from the
urban MSA to derive an estimated wage index for the rural area. We do
not believe that using the BLS data to impute a rural wage index is the
best alternative as it does not meet our criterion of using pre-floor,
pre-reclassified hospital data. Also, using the BLS wage data would
require a determination as to which health sector occupations to
consider. This alternative methodology would also not weight the
occupations appropriately. In contrast, the pre-floor, pre-reclassified
hospital wage data encompasses wages and hours, that is, actual
utilization per occupation.
Using OMB's geographic classification system, the entire rural
Massachusetts area, consists of Dukes and Nantucket Counties. Both of
these counties are islands. This creates a unique set of circumstances
to consider.
As we stated in the August 3, 2006 proposed rule, we also believe
that an imputed proxy should (1) use pre-floor, pre-reclassified
hospital data, (2) use rural wage data, (3) be easy to evaluate, and
(4) be easily updatable from year-to-year. After a thorough review of
the comments received and a further review of the needs and concerns
inherent in this situation, we agree with the commenters that an
additional criterion should be added, that is, that the most ``local''
data available should be used to impute a rural wage index. We have re-
evaluated our proposed method of imputing a rural wage index, (that is,
using the CY 2005 wage index) and have decided that a more appropriate
proxy is needed. Although our proposed methodology uses local, rural
pre-floor, pre-reclassified hospital wage data, this method is not
updateable from year-to-year. In addition, we now believe that the
alternative methodology noted in the August 3, 2006 proposed rule (that
is, using an average of the wage indexes in the Census Division) is not
optimal because although it uses pre-floor, pre-reclassified hospital
wage data from rural areas, it does not use the most local data
available.
We believe that the alternative methodology of using the wage index
from contiguous CBSAs best meets our criteria for imputing a rural wage
index and represents an appropriate wage index proxy for rural areas
without
[[Page 65906]]
hospital wage data. While it does not use rural data, it does use pre-
floor, pre-reclassified hospital wage data, it is easy to evaluate, it
is updateable from year to year, and it uses the most local data
available. Therefore, we are revising our methodology for imputing a
wage index for rural areas without hospital wage data. We will use the
average wage index from all CBSAs that are contiguous to that rural
area if the rural area does not have rural hospital wage data.
In determining an imputed rural wage index, we interpret
``contiguous'' as sharing a border. In the case of Massachusetts, the
entire rural area consists of Dukes and Nantucket Counties. We
determined that the borders of Dukes and Nantucket Counties are
``contiguous'' with Barnstable and Bristol Counties. The wage indexes
for Barnstable (1.2539) and Bristol (1.0783) are averaged resulting in
an imputed rural wage index of 1.1661 for rural Massachusetts for CY
2007. While we believe that this policy could be readily applied to
other rural areas that lack hospital wage data (possibly due to
hospitals converting to a different provider type (such as a CAH) that
does not submit the appropriate wage data), should a similar situation
arise in the future, we may re-examine this policy.
However, we do not believe that this final policy is appropriate
for Puerto Rico. As noted in the August 3, 2006 proposed rule, there
are sufficient economic differences between the hospitals in the United
States and those in Puerto Rico, including the fact that hospitals in
Puerto Rico are paid on blended Federal/Commonwealth-specific rates
that a separate distinct policy for Puerto Rico is necessary.
Consequently, any alternative methodology for imputing a wage index for
rural Puerto Rico would need to take into account those differences.
Our policy of imputing a rural wage index based on the wage index(es)
of CBSAs contiguous to that rural area does not recognize the unique
circumstances of Puerto Rico. We received neither comments on our
proposed approach to impute a wage index for rural areas in Puerto Rico
nor any alternative suggestions. While we have not yet identified an
alternative methodology for imputing a wage index for rural Puerto
Rico, we will continue to evaluate the feasibility of using existing
hospital wage data and, possibly, wage data from other sources.
Accordingly, we will continue to use the most recent wage index
previously available for Puerto Rico, that is, the wage index from
2004, which is 0.4047.
Health Care Information Transparency and Health Information Technology
Comment: One commenter addressed our discussion of health care
information transparency and health information technology. The
commenter disagreed with our implication that public comment was
previously solicited from the home health community via the 2006 IPPS
proposed rule published on August 25, 2006. However, the commenter is
pleased that CMS has initiated a public dialogue in this area. The
commenter suggests that CMS conduct a technology inventory in home
health services to determine utilization and perceived roadblocks to
expanded utilization. The commenter also believes that any such mandate
must be accompanied by adjustments in payments. Additional commenters
raised concerns about the potential impact of health information
technology. Commenters do not believe that CMS has sufficiently
supported the significant investments agencies have had to make in the
past several years to establish and maintain HIT capabilities.
Commenter concerns focused on the potential financial impact on
providers who have invested significantly in HIT. Commenters believe
that HIT requires a shared investment between providers and purchasers
of care, to include CMS.
Response: As explained in the proposed rule, we intend to consider
both the health care information transparency initiative and the use of
HIT as we refine and update all Medicare payment systems. As previously
stated, the 2007 Budget states that ``the Administration supports the
adoption of health information technology (HIT) as a normal cost of
doing business to ensure patients receive high quality care.'' We are
not including specific recommendations in this final rule. However, we
appreciate the input and recommendations provided in the use of HIT and
welcome further comments on this important topic from HHAs.
Comment: One commenter stated that the public does not understand
how Medicare's HH PPS works. The commenter believes that a prospective
system is a ``soft'' reimbursement methodology, as payment rates have
little relationship to home health pricing noting that in some
instances the HH PPS payment far exceeds charges and in other instances
the payment falls short of charges.
Response: We are actively pursuing the goal of price and quality
transparency generally in the health care system. We have already
released payment information on inpatient services and ambulatory
surgical centers and are considering how to do so in other care
settings. We agree that any pricing information released publicly
should be clearly understood by the public, both consumers and
patients. We recognize that Medicare payment for home health services
captures a wide variety of costs and that payment rates may not always
exactly match the costs for specific patients. However, as a
prospective payment system, HH PPS payments estimate the average cost
of providing services and are designed to recognize the higher costs
associated with care for more severely ill patients. As such, the
information could be of great interest to individual patients and the
general public when they consider treatment options. It may also be
important for patients and their families to understand what services
the payment covers, to assist in planning for their health care needs.
The price of home health care is also an important component of
price information in broader episodes of care. For example, a patient
hospitalized with congestive heart failure may have a variety of post-
acute care options, including being discharged home without home health
services. The ability to identify the cost of different services,
including home health, in a total episode of care allows patients,
providers, and the Medicare program to be better educated about the
value of different mixes of services. This type of analysis, including
knowing the price of home health services, could provide valuable data
such as re-admission information and indicating the value of specific
care sites to patients.
We are not including specific recommendations in this final rule.
However, we will continue to identify price and quality information
that could be publicly released to help inform patient and consumer
health care decisions and encourage higher value health care. We
welcome further comments on this important topic from HHAs.
Consolidated Billing and Supply Issues
Comment: One commenter requested that CMS exclude HCPCS Code A7043
(vacuum drainage bottle and tubing for use with implanted catheter)
from the HH PPS. The commenter believes that the regulations authorize
CMS to exclude prosthetic devices and items related to prosthetic
devices that are covered under Part B from the HH PPS. The commenter
stated that the Pleurx pleural catheter and vacuum drainage bottle meet
the definition of a prosthetic device because they replace the
malfunctioning pleura by artificially
[[Page 65907]]
draining the pleura. Additionally, the commenter believes that the HH
PPS rates do not adequately compensate HHAs when they care for
beneficiaries requiring the Pleurx pleural catheter and vacuum drainage
bottle.
Response: We addressed consolidated billing requirements in the
Final Rule for the HH PPS published on July 3, 2000 (65 FR 41139).
Medical supplies are a covered home health service and are bundled into
the payment rate under the HH PPS. Section 1861(m)(5) specifically
includes catheters and catheter supplies as a covered home health
service. Therefore, vacuum drainage bottles and tubing for use with an
implanted catheter are bundled medical supplies while the patient is
under a home health episode of care.
Moreover, as we have consistently noted in responding to comments,
the statute does not provide for an exception or carve-out of medical
supplies from the PPS rate for patients under a plan of care under the
HH PPS. The costs of all such supplies are included in the HH PPS rate
(see 65 FR 41139).
We disagree with the commenter that the HH PPS rates do not
adequately compensate HHAs when they care for beneficiaries requiring
vacuum drainage bottles and tubing for use with the implanted catheter
because this medical supply was included within the original list of
199 non-routine medical codes subject to home health consolidated
billing effective October 1, 2000. While the HCPCS code for vacuum
drainage bottles has changed, the cost of vacuum drainage bottles was
included in the original case-mix weights used to determine the HH PPS
rates (65 FR 41138).
Comment: Several commenters raised concerns about being unable to
obtain the same brand of single-use urinary catheter from their HHA
that they received directly from a DMEPOS supplier prior to receiving
home health. These commenters believed that excluding HCPCS code A4353,
which includes single-use catheters, would allow them to receive their
catheters directly from the DMEPOS supplier. A number of commenters
also request that HHAs be allowed to omit a patient's chronic urinary
condition from the patient's specific home health plan of care which
they say will allow the patient to continue to obtain the same name
brand of single-use catheter they were using prior to receiving home
health.
Response: As noted above, medical supplies are bundled into the HH
PPS payment rate and cannot be excluded from that rate. As to this
specific item under HCPCS code A4353, that item is considered to be a
medical supply and accordingly bundled into the HH PPS payment rate.
We remind the commenters that if they believe that a product is not
adequately described in the existing HCPCS Level II code set, they may
submit an application to CMS to revise the code set, using the format
and guidance provided on CMS' HCPCS Web site at http://www.cms.hhs.gov/medhcpcsgeninfo
.
We note that under consolidated billing, the billing for those
medical supplies is the responsibility of the HHA. If the patient's
physician determines that a particular feature of a given supply is
medically necessary for the patient, the physician may specify the
designated feature in the physician's order for the supply and in the
plan of care. If the HHA determines that there exists an appropriate
substitute for the supply ordered by the physician, it may provide that
patient with the appropriate substitute supply. If the home health
patient does not agree with the HHA that the substitute supply is
appropriate, the patient should contact us through the Medicare Hotline
at 1-800-MEDICARE (1-800-633-4227). This toll-free helpline is
available 24 hours a day, 7 days a week to answer questions.
Beneficiaries can speak to a customer service representative in English
or Spanish. TTY users should call 1-877-486-2048.
We disagree with the request that a HHA omit a medical condition
from a plan of care in order to allow the patient to obtain desired
medical supplies outside of the plan of care. The regulations at 42 CFR
484.18 require that the plan of care covers all pertinent diagnoses,
including types of services and equipment required. In addition to
calling 1-800-MEDICARE, if the home health patient believes that she is
not receiving the necessary Medicare covered supplies, she may call the
Regional Home Health Intermediary (RHHI) or CMS regional office. Under
the Contacts section of our Web site at http://www.cms.hhs.gov/center/hha.asp
we provide information on how to contact the RHHIs and CMS
regional offices.
HH PPS Refinements
Comment: One commenter urged CMS to undertake a review of the HH
PPS and make appropriate adjustments to the case-mix weights before
2008. Another commenter requested that there be a review of LUPA rates,
and to subsequently increase the LUPA rates to ensure that they cover
the costs of providing care to those patients. One commenter
recommended that an ``add-on'' to the HH PPS payment be made for dually
eligible beneficiaries in order to recognize the added costs incurred
by such patients. The same commenter also believes that the costs
associated with wound care are not adequately paid for in the current
case-mix system.
Response: Our ongoing research agenda on the HH PPS refinements
encompasses review of case-mix adjustment and other payment adjustment
provisions under the HH PPS. Our continuing work also includes review
of overall system performance to the extent data permit analysis of
this topic. We intend to address certain aspects of the HH PPS, which
could include LUPA rates, when we initiate a refinement regulation. We
also note it is common with new payment systems for providers to go
through a period of adaptation. The adaptation process influences the
data we use to study refinements, and those data lag by up to a year
from the time a service is rendered to when the claim is submitted and
processed into a standard analytical file. Our study results will be
more effective and provide a better basis for policy proposals when the
data used in the studies reflect the ``end point'' of the adaptation
period. Assuming that the necessary data files will become complete, we
believe that the end point of the adaptation period will allow us to
pursue a refinement rule in the near future.
Comment: A commenter recommended that CMS establish a home health
technical advisory group to regularly review and update the multitude
of component parts of the HH PPS reimbursement methodology.
Response: We appreciate the comment; however, we do not believe
such a group is necessary at this time. We have always received input
from the industry on various aspects of our Medicare payment systems,
and we anticipate this practice will continue into the future.
Additionally, for the past few years, we have conducted ``open-door''
forums to provide the public with an opportunity to provide input and
comment on the HH PPS and related issues. Finally, as part of ongoing
refinement research, a technical expert panel (TEP) addressed the
various aspects of the HH PPS for possible refinements to the system.
We strongly believe that specific refinements to the HH PPS, if
appropriate, should be addressed in a single refinement regulation. In
doing so, the causes and effects that any particular refinement would
have on the rest of the system could be taken into effect, eliminating
the risk of
[[Page 65908]]
implementing any one refinement in a vacuum and resulting in a complete
and responsible refinement to the system.
Classes of Oxygen and Oxygen Equipment
Statutory Authority
Comment: One commenter asserted that the statute does not give
authority for CMS to create new classes for these items and that
payments must be made at the rate set by statute.
Response: We disagree. Section 1834(a)(9)(D) of the Act provides
authority to create separate classes and payment amounts for any item
of oxygen and oxygen equipment as long as they are budget neutral, that
is, the separate classes and payment amounts do not result in
expenditures for any year to be more or less than expenditures that
would otherwise have been made if the classes had not been established.
New Oxygen Generating Portable Equipment Technology
Comment: One commenter commended CMS for recognizing the many
benefits that oxygen generating portable equipment (OGPE) can provide.
Some commenters urged that the proposed payment rate for OGPE be
increased to provide adequate compensation for suppliers and to
encourage suppliers to invest in the new technologies. Two commenters
asked CMS to reconsider the proposed payment rates for OGPE to
accurately reflect the cost of the equipment; which is claimed to range
from $2,500 to $3,500. Some commenters recommended that CMS should not
implement the proposed payment rates changes at this time and that
setting new payment rates should be delayed until sufficient data is
gathered to identify the costs of oxygen services.
Response: We appreciate the support for our proposal to create a
new payment category for OGPE. We do not agree with the commenters who
suggested delaying the new categories because we are concerned that
maintaining the current system could create incentives for suppliers to
utilize older technology rather than newer technology that may be more
appropriate for certain beneficiaries. We believe that it is
appropriate and necessary to implement a new payment class for OGPE in
order to ensure access to these items; therefore, we will finalize a
new payment category for OGPE.
In the proposed rule, we explained that there are currently two
different types of OGPE: transfilling units that work independently or
in conjunction with standard, stationary oxygen concentrators to fill
portable oxygen canisters in the home; or portable oxygen concentrators
that meet both the patient's stationary and portable oxygen needs. In
both cases, the supplier can bill for both the monthly payment for
oxygen and oxygen equipment (currently averaging $199.84) and the
portable equipment add-on (currently averaging $31.79). In establishing
the new payment rate for OGPE, we proposed to consider the savings that
would be generated from use of these new technologies. The savings
would come from not having to make payments for portable oxygen
contents for beneficiary owned portable systems that generate their own
oxygen. The new, enhanced monthly payment for OGPE would be paid in
conjunction with the monthly payment for stationary equipment. The
combined monthly payments for stationary oxygen equipment and OGPE
would provide extra payments to suppliers of the newer technology
portable oxygen equipment, with the extra payments being directly
linked to the savings generated for the program by eliminating the need
to make future payments for portable oxygen contents.
The proposed add-on for OGPE of $64 was derived using a multiple
step process described in section I of the provisions of the proposed
regulation. As explained above, this process would involve determining
savings generated from not having to pay proposed monthly payments of
$55 for portable oxygen contents during the beneficiary ownership
period and applying the savings evenly over the 36-month OGPE rental
period. A total payment of $241 was proposed for stationary equipment
($177) plus the OGPE add-on payment ($64). The final process for
calculating the OGPE add-on payment, like the proposed process,
involved determining savings generated from not having to pay final
monthly payments of $77.45 for portable oxygen contents during the
beneficiary ownership period and applying the savings evenly over the
36-month OGPE rental period. To determine these savings we multiplied
$77.45 by 24 months (number of months in the equipment ownership
period) to get $1,858.80. We divided $1,858.80 by the 36 months of the
rental period to get the OGPE add-on of $51.63 per month. However, as
explained above in the discussion of the final methodology necessary to
assure annual budget neutrality of the new classes of oxygen and oxygen
equipment, distribution of use of items in the various classes over
five years is factored into the calculation used to determine the
budget neutrality adjustment factor. Therefore, the final payment rates
for the new classes are based on current utilization and an assumption
of the number of beneficiaries that will be using OGPE in the future.
The total payment for stationary equipment and OGPE for 2007 is $250.03
($198.40 for stationary + $51.63 for OGPE). The total payment for
stationary equipment and OGPE is estimated to be $250.03 in 2008,
$244.84 in 2009, and $241.02 in 2010; this compares to the total
payment in the proposed rule of $241.
We also note that in response to comments on the budget neutrality
of our proposal, the final national limited monthly payment rates for
each oxygen class were computed using weighted average fee schedule
amounts instead of straight average fee schedule amounts. As a result,
we have used slightly different numbers in our responses to comments
than we used in the proposed rule. Our revised budget neutrality
analysis is discussed in full below.
Comment: One commenter stated that CMS needs to provide assurance
that payment rates will not decrease, except in the case of competitive
bidding, and that each year the rates will be increased by the
percentage change in the Consumer Price Index for Urban Consumers (CPI-
U), the covered item update factor that is generally established as the
annual update for DME, unless otherwise indicated.
Response: We cannot provide assurance that oxygen payment rates
will never be decreased in the future or that rates will always be
increased by the CPI-U update. CMS is required to implement provisions
of law passed by Congress, including the covered item updates to the
fee schedule amounts for oxygen and oxygen equipment. Further, in order
to maintain annual budget neutrality for the oxygen payment classes as
required by Section 1834(a)(9)(D)(ii) of the Act, CMS may need to
adjust the payment amounts as appropriate.
Definition of Modality
Comment: Many commenters asked us to clarify the definition of
``modality.'' The commenters stated that the definition should be based
on clinical characteristics of the beneficiary rather than physical
characteristics of the device such that: a stationary oxygen class of
patients who are moribund, bed bound with limited need to leave the
home; a portable oxygen class of patients who require oxygen at night
only and have limited mobility; and an ambulatory oxygen class of
patients
[[Page 65909]]
whose oxygen needs include support for frequent ambulation. The
commenters state that the HCPCS code should be modified to ensure that
each respective clinical class can be identified.
Response: Medicare currently pays for two classes of oxygen
equipment, stationary and portable. For the stationary class, there are
three modalities that Medicare pays the same ``modality neutral''
payment rate for: concentrators, liquid cylinders and gaseous tanks.
For the portable class, Medicare makes a modality neutral payment for
all types of portable equipment. For the final rule, we are adding a
new payment class for OGPE and new separate payment classes for
delivery of stationary and portable oxygen contents. As has always been
the case, a physician may order a specific oxygen equipment modality
based on the clinical needs of the patient, and the supplier is bound
by that order. However, there is currently no Medicare national
coverage determination (NCD) that establishes medical necessity
criteria for different oxygen modalities. Therefore, at this time, we
do not believe it is necessary or appropriate to separate oxygen and
oxygen equipment into different classes based on the clinical
characteristics of different beneficiary populations.
Comment: A few commenters asked us to clarify the medical policy
that defines the criteria allowing patients to switch from one modality
of oxygen equipment to another modality. The commenters also asked CMS
to create a payment policy to pay suppliers for this type of equipment
change. Some commenters recommended that CMS instruct its DME program
safeguard contractor (PSC) to incorporate specific medical necessity
coverage requirements in a local coverage determination (LCD) that
specifies under what circumstances or diagnoses a beneficiary could
change from one modality of equipment to another, how suppliers will be
paid for furnishing a new equipment modality to a beneficiary, and
specific documentation requirements for both the supplier and physician
for a change in modality.
Response: A physician prescription for home oxygen is required for
coverage for home oxygen equipment. Generally, the physician prescribes
the units of oxygen the patient needs and the beneficiary works with
the supplier in deciding the modality of the oxygen equipment. In the
final rule, we are allowing beneficiaries the option to change
modalities during their rental period (this policy modification is
discussed below); however, as we proposed in section L of the proposed
rule, a new 36-month rental period would not begin in order to comply
with the modality neutral payment rules for oxygen and oxygen equipment
that we developed in accordance with sections 1834(a)(5) and (9) of the
Act. Even if Medicare coverage rules and medical necessity criteria for
different modalities of oxygen equipment were established in an NCD or
LCD, there would be no effect on Medicare payments for specific types
of items furnished under each payment class. It is important to note,
however, that Medicare coverage and medical necessity for oxygen and
oxygen equipment is outside the scope of this rulemaking effort.
Stationary and Portable Oxygen Contents
Comment: One commenter asked for justification of the 65 percent
and 35 percent apportionment of the payment for oxygen contents. We
also received comments recommending the same payment rate for all types
of oxygen contents because oxygen contents are the same regardless of
the weight of the container. One commenter recommended we keep the
reduction of approximately $22 to stationary equipment (from $199 to
$177) and reallocate the excess savings to (a) portable gaseous oxygen
contents and/or equipment, increasing the rates to $75 to $80 and
applying the increased rate to portable gaseous oxygen equipment
furnished during the equipment rental period and portable gaseous
oxygen contents furnished after the equipment rental period and (b)
portable liquid oxygen contents and/or equipment, increasing the rates
to $90 to $95 and applying the increased rate to portable liquid oxygen
equipment furnished during the equipment rental period and portable
liquid oxygen contents furnished after the equipment rental period.
Response: In the proposed rule, we proposed to apportion the
current oxygen contents rate of $156 per month by 65 percent and 35
percent based on the weight of the containers and other factors that
might make delivery of stationary oxygen contents more expensive than
delivery of portable oxygen contents. Stationary oxygen containers are
larger and heavier than the portable oxygen containers; therefore, we
proposed to apportion a greater amount of the payment to delivery of
stationary oxygen contents. We received comments indicating that the
average monthly costs of furnishing both types of oxygen contents are
the same despite the fact that stationary oxygen contents are bulkier
than portable oxygen contents. This is because stationary oxygen
contents are delivered and refilled at a lower frequency than portable
oxygen contents. Therefore, we are modifying the proposed payment rates
for the two types of oxygen contents based on an even (that is, 50-50
percent) split in the current $154.90 weighted average payment amount
for both stationary and portable oxygen contents. As a result, we will
be paying the same monthly rate of $77.45 for delivery of each of
stationary oxygen contents and portable oxygen contents. We will
therefore continue to pay $154.90 in cases where both stationary and
portable oxygen contents are medically necessary and are delivered. A
payment of $77.45 per month rather than $55 per month for delivery of
portable oxygen contents will further ensure that beneficiaries will
receive necessary contents for their portable oxygen systems and is
consistent with a suggestion from one commenter that payment for
delivery of portable gaseous oxygen contents should be from $75 to $80.
Most patients currently use gaseous portable oxygen systems as opposed
to liquid portable gaseous systems or portable concentrators. A very
small number of beneficiaries use stationary liquid or gaseous systems,
and, in most cases, the supplier that delivers stationary oxygen
contents for beneficiaries who use both stationary and portable liquid
or gaseous systems would also be the supplier of the portable oxygen
contents as well. Therefore, we believe that reducing the proposed
payment for stationary oxygen contents from $101 to $77.45 is
appropriate in light of the increased payment for portable oxygen
contents.
Comment: One commenter suggested that CMS establish a delivery fee
for each time a supplier delivers oxygen.
Response: The longstanding Medicare policy for payment for delivery
of DME and other supplier expenses is that payment for these costs are
included in the single payment made for furnishing the equipment. This
policy is based on section 1834(a)(5) of the Act, which provides that a
monthly payment amount recognized under section 1834(a)(9) be paid for
oxygen and oxygen equipment, and section 1834(a)(9), which mandates
that monthly payment (or fee schedule) amounts be calculated based on
payments made in 1986 under the reasonable charge payment methodology.
The reasonable charges that were used to calculate the fee schedule
payment amounts included delivery costs and all other costs for
furnishing the equipment. Therefore,
[[Page 65910]]
the cost associated with the delivery of oxygen contents is included in
the fee schedule payment amounts for stationary and portable oxygen
contents. Furthermore, section 1834(a)(9)(D)(i) of the Act requires
that monthly payment rates are to be established for each class of
oxygen and oxygen equipment. Since total Medicare expenditures under
the new classes and payment amounts will be the same as they would have
been under the old classes and fee schedule amounts, we believe that
the new payment rates incorporate the delivery costs that made up part
of the old fee schedule amounts.
Comment: One commenter was concerned that the payment rate for
delivery of oxygen contents for beneficiary-owned portable oxygen
equipment would not be enough to cover the number of tanks or cylinders
needed for each beneficiary. The commenter indicated that under the
previous payment methodology where monthly payments for oxygen and
oxygen equipment were made as long as medical necessity continued,
suppliers were able to offset costs associated with delivering portable
oxygen contents with the payment made for the stationary oxygen and
oxygen equipment. The commenter expressed concern that the proposed $55
monthly payment for delivery of portable oxygen contents will not cover
the costs of delivering more than 11 portable tanks per month. In
addition, the commenter stated that this figure does not include the
cost of delivery. Another commenter noted that the current fee schedule
amount of approximately $21 per month would not cover the costs of one
delivery per month of portable oxygen contents, and that this will
force suppliers to adopt a policy whereby the beneficiary must pick up
tanks from the supplier's store.
Response: We agree with the commenters that the payment rate for
portable oxygen contents of $21 is insufficient as a monthly payment
for the delivery of portable oxygen contents, and therefore; we are
finalizing our proposal to increase it in this final rule. We are
dividing $154.90, the current weighted average payment amount for both
stationary and portable oxygen contents evenly so that the payment rate
for portable oxygen contents will be increased from the current
weighted average payment amount of $20.77 to $77.45 per month. The
revised payment rate for stationary oxygen contents will also be $77.45
per month. These monthly payment rates include delivery of tanks and
cylinders, a service that the supplier is required to perform in order
to be in compliance with standards set forth at Sec. 424.57(c)(12).
Based on comments received on this issue, we believe that the finalized
payment rate of $77.45 will adequately pay suppliers for delivery of
stationary or portable oxygen contents. We are therefore confident that
the payment rate adequately covers the supplier's costs of delivering
oxygen contents.
Comment: One commenter asked for clarification on payment if there
is a change in equipment due to medical necessity. For example, the
commenter asked whether a new 36-month rental period starts when there
is an increase in the patient's oxygen volume that would require
delivery of more portable oxygen tanks.
Response: As we discuss more fully below, suppliers can furnish
another capped rental item or type of oxygen equipment with a physician
prescription or if the beneficiary would like newer technology or an
upgraded item. However, unless the change in equipment is based on
medical necessity, a new rental period will not start. In addition,
because there is no distinction made between oxygen equipment
modalities for payment purposes under the Medicare program, we would
not consider a change from one modality to another to be a change in
the type of equipment furnished to a beneficiary. Accordingly, a new
period of continuous use would not start in those circumstances.
Budget Neutrality
Comment: Several commenters claimed that the proposed rates were
not budget neutral. They claimed that the calculation of decreased
expenditures that would result from a $22 reduction in payment for
stationary equipment is underestimated and that such payment reduction
translates to savings ranging from $239 million to $260 million. One
commenter stated that the proposed rule was not budget neutral for each
year as required by statute. Another commenter pointed out that the
2004 data did not have specific utilization rates for portable
concentrators or transfilling systems since separate HCPCS codes did
not exist for these services at that time.
Response: We have revised the offset/budget neutrality calculations
that we proposed based on comments received and have modified the
payment rates for the classes of oxygen accordingly.
First, in response to the commenter that expressed concern with our
use of 2004 data, we have updated our analysis by using the latest
available data from the SADMERC on the number of beneficiaries for
which claims were received from July 1, 2006 through September 30,
2006, for HCPCS codes E0424, E0431, E0434, E0439, E1390, E1391, and
E1392 to determine the distribution of beneficiaries among the
categories of stationary and portable oxygen equipment. This data is
used to count the number of beneficiaries using items in each equipment
class. The number and percent distribution of beneficiaries using the
different categories of equipment are shown in table 10. These latest
data show 0.3 percent of beneficiaries using portable concentrators.
While using these later claims gives us data on users of portable
concentrators, we do not have data on beneficiaries using transfilling
systems since the code for such equipment began on October 1, 2006.
Thus, for purposes of calculating rates, we had to make an assumption
about the percent of beneficiaries who will use OGPE equipment (which
include both portable concentrators and transfilling systems) after the
new classes and payment rates go into effect. From comments received,
we assumed a shift of 5 percent of beneficiaries towards OGPE for our
budget neutrality calculations. We will revisit this assumption on an
annual basis and make adjustments through program instructions to rates
applicable to years after 2007 if actual utilization of oxygen
equipment by beneficiaries is different from our assumptions.
Table 10.--Categories of Oxygen Users
------------------------------------------------------------------------
Percent of
Equipment/Modality Number of users
beneficiaries (percent)
------------------------------------------------------------------------
Stationary Equipment Only............. 327,863 31.3
Liquid/Gas Stationary AND Portable 57,950 5.5
Equipment............................
Concentrator AND Portable Equipment... 657,948 62.8
[[Page 65911]]
Stationary AND Oxygen Generating 3,248 0.3
Portable Equipment...................
---------------------------------
Total Number of Beneficiaries..... 1,047,009 100.0
------------------------------------------------------------------------
As in the proposed rule, we used a five year period for determining
the rate changes because the reasonable useful lifetime policy for DME
equipment allows beneficiaries to elect to obtain a new item after five
years of use. Therefore, we assumed that Medicare would make three
years of rental payments and two years of payment for oxygen contents.
To calculate budget neutral rates, as in the proposed rule, we
compared estimates of Medicare spending for oxygen equipment and
contents based on current classes of items and payment rates with
estimates of the spending that Medicare would make based on the new
classes and payment rates outlined in this final rule. In order to
further address the concerns of commenters that the payment rates for
the new classes be budget neutral, we compared the payment rates for
the new classes to the current, weighted average monthly payment
amounts for oxygen and oxygen equipment (for example, $199.84 for
stationary equipment), as opposed to comparing them to the straight
average monthly payment amounts rounded to the nearest dollar (for
example, $199 for stationary equipment). Based on the concerns
expressed by commenters regarding the importance of assuring the budget
neutrality of the new classes of oxygen and oxygen equipment, we are
using the average of the current monthly payments per State weighted by
actual utilization by State to establish a more precise average
Medicare payment for each class of oxygen and oxygen equipment. To
estimate total expenditures for oxygen and oxygen equipment for a given
year, we multiplied the monthly payment rate for each category of
equipment by the total number of users of each such category, then by
the percent of users at the midpoint of each of three equipment rental
years, then by 12 for the number of months in a year. Then, we
multiplied the monthly payment rate for each category of oxygen
contents by the total number of users of each such category, then by
the percent of users at the midpoint of each of two beneficiary
ownership years, then by 12 for the number of months in a year. We
added the estimated spending for equipment and contents to obtain the
five year total of payments for equipment and contents. We used data
from the September 2006 OIG report, entitled ``Medicare Home Oxygen
Equipment: Cost and Servicing'' (OEI-09-04-00420), on the distribution
of the number of beneficiaries using stationary concentrators by the
number of months rented that showed the following percentages of oxygen
users at the midpoint of each year: 61 percent for the first year, 36
percent for the second year, 26 percent for the third year, 19 percent
for the fourth year, and 14 percent for the fifth year. We then used
this same methodology to estimate Medicare spending incorporating the
payment rate changes in this final rule. Since spending is greater
under the payment rate changes in this final rule, we applied a budget
neutrality adjustment to the monthly payment amount for stationary
equipment in order to achieve the same expenditures that would be spent
under payment rates without the changes in the final rule.
In response to comments received about our proposed methodology not
being budget neutral annually, we calculated budget-neutral rates for a
five-year period from 2006 to 2010, applying the methodology described
above. The complete, detailed budget neutrality analysis, data, and
payment rate calculations are available at the following internet
website: http://www.cms.hhs.gov/DMEPOSFeeSched/. This results in
smaller budget-neutrality adjustments in the early years and larger
ones in the later years because the increased expenditures in the first
three years results primarily from the OGPE add-on payment. The full
effect of the higher payments for portable oxygen contents will not be
realized until 2010, which will be the second year of the equipment
ownership for beneficiaries who have been renting oxygen equipment on a
continuous basis since 2006.
Table 11 shows the 2007 budget neutral monthly payment rates and
our estimates of the budget neutral monthly payment rates for 2008
through 2010 for the five classes of oxygen and oxygen equipment, in
addition to the combined rates for stationary and portable oxygen
contents. The rates for stationary equipment decrease by year to offset
the new OGPE class and the increase in the portable contents rate.
Table 12 shows the 2007 monthly payment rates and our estimates of the
monthly payment rates for 2008 through 2010 for four of the most common
combinations of oxygen equipment.
Table 11.--Current Weighted Average Monthly Payment Amounts Compared to Proposed and Final Monthly Payment Rates
for Classes of Oxygen and Oxygen Equipment
----------------------------------------------------------------------------------------------------------------
Oxygen class Current Proposed Final 2007 2008* 2009* 2010*
----------------------------------------------------------------------------------------------------------------
During Equipment Rental Period (36 Months)
----------------------------------------------------------------------------------------------------------------
Stationary Equipment (offset needed).... $199.84 $177.00 $198.40 $198.40 $193.21 $189.39
(-22.84) (-1.44) (-1.44) (-6.63) (-10.45)
Portable Add-on......................... 31.79 32.00 31.79 31.79 31.79 31.79
OGPE Add-on............................. N/A 64.00 51.63 51.63 51.63 51.63
----------------------------------------------------------------------------------------------------------------
[[Page 65912]]
Oxygen class Current Proposed Final 2007 2008 2009 2010
----------------------------------------------------------------------------------------------------------------
Contents Payments After Equipment Ownership
----------------------------------------------------------------------------------------------------------------
Stationary & Portable Contents.......... 154.90 156.00 154.90 154.90 154.90 154.90
Portable Contents Only.................. 20.77 55.00 77.45 77.45 77.45 77.45
Stationary Contents Only................ N/A $101.00 $77.45 $77.45 $77.45 $77.45
----------------------------------------------------------------------------------------------------------------
*Rates for 2008 and beyond are budget-neutral based on assumed OGPE utilization of 5 percent. Actual OGPE
utilization will be reviewed on an annual basis and rates will be adjusted, if necessary, through program
instructions to ensure annual budget neutrality.
Table 12.--Payments for Various Combinations of Oxygen Equipment
[Estimated for calendar years 2008 thru 2010]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Categories of equipment During rental period Contents after ownership
--------------------------------------------------------------------------------------------------------------------------------------------------------
Concentrator only:
2007/2008............................ $198.40 $0
2009................................. 193.21 0
2010................................. 189.39 0
Concentrator + gaseous portable:
2007/2008............................ 230.19 (198.40 + 31.79) 77.45
2009................................. 225.00 (193.21 + 31.79) 77.45
2010................................. 221.18 (189.39 + 31.79) 77.45
Concentrator + OGPE:
2007/2008............................ 250.03 (198.40 + 51.63) 0
2009................................. 244.84 (193.21 + 51.63) 0
2010................................. 241.02 (189.39 + 51.63) 0
Liquid stationary & portable:
2007/2008............................ 230.19 (198.40 + 31.79) 154.90 (77.45 x 2)
2009................................. 225.00 (193.21 + 31.79) 154.90 (77.45 x 2)
2010................................. 221.18 (189.39 + 31.79) 154.90 (77.45 x 2)
--------------------------------------------------------------------------------------------------------------------------------------------------------
These estimates assume that 5 percent of oxygen users will use OGPE
equipment in all years. However, we will monitor actual use and, as
part of our annual budget-neutrality determination, we will revise
rates through program instructions under the methodology specified in
this final rule if actual OGPE usage is different from our assumption.
We also plan to revise the payment rates in the future based on updated
data on the distribution of beneficiaries using oxygen equipment and
the number of months they use the equipment. These rates apply to all
beneficiaries who use oxygen equipment on or after January 1, 2007,
including both new and existing users.
Comment: Some expressed concern that the proposed payment amounts
for portable oxygen equipment and portable oxygen contents are not
sufficient to offset the cost of providing these systems. The
commenters recommend reallocating the savings that comes from the
proposed reduction of the stationary class to upwardly adjust the
monthly payment for portable equipment and contents. Some commenters
strongly urged CMS to offset any future cuts in home oxygen
concentrator payments with appropriate increases in other classes of
oxygen specifically portable and ambulatory classes.
Response: We have changed the payment amounts based on comments
received and have increased portable contents payment amount from
approximately $20.77 to $77.45 per month and have increased the add-on
rate for OGPE from approximately $31.79 (the current portable add-on
rate during the rental period) to $51.63 per month. We have also
recalculated the offsets for budget neutrality and in order to maintain
budget neutrality, and will not be reducing stationary payments from
approximately $199.84 to $177 as proposed. The stationary equipment
payment will be $198.40 in 2007, and is projected to be $198.40 in
2008, $193.21 in 2009, and $189.39 in 2010, based on current
calculations discussed above. The fees for 2008 and later would be
adjusted on an annual basis, if necessary, to ensure the annual budget
neutrality of the change in payment classes and rates. We will annually
reevaluate the actual distribution of oxygen equipment and make any
adjustment in the payment amounts through program instructions that are
necessary to maintain annual budget neutrality as required by section
1834(a)(9)(D)(ii) of the Act.
Data
Comment: A few commenters were concerned about the lack of data
provided that established the budget neutrality proposal and asked CMS
to release the data and assumptions. A few commenters stated that the
proposed rule did not conform to the requirements of the Data Quality
Act (DQA) that require Agencies to provide information on sources of
the disseminated information as well as supporting data and models in a
scientific, financial, or statistical context so the public may
question the objectivity of the data and source.
Response: The DQA requires agencies to, among other things, issue
guidelines to ensure and maximize the quality, objectivity, utility,
and integrity of information disseminated by the agency. While the DQA
applies to a wide variety of information dissemination activities and
all types of media, it has not been established that the DQA applies to
rulemaking. Nevertheless, we are providing extensive details in this
final rule about the data and methodology used to calculate budget
neutrality. Consistent with our guidelines for information quality
assurance, the information upon which we relied is from a reliable
source that uses accepted methods for data collection and analysis, and
we reviewed the quality of the information before using it. Where CMS
is responsible for disseminating influential information (that is,
information that will have a substantial impact on important public
policies or important private sector decisions), we ensure that there
is a high degree of transparency about the data and methods to
facilitate its reproducibility by qualified third parties. To the
extent
[[Page 65913]]
the data upon which we rely is not confidential, our guidelines call
for identification and documentation of data sets in producing
estimates and projections, and for clear descriptions of the methods
used.
Transition
Comment: Some commenters asked CMS to allow for a grace period
during which suppliers could transfer patients, with their consent, to
other modalities. Many commenters urged CMS to allow for a
grandfathering process so that those who began renting oxygen on
January 1, 2006 would be under former payment rates and policies. These
commenters argued that the final rule should only apply prospectively.
Response: The final rule, including the new oxygen payment classes
and rates, will be effective on January 1, 2007. However, as explained
above and illustrated in table 11, the new payment rates will be
annually adjusted if necessary to ensure budget neutrality. We disagree
with the comment that we allow for a grandfathering provision whereby
beneficiaries who began renting equipment on January 1, 2006 be allowed
to continue under the former payment rates and policies. Such an
approach would deny such beneficiaries the opportunity to obtain access
to the new technology equipment. We will periodically reevaluate actual
distribution and make any adjustment in payment amounts through program
instructions that are necessary to maintain annual budget neutrality as
required by statute. Adjustments in payment amounts will be determined
based on the model we are using to ensure annual budget neutrality as
explained above. As we discuss below, we will allow for changes in
modalities during the rental period if the beneficiary requests an
upgrade or if the physician provides a new order for the equipment
modality.
Comment: One commenter strongly urged CMS to adopt a blended rate
during a three-year transition policy. Traditionally CMS has
established blended rates by taking 75 percent of the original rate and
25 percent of the new rate during the first year; 50 percent and 50
percent in the second year; and 25 percent and 75 percent in the third
year.
Response: As explained above, we have revised the calculation of
the budget-neutral oxygen equipment payment amounts in response to
comments. Our revised approach calculates the budget-neutral rates that
will apply for the first five years based on our estimates of the
number of beneficiaries that will use specific types of equipment
during each of these years. We have also determined that we may need to
adjust the rates on an annual basis after the fifth year to ensure that
budget neutrality is maintained. Based on our calculations, we do not
believe that the blended percentages recommended by the commenter would
result in budget neutral payment amounts.
Deficit Reduction Act Requirements
Rental Cap
Comment: Numerous commenters were concerned that the 36-month
rental period for oxygen equipment will not help beneficiaries and will
create undue hardship for them because they will lose services that
they have valued for years. Moreover, they stated that current Medicare
benefit guidelines, as well as guidelines issued by all major national
insurance companies, State Medicaid programs and all home care industry
accreditation organizations, have always classified oxygen equipment as
``high maintenance equipment needing frequent maintenance service which
is not recommended or advisable for patients to own.'' Other commenters
predicted that hospital admissions will likely be increased as a result
of the cap. These commenters argued that capping home oxygen services
would direct patients toward the most expensive part of our health care
system, which is hospitalization. Another commenter felt it was
inappropriate to transfer title to this equipment to a patient because
medical oxygen is a prescribed drug. The commenter believes that
allowing beneficiaries to assume ownership is akin to giving them the
source of a controlled substance.
Response: The Congress mandated in section 1834(a)(5)(F)(ii)(I) of
the Act (added by section 5101(b)(1) of the DRA) that on the first day
that begins after the 36th continuous month during which payment is
made for rented oxygen equipment, title to the oxygen equipment must
transfer to the beneficiary. Section 1834(a)(5)(F)(ii)(II) provides
that the Secretary must make reasonable and necessary maintenance and
servicing payments for the equipment after the beneficiary assumes
ownership of it and we are planning to do so, as detailed in the
provisions of this final rule and in response to comments received
regarding maintenance and servicing of beneficiary-owned equipment.
Suppliers will be paid on a monthly basis for the delivery of oxygen
contents in tanks and cylinders in accordance with the requirements of
section 1834(a)(5)(F)(ii)(II) of the Act. As part of this ongoing
service, we expect suppliers to deliver tanks and cylinders in proper
working condition. As a result, we believe that beneficiary-owned
equipment will be properly maintained and that beneficiaries will not
suffer undue hardship as a result of the title transfer provisions. We
also do not see how the title transfer provisions will affect how much
oxygen beneficiaries use, since oxygen must be prescribed by a
physician and delivered by a supplier in accordance with that
prescription.
Comment: Several commenters remarked that, as beneficiaries, they
cannot afford to take care of their oxygen equipment once title to the
equipment has transferred to them and request that we reconsider the
rule. One commenter noted that his/her portable equipment must be
replaced at least a couple of times a year due to malfunctions.
Response: Although section 1834(a)(5)(F) of the Act requires
beneficiary ownership of oxygen equipment after 36 continuous rental
payments are made, this subparagraph also mandates that payment be made
for reasonable and necessary maintenance and servicing of the
beneficiary-owned equipment. The provisions of this final rule describe
the changes we are making in the regulations to ensure that the
beneficiary will continue to have access to equipment that will
function for the entire reasonable useful lifetime established for the
equipment. In accordance with existing regulations, if the equipment
has been in continuous use for the equipment's useful lifetime, the
beneficiary may elect to obtain new equipment. However, we note that a
beneficiary would not be required to obtain new oxygen equipment as
long as the equipment continued to function properly. In addition, as
we discuss below, we are finalizing a provision under which a supplier
may be required to replace the item at no charge to the beneficiary if
the equipment does not function for the entire useful lifetime. In
addition to meeting the annual Part B deductible, for assigned claims,
the beneficiary is only responsible for paying 20 percent of the
allowed charge for reasonable and necessary maintenance and servicing
of beneficiary-owned equipment. We believe that these policies will
help limit beneficiary costs once title to oxygen equipment has
transferred.
Comment: One commenter expressed concern about the 13-month rental
period for capped rental DME and recommended that CMS reconsider the
assignment of certain products to the capped rental category,
particularly
[[Page 65914]]
those that sell for under $250.00 or rent for under $25.00 per month.
The commenter argued that the expense of submitting and processing
claims for 13 months exceeds any savings from short-term rentals.
Response: The statute only allows for purchase of DME that is:
inexpensive or routinely purchased (section 1834(a)(2)(A) of the Act);
a power-driven wheelchair (section 1834(a)(7)(A)(iii) of the Act); or
customized (section 1834(a)(4) of the Act). In accordance with the
statute, inexpensive DME includes equipment having a purchase price of
$150 or less and routinely purchased DME is equipment that is acquired
at least 75 percent of the time by purchase. In accordance with section
1834(a)(7) of the Act, capped rental DME is DME not described in any of
the other payment categories in paragraphs (2) through (6) of section
1834(a) of the Act. We do not have authority to redefine these
categories because they are statutorily based.
Transfer of Title
Comment: A commenter noted that the loss of title to the oxygen
equipment will serve as a disincentive for suppliers to invest in
advancing oxygen equipment technology. As a result, manufacturers will
shift their research and development efforts away from the development
of smaller, longer-lasting portable systems and instead, focus on the
development of cheaper devices.
Response: We are obligated to implement section
1834(a)(5)(F)(ii)(I) of the Act, which requires that on the first day
that begins after the 36th continuous month in which rental payments
are made for oxygen equipment, the supplier transfer title to the
equipment to the beneficiary. However, we disagree with the commenter
that this rule will act to stymie advancements in oxygen equipment
technology and are finalizing policies in this rule that we believe
will properly incentivize suppliers to invest in new oxygen technology.
In the case of portable oxygen equipment, the purpose of establishing
an additional payment class for OGPE is to increase payments for the
newer, more efficient, but more expensive OGPE technologies. In
addition, as discussed below, we are clarifying in this final rule that
beneficiaries may select newer technology items or upgraded items
during the equipment rental period by agreeing to sign an Advanced
Beneficiary Notification (ABN).
Comment: Several commenters were concerned about the development of
a secondary market for oxygen equipment resulting from individuals
interested in selling their used equipment. They stated that the sale
of these medical devices would not be monitored to ensure the condition
of the device being sold, patient safety or clinical effectiveness.
Several commenters requested that we work with the FDA to develop
standardized guidelines that apply specifically to the public's resale
of used medical devices.
Response: We are aware that there may be safety issues associated
with the resale of used oxygen equipment, and our regulations would not
supersede any other Federal or State laws that govern these
transactions. However, section 1834(a)(5)(F)(ii)(I) specifically
mandates beneficiary ownership of both stationary and portable oxygen
equipment after 36 months of continuous use. It has long been common
practice for suppliers to pick up beneficiary-owned DME after medical
necessity ends, in cases where the beneficiary or relatives of the
beneficiary make such a request. In order to minimize the possibility
that beneficiaries will incorrectly dispose of oxygen equipment that is
no longer medically necessary, we will encourage suppliers to advise
beneficiaries that they can pick-up and store the beneficiary's oxygen
equipment if the beneficiary no longer needs it. Suppliers would be
paid for picking up and storing oxygen tanks and cylinders that are no
longer medically necessary (see below for a full discussion of this
modification to our maintenance and servicing proposal). We will also
note in the final regulations that in cases where suppliers have picked
up beneficiary-owned oxygen equipment under these circumstances and the
beneficiary's medical necessity for the equipment subsequently resumes,
the supplier must return to the beneficiary similar equipment of equal
or greater value to the beneficiary-owned equipment that was picked up,
unless the beneficiary elects to obtain new equipment because the
reasonable useful lifetime for the previous equipment has expired, or
unless a different oxygen modality is prescribed and the beneficiary
signs an advanced beneficiary notice (ABN) (see below for a full
discussion of this policy modification).
Comment: Several commenters urged that CMS and the Food and Drug
Administration (FDA) discuss the ability of suppliers of oxygen
contents for beneficiary-owned equipment to comply with 21 CFR 210 and
211. Further, the commenters stated that CMS must outline the process
for reimbursing suppliers for any in-home services they would need to
perform in the event of an FDA recall after the beneficiary takes title
to the device. Another commenter noted that once the beneficiary takes
ownership, many devices will no longer be trackable for recall
purposes. Several commenters recommended that CMS develop safety
standards that can be applied to beneficiary owned equipment. Standards
would help ensure that beneficiaries/caregivers comply with Department
of Transportation (DOT), FDA and the Compressed Gas Association oxygen
guidelines as well as ensure that they do not inappropriately handle or
dispose of cylinders. One commenter observed that the proposed rule
provided no clarification on how many cylinders Medicare expects to be
transferred in ownership to the patient. There are several factors that
can influence the number of cylinders a patient receives, such as
oxygen liter flow, activity level of the patient, and distance from the
patient's residence to the supplier's warehouse. Given these variables,
the commenter noted that a patient could receive from 2-6 cylinders at
the time of set-up. Additionally, beneficiaries may receive more
cylinders temporarily to accommodate travels outside of the supplier's
service area. One commenter questioned how CMS will address instances
where beneficiaries require more or less portable cylinders post title
transfer. Another commenter requested that Medicare not require
suppliers to transfer title to oxygen tanks to beneficiaries since it
would be burdensome and unmanageable for suppliers to keep track of
virtually identical tanks. Under the current regulatory framework for
oxygen as a medical gas, one commenter noted that suppliers are not
permitted to label oxygen containers with the beneficiary's name which
makes it difficult to develop tracking systems to ensure that each
patient's cylinders can be identified. One commenter estimated that
beneficiaries use anywhere from 2 to 10 or more tanks of oxygen per
week. Another commenter recommended that we not require transfer of
title for both sets of cylinder vessels, but rather only those that are
in use in the home and not the ones that the supplier refills in its
business location. One commenter recommended that we retain the
current, efficient approach where the supplier owns all the cylinders
because this allows the supplier to use different cylinders with the
same patient. Several commenters noted that our proposal to transfer
title to both the oxygen cylinder that is being filled and the one in
the beneficiary's home is unworkable given
[[Page 65915]]
its impact on supplier's operations and the regulatory framework for
oxygen as a medical gas. The FDA guidance defines the custody, control
and management of filling liquid container to be in compliance when the
filling company owns the liquid containers. When the patient owns the
liquid containers after 36 months, the company would no longer be able
to fill the container without extensive testing prior to filling
because the containers would be considered by FDA to be out of the
filler's control. In addition, the filling company would no longer be
assured that the container was maintained in accordance with the
manufacturer's specification. The DOT requires that the filling company
have access to service and maintenance records in order to determine
which inspections and tests to perform and at what frequency. If this
information is not available to the filler, then the FDA mandates
additional testing which requires more sophisticated testing equipment
than the typical supplier of home medical oxygen has available.
Similarly, in accordance with DOT regulations, a cylinder filled with a
hazardous material may not be offered for transportation unless it was
filled by the owner of the cylinder or with the owner's consent. This
requires that the manufacturer of the medical oxygen, that is, the
company that fills the oxygen container under FDA regulations, to have
the equipment owner's permission prior to refilling the container.
After the patient owns the oxygen equipment, compliance with this
regulation will be very difficult for the supplier, especially if the
transfilling is done by a third-party. The new supplier has no
knowledge of how the compressed gas cylinders have been stored and
maintained and how or when federally-mandated hydrostatic testing has
been performed. The commenter predicted that it is likely that the new
supplier will decline to service the cylinders for fear of employee
injury and subsequent liability. Several commenters urged us to confer
with the FDA about the application of FDA regulations to patient owned
cylinders.
Response: We are aware that oxygen tanks and cylinders must be
handled in accordance with Federal statutes and regulations and expect
that suppliers' equipment will meet the requirements set forth in these
statutes and regulations before they transfer title to the equipment to
the beneficiaries. Once title transfers, the supplier will still be
required to deliver refilled oxygen contents in tanks and cylinders. We
are also aware that beneficiaries might not know about other Federal
laws that govern the disposal and resale of oxygen equipment. Although
CMS doesn't administer or enforce these laws, we believe it is
appropriate to take steps to ensure that beneficiaries are made aware
of them. Therefore, we are adding a provision to the final rule that
would require suppliers to educate beneficiaries at the time of title
transfer about safety issues associated with disposing of oxygen
equipment that is no longer medically necessary, and to advise
beneficiaries that they must comply with any applicable Federal, State,
and local laws that govern the disposal or resale of oxygen equipment.
In addition, as we stated above, we would encourage suppliers to advise
beneficiaries that they can pick-up and store the tanks once they are
no longer medically necessary, and Medicare would pay for this service
(discussed below). Further, suppliers could offer to buy the tanks back
from the beneficiary.
In the proposed rule, we proposed that the title to two sets of
cylinders or tanks would be transferred to the beneficiary after 36
months of continuous rental. That is, title would transfer for one set
of cylinders or tanks that the beneficiary would use at home, and title
would transfer for a second set that would be refilled at the
supplier's location. The number of tanks or cylinders is dependent on
how many tanks or cylinders a beneficiary uses and how many tank or
cylinder deliveries a supplier makes during a given month. After
considering the comments, we have concluded that it is unrealistic and
inappropriate to require suppliers to comply with a policy where
beneficiaries own specific tanks that must be refilled by suppliers for
specific beneficiaries. Therefore, we are changing this policy in this
final rule. Even though the beneficiary owns the equipment, the
supplier may switch out the tanks or cylinders with their tank and
cylinder supply, similar to how propane tanks are refilled in the
market today. Just as owners of propane tanks receive different tanks
each time they need replacement contents, we are clarifying in this
final rule that this propane tank model will be the practice under
Medicare with delivery and refilling of oxygen contents for
beneficiary-owned oxygen tanks and cylinders. Because this policy
modification will enable suppliers to continue swapping tanks and
cylinders for beneficiaries, as they currently do, we believe that
suppliers should also be able to handle recall situations as they
currently do. In the case of other beneficiary-owned oxygen equipment
such as concentrators, we expect suppliers to handle recalls in the
same way manner that they currently handle recalls of other
beneficiary-owned DME, such as power-driven wheelchairs. The decision
regarding whether such services would be considered reasonable and
necessary maintenance and servicing would be made by the Medicare
contractor. For example, if suppliers currently bill and are paid by
Medicare contractors for labor and parts when performing in-home
services needed in the event of an FDA recall after the beneficiary
takes title to a DME device such as a power wheelchair, then they
should continue this practice. If the supplier has never furnished DME
paid on a purchase basis by Medicare or capped rental items, they
should consult with the Medicare contractor to determine if these
services would be considered reasonable and necessary maintenance and
servicing.
Comment: One commenter stated that the OIG study on oxygen entitled
``Medicare Home Oxygen Equipment: Cost and Servicing,'' is flawed and
presents an inaccurate representation of Medicare ``equipment and
servicing.''
Response: The commenter provides no factual information to support
their claim that the findings of this study are flawed. Although none
of the policies of this final rule are based solely on the findings in
this report, we do believe that the information in the report is
credible and provides useful information regarding the maintenance and
servicing of and costs of oxygen concentrators as reported by
suppliers. Since we did not author the OIG study on oxygen, any
concerns or comments about the contents of this report should be
addressed to the Department of Health and Human Services, Office of the
Inspector General.
Comment: A commenter requested access to the Medicare Common
Working File (CWF), the system that houses beneficiary specific
information regarding Medicare eligibility and past claims history, in
order to obtain beneficiary specific information such as whether the
beneficiary has received the ``same or similar'' equipment from another
supplier in the past. The commenter stated that suppliers must also be
able to access historical usage data so that they may understand
whether they will be paid for the equipment and services they are being
asked to provide within 2 to 4 hours of the typical referral. Another
commenter suggested that if access to information in the CWF was not
possible, CMS must establish criteria for using ABNs to notify the
beneficiaries of their financial
[[Page 65916]]
responsibility if there is ``same or similar'' medical equipment.
Response: The request for access to the CWF is outside the scope of
this rulemaking process. We note that general criteria for use of the
ABN can be found in Chapter 30 of the Medicare Claims Processing
Manual, located at http://www.cms.hhs.gov/Manuals/IOM/list.asp.
Comment: Several commenters questioned whether Medicare would
require suppliers to transfer title to capped rental items and oxygen
equipment to beneficiaries who have not paid their coinsurance or
deductibles under Part B. One commenter recommended that we provide an
exception to the title transfer requirement if a beneficiary has failed
to pay his or her coinsurance for a significant period (such as more
than 6 months) across the course of the 36-month rental period. The
commenter also suggested that we could take responsibility, once the
title transfers, for attempting to collect the amount of missed
coinsurance payments from the beneficiary or pay the supplier's bad
debt for unpaid deductibles and coinsurance. Several commenters urged
that we clarify this provision in the final rule and recommended that
title to the equipment should not transfer to the patient until payment
is made in full for all services rendered through the 36th month.
(Medicare typically pays the 36th month's rate approximately 30 days
later).
Response: Section 5101 of the DRA is clear that the title to
equipment transfers from the supplier to the beneficiary on the first
day that begins after the 13th continuous month in which payment is
made for capped rental items and on the first day that begins after the
36th continuous month in which payment is made for oxygen equipment.
The statute mandates that ownership transfer after the 13th and 36th
continuous month for capped rental items and oxygen equipment, and does
not make transfer of ownership contingent on payment of beneficiary
coinsurance. We believe that suppliers have a sufficient period of time
to collect any outstanding beneficiary coinsurance during the rental
period before title is required to be transferred. In addition, our
rules would not preclude a supplier from seeking unpaid coinsurance or
deductible amounts from a beneficiary after title has transferred. CMS
or the carrier will have the discretion to review cases that allow
suppliers to stop furnishing an item to a beneficiary, if warranted.
Comment: Some commenters are concerned that the proposed rule does
not provide sufficient clarity and specificity for stakeholders and
Medicare beneficiaries alike to fully recognize the impact the final
rule will have on beneficiaries when it becomes effective. The
commenters predicted that the complexity of oxygen equipment, as well
as the fact that each different type of equipment carries with it
different safety and routine maintenance requirements, will be
overwhelming for the average Medicare beneficiary.
Response: We recognize that equipment maintenance may be
overwhelming for some beneficiaries and, as we explain in more detail
below, we are revising the final rule to allow for payment every six
months for general maintenance and servicing of certain beneficiary-
owned oxygen equipment. These payments would be made in addition to
payment for any reasonable and necessary replacement parts and repairs
that are non-routine and not covered by the manufacturer's warranty. We
intend to monitor the implementation of these provisions to ensure
beneficiary safety.
Back Up Equipment
Comment: Some suppliers furnish backup oxygen equipment for use by
beneficiaries in the event of power failures or malfunction of primary
oxygen equipment. Several commenters requested that the final rule
state that since Medicare has not made any rental payments for backup
oxygen equipment, title to this equipment should not transfer to the
beneficiary. The commenters believe that title to backup equipment does
not transfer under the coverage rules established under Medicare
contractor local coverage determinations (LCDs) for oxygen equipment.
Response: We agree with the commenters that the title for backup
oxygen equipment would not transfer to the beneficiary after 36 months
because Medicare does not make rental payments for this equipment. In
addition, the LCDs referred to by the commenters correctly reflect
Medicare's policy that equipment is not medically necessary if it is
identical or similar to equipment already in use by the beneficiary and
is used to meet the same set of medical needs. That is, backup
equipment is a second piece of equipment used for precautionary reasons
to deal with an emergency in case the primary piece of equipment
malfunctions rather than to meet a different set of medical needs.
Therefore, the beneficiary-ownership provision would not apply to
backup oxygen equipment.
Payment for Oxygen, Oxygen Equipment and Capped Rental DME
Comment: Several commenters requested that a new rental period
begin whenever a change in supplier takes place, regardless of the
reason. One commenter indicated that now that payments for oxygen
equipment will be limited to 36 months of continuous use, the
administrative burden on suppliers, such as ascertaining how many
Medicare rental payments have already been made for specific items used
by specific beneficiaries, will increase. The new suppliers will need
additional resources to complete a thorough screening of all new
patients to determine the amount of Medicare payments that may be made
for specific items.
Response: Longstanding policy found in Sec. 414.230(g) regarding a
change in suppliers during a period of continuous use of rented DME
indicates that a change in supplier will not result in a new rental
episode. In accordance with the amendments made by section 5101 of the
DRA to section 1834(a)(7)(A) of the Act, and section 1834(a)(5) of the
Act, payment may not extend over a period of continuous use of longer
than 13 or 36 months, respectively, for capped rental items and oxygen
equipment. For the reasons indicated below, we are applying the policy
in Sec. 414.230(g) to all beneficiary-owned capped rental items and
oxygen equipment.
Comment: One commenter requested that we acknowledge those
situations in which the title is not held by a supplier that rents
oxygen equipment or cylinders to beneficiaries. The commenter indicated
that it is common practice for a supplier to rent equipment from a
manufacturer and never hold title to the equipment, but stated that the
36-month rental cap for oxygen equipment fails to address this common
problem.
Response: We understand that in some instances, suppliers furnish
oxygen equipment to beneficiaries that they themselves have rented from
manufacturers or leasing companies. However, under section
1834(a)(5)(F)(ii)(I) of the Act (added by section 5101(b)(1)(B) of the
DRA), suppliers are required to transfer title of oxygen equipment to
beneficiaries on the first day that begins after the 36th month during
which payment is made for the equipment. In addition, under section
1834(a)(7)(A)(ii) of the Act (added by section 5101(a)(1) of the DRA),
suppliers are required to transfer title of capped rental equipment to
beneficiaries on the first day that begins
[[Page 65917]]
after the 13th month during which payment is made for the equipment.
Therefore, regardless of what arrangements a supplier might make with a
manufacturer or leasing company, the supplier must be in a position to
transfer title to the equipment in accordance with these statutory
provisions.
Payment for Maintenance and Servicing
Comment: One commenter requested that during the period of
continuous use, suppliers be permitted to continue the current practice
of replacing equipment in need of service or repair with equipment of
the same type that is in good working order. The commenter further
requested that the rule build in the added costs of administration and
delivery if the original piece of equipment must be delivered to the
patient.
Response: We recognize that under current practice, suppliers
sometimes choose to replace oxygen or capped rental equipment, rather
than repair it, during the rental period, and as we discuss below, we
have decided to allow this practice to continue. However, as discussed
in detail in the proposed rule, we continue to be concerned that
beneficiaries be protected from situations where equipment may be
replaced with equipment of lesser value prior to the transfer of title
to the equipment. Therefore, we would require that the replacement
equipment must be in the same or better condition as the equipment
being replaced. Delivery of the equipment is included in the monthly
rental payment amount.
Comment: Several commenters stated that the proposed rule does not
address the service components that are currently provided to
beneficiaries which may require trained and qualified personnel to
administer. These services include: Verifying oxygen purity, oxygen
dose verification, verification of alarm system functions, cleaning and
replacement of filters, disposable oxygen accessories, 24-hour, 7-day
per week on-call and emergency support, patient training, and clinical
professional support. The proposed rule also does not address that some
manufacturers require equipment maintenance, which requires disassembly
of the device, to be performed every 5,000 hours and this must be
performed at the supplier's facility. This additional equipment
maintenance requires suppliers to incur the additional costs of picking
up the equipment and providing loaner equipment. One commenter stated
that regular maintenance takes place in the patient's home, on average,
every 90 days. Another commenter provided a statistic from the June
2006 Morrison Informatics Inc. study, which demonstrated that non-
equipment costs comprise 72 percent of suppliers' total costs.
Commenters also noted that the new quality standards confirm that the
non-equipment professional and administrative services cost categories
reported in the Morrison study are legitimate costs that should be
recognized in the Medicare payment for home oxygen. Further, the rule
does not address reimbursement for licensed respiratory therapists who
conduct in-home clinical patient assessments according to written or
verbal physician orders for beneficiaries who own oxygen equipment. The
commenters urged CMS to allow patients to continue receiving these
assessments, but note that this activity will only be sustainable if
CMS establishes a new HCPCS code and appropriate reimbursement rate.
The commenter noted that suppliers cannot provide these assessments
without fair reimbursement rates because it could constitute an illegal
inducement and raise other fraud and abuse concerns. Commenters stated
that we need to establish regular and ongoing payment after ownership
transfers to support beneficiary access to necessary clinical, support,
and other services.
Response: Section 1834(a)(5)(F)(ii)(II) of the Act requires CMS to
pay separately for any reasonable and necessary maintenance and
servicing after the beneficiary assumes ownership of oxygen equipment,
and section 1834(a)(7)(A)(iv) of the Act requires the same in the case
of capped rental DME items. We proposed to use the standard in Sec.
414.210(e) of our regulations to define the ``maintenance and
servicing'' for which Medicare would make payment under section 5101 of
the DRA. We also proposed to apply our existing policy of not covering
certain routine or periodic servicing of purchased equipment, such as
testing, cleaning, regulating, changing filters, and general
inspection, that could be done by the beneficiary or caregiver, and
referred to chapter 15, section 110.2B of the Medicare Benefit Policy
Manual for further guidance on what types of routine maintenance would
not be covered. After considering comments that raise concerns
regarding a beneficiary's ability to properly maintain his or her
oxygen equipment, as well as safety issues that could arise if the
equipment is not properly maintained, we have decided to revise our
policy in the final rule under which, beginning 6 months after title to
oxygen equipment transfers to the beneficiary, the supplier may bill
for general maintenance and servicing of certain beneficiary-owned
oxygen equipment once every 6 months. We believe that allowing payment
every 6 months is reasonable based on findings by the Department of
Health and Human Services, Office of the Inspector General, in a
September 2006 report entitled ``Medicare Home Oxygen Equipment: Cost
and Servicing,'' that the current frequency of suppliers in checking
concentrators (every four months, on average) exceeds the guidelines of
the two major manufacturers that accounted for two-thirds of the
concentrators rented by beneficiaries sampled for purposes of the
report. In addition, according to guidelines from two major
concentrator manufacturers, comprehensive preventative maintenance need
only performed annually or after several thousand hours of use. Under
this policy, suppliers could bill for general maintenance and servicing
of all oxygen equipment except liquid or gaseous equipment (stationary
and portable) because these types of systems consist primarily of tanks
or cylinders, as well as replacement supplies and accessories (for
example, masks and tubing) which we proposed to pay for separately, and
we would expect that as a part of the tank and cylinder filling
process, suppliers would check to ensure that the tanks and cylinders
were functioning properly. However, we will make payment for the pick-
up and storage or disposal of tanks and cylinders that are no longer
medically needed by the beneficiary. We are also specifying that the
general maintenance and servicing payments for oxygen equipment other
than liquid and gaseous equipment would not begin until at least 6
months after the date that title to the equipment transfers because
suppliers should only be transferring title to equipment that is in
good working order and that has been routinely maintained. Payment for
general maintenance and servicing would be limited to 30 minutes of
labor, which we believe will adequately compensate suppliers based on
findings by the OIG in the same September 2006 report that many routine
maintenance activities performed by suppliers on concentrators could be
performed in less than 5 minutes. Finally, as we explained above, these
payments for general maintenance and servicing would be made in
addition to payment for reasonable and necessary repairs of
beneficiary-owned oxygen equipment. Suppliers would be able to bill for
such
[[Page 65918]]
non-routine maintenance, to the extent that the parts and labor are not
covered by the manufacturer's warranty, beginning immediately after the
beneficiary assumes ownership of the equipment, and as we proposed,
payment would be made for the parts in a lump sum amount based on the
carrier's consideration of the cost for the item because this is
consistent with how we currently pay for replacement parts for other
beneficiary-owned DME. We would also make an additional labor payment
if such non-routine maintenance is performed at the same time as
general maintenance, as long as the non-routine repair takes longer
than 30 minutes. In addition, we are finalizing our proposal to pay on
a purchase basis for all supplies and accessories (e.g., tubing, masks,
cannulas, etc.) necessary for the effective use of beneficiary-owned
oxygen equipment.
In addition, to further limit the possibility raised by commenters
that beneficiaries will incorrectly dispose of tanks and cylinders, we
are modifying our proposal to allow suppliers to submit a bill for
picking up beneficiary-owned oxygen tanks and cylinders that are no
longer medically necessary should a beneficiary request such a pick-up.
The supplier could submit this bill any time after the beneficiary has
acquired ownership to the tanks or cylinders. This pick-up allowance
would not apply to other types of oxygen equipment, such as
concentrators, because beneficiary storage of such equipment does not
raise safety concerns.
In-home clinical patient assessments by licensed respiratory
therapists fall outside the scope of the Medicare Part B benefit for
DME.
Comment: Several commenters requested that Medicare develop
standard protocols for routine maintenance of oxygen equipment and
reimburse suppliers for providing this service. Several commenters
requested that the non-routine maintenance include: inspection of
internal components for dust, debris, wear; internal filter changes;
oxygen purity testing that requires an oxygen analyzer device; coil
cleaning and any maintenance that requires breaking internal seals.
Several commenters requested that ``routine maintenance'' and ``non-
routine maintenance'' be clearly defined in the final rule,
specifically for oxygen and capped rental DME. Several commenters
proposed that routine maintenance be defined as follows: wiping down
outside surfaces of oxygen devices, changing the external cabinet
filter, changing oxygen tubing and cleaning and replacing oxygen
humidifier bottles.
Response: As we explained above, we are modifying our maintenance
and servicing proposal for oxygen equipment to allow for general
maintenance and servicing of oxygen equipment other than liquid or
gaseous oxygen equipment. Medicare will pay for up to 30 minutes of
labor spent performing general, routine maintenance during each of
these maintenance calls. Medicare will also pay separately for any
replacement parts that are necessary to properly service the equipment
during these calls, and for labor associated with any non-routine
maintenance required as part of the visit if it takes longer than the
30 minutes we are already paying for under the general maintenance and
servicing policy. However, to the extent that a supplier services
beneficiary-owned oxygen equipment more often than every six months, or
services beneficiary-owned capped rental items at any time, Medicare
will only make payments for non-routine maintenance and servicing. In
the proposed rule, we stated that examples of the types of maintenance
and servicing that would be covered as non-routine maintenance of
oxygen equipment and capped rental DME can be found in section 110.2.B
of Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02). This
policy has been in the manual for many years and we have never
experienced any major problems associated with interpretation of these
guidelines on what constitutes reasonable and necessary maintenance and
servicing. We also believe that the examples provided in the manual
represent good, general guidance that will enable beneficiaries and
suppliers to discern what types of maintenance and servicing would be
covered. We therefore do not believe that it is necessary to provide a
listing of every service that constitutes routine and non-routine
maintenance.
Comment: Several commenters recommended that we develop a
methodology to provide for emergency services for beneficiary-owned
equipment. Commenters also requested that this emergency mechanism,
including after-hours care, in-home assessments, patient education and
adherence monitoring, take into account the value of the therapists'
time, mileage reimbursement expense and related costs. One commenter
noted that patients rely on the 24-hour, 7-day-a-week on-call service
to answer major and minor questions related to their equipment. A large
percentage of these calls result in an in-home visit after hours and on
the weekend.
Response: Payment will be made for any reasonable and necessary
maintenance and servicing of beneficiary-owned DME, including emergency
situations. In addition, consistent with current Medicare policies,
payment for rental of loaner equipment would be made while repairs of
beneficiary-owned equipment are provided. In-home clinical patient
assessments by licensed respiratory therapists fall outside the scope
of the Medicare Part B benefit for DME.
Comment: One commenter predicts that a number of beneficiaries may
hire a third party to perform routine maintenance tasks that the
beneficiary would otherwise be responsible for performing once he or
she takes title to oxygen equipment to ensure that there is no chance
for error. As a result, these beneficiaries may likely pay more for
home oxygen therapy than they are paying under the current provisions.
Response: As we discussed above, we are allowing payment for
general maintenance and servicing of beneficiary-owned oxygen equipment
other than liquid or gaseous oxygen equipment. In addition, a liquid or
gaseous system consists of only tanks or cylinders, which we would
expect a supplier to maintain as part of the filling process, and
supplies, which we will pay for separately. As a result, we expect that
a beneficiary's maintenance costs will not be significantly higher
under this rule than it was under the previous rules.
Comment: One commenter recommended that we conduct a study in a
clearly-defined marketplace to ascertain the level of hospitalizations,
emergency room visits, physician office visits, or other Part A/B
expenses incurred by beneficiaries as a result of their being unable to
access a qualified supplier after they assume ownership of the medical
equipment under the new rules.
Response: We disagree that such a study is necessary. As described
in detail above, we have provided for appropriate payments for
maintenance, servicing, and repairs of beneficiary-owned equipment.
Therefore, we believe that beneficiaries will have sufficient access to
qualified suppliers after assuming ownership of equipment.
Comment: A few commenters noted that the proposed rule does not
provide any guidelines or timetable as to how often Medicare will pay
to replace the disposable supplies associated with home oxygen therapy,
such as cannulas, oxygen tubing, humidification bottles, adaptors, and
filters. These components
[[Page 65919]]
require frequent replacement and are currently included in the monthly
Medicare rental fee. As the proposed rule is currently drafted,
suppliers would be required to provide replacements of necessary
supplies for free and commenters believe that this will lead to a
reduction in the number of suppliers that furnish oxygen.
Response: Medicare has traditionally paid for supplies and
accessories that are necessary to use in conjunction with the
beneficiary-owned DME item. This policy can be found in section 110.3
of Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02). We
proposed to apply this policy to supplies and accessories used in
conjunction with beneficiary-owned oxygen equipment and capped rental
items and did not receive comments opposing this proposal. Therefore,
we are finalizing our proposal to pay separately for these supplies and
accessories as often as is reasonable and necessary.
Comment: Several commenters are concerned that serious health
problems could affect a Medicare beneficiary's ability to understand
and take responsibility for routine maintenance and servicing of his or
her oxygen equipment. Commenters noted that some beneficiaries are
physically and mentally unable to perform the necessary routine
maintenance on equipment, and it is simply unsafe to impose the
responsibility for maintaining this equipment on beneficiaries. Another
commenter noted that even the OIG's September 2006 Oxygen Report,
entitled ``Medicare Home Oxygen Equipment: Cost and Servicing'' (OEI-
09-04-00420), reinforced the point that a certain percentage of
patients will not be able to perform routine maintenance by stating
that ``50 percent of the service visits conducted through the surveyed
patients included what has been describes routine maintenance.'' Other
commenters noted that transferring the burden of maintenance and repair
of sophisticated oxygen technologies to the beneficiary and, therefore,
the total management of their home oxygen therapy regimen, presents
serious risk to patient safety and care. Commenters also indicated that
oxygen and oxygen equipment are more technically complex than other
types of DME and can cause serious injury if improperly maintained and
serviced.
Response: Although we believe that the one commenter misquoted the
OIG report and took their data out of context, we agree with the
commenters' general concerns regarding the ability of beneficiaries to
properly maintain their oxygen equipment once they acquire title to it
and are revising the rule to permit payments for general maintenance
and servicing of certain beneficiary-owned equipment as explained
above.
Comment: Several commenters suggested that we establish HCPCS codes
to adequately describe the parts and repair services that will be
covered and reimbursed for beneficiary-owned oxygen equipment. Another
commenter requested that we implement a national policy and fee
schedule for repair parts and labor that is eligible for either a
Consumer Price Index (CPI) or Medicare Economic Index (MEI) adjustment
annually. The fee schedule should reflect the fully-loaded costs of
providing repair, not just repair parts and labor. A standardized
approach will address those instances where a supplier goes out of
business and is unable to assist in maintaining equipment. Another
commenter indicated that services that are currently included as part
of the monthly bundled rate for oxygen and equipment would no longer be
provided after the 36th month unless a HCPCS code and allowable is
developed.
Response: We have generally given the carrier discretion to
determine rates for labor and parts with respect to the non-routine
repair of beneficiary-owned equipment based on reasonable charges and
believe that this methodology results in adequate reimbursement to
suppliers. However, should these commenters wish to make specific
requests or recommendations for addition of specific codes for
replacement parts, we would encourage them to participate in the HCPCS
editorial process, which is described online at: http://www.cms.hhs.gov/MedHCPCSGenInfo/
.
Comment: Several commenters request that we provide guidance on the
type of documentation that CMS expects suppliers to obtain to support
repair claims. They stated that DME MACs and CMS must have clear
policies outlining when Medicare will pay for repairs and the
documentation it will require to support those claims.
Response: In accordance with the rules at Sec. 414.210(e),
Medicare carriers have long had discretion to require any documentation
from suppliers that is necessary to enable them to make determinations
regarding whether maintenance and servicing of beneficiary-owned DME is
reasonable and necessary. The carriers provide guidance to suppliers
regarding the specific documentation that is needed for these purposes.
Comment: Several commenters requested that ``labor'' be redefined
to start when the technician leaves the facility and ends when he or
she returns to the shop. The labor time charge should not be just for
technician time in the home or shop. The commenters noted that the
current parts and labor fees do not take into consideration any travel
time or time to evaluate the equipment.
Response: Medicare payment for labor is based on 15-minute
increments for time when the technician is working on the equipment.
Separate payment is not allowed for delivery and service charges for
DME such as travel time to and from the beneficiary's home. Such
payment is included in the payment for the item or service. This policy
has been in place for many years and we have not encountered serious
problems with access to repair of beneficiary-owned DME. However, this
policy does allow for additional payment for extraordinary expenses in
rare or unusual circumstances as specified in current program
instructions. This policy can be found in section 60 of Chapter 20 of
the Medicare Claims Processing Manual (Pub. 100-04). This payment
determination for travel is at the discretion of the carrier.
Payment for Replacement of Equipment
Comment: Many commenters expressed concern about our equipment
replacement proposal. Numerous commenters believed that this provision
places an unreasonable economic burden on suppliers. Commenters
indicated that we should specify that, once ownership shifts to the
patient, it becomes the patient's responsibility to maintain and repair
the equipment. Some commenters believe that, given the 5-year useful
life of the equipment, the circumstances that would require equipment
to be replaced may be so far removed from the date that title
transferred that there would be no plausible connection between the
supplier's actions and a conclusion that the supplier delivered
substandard equipment. Commenters noted that the proposed rule does not
allow for the supplier to receive a new continuous rental period for
replacement equipment which is not yet patient-owned, so it is
inequitable to require a supplier to replace free of charge the
patient-owned equipment that prematurely fails because the patient did
not maintain it in accordance with the manufacturer's guidelines. This
situation should be remedied by providing for a new continuous rental
should the beneficiary's action during the ownership useful lifetime
period result
[[Page 65920]]
in the premature failure of the equipment. Commenters also complained
that routine maintenance often must be performed by the user and that
the supplier has no means to ensure when or if this was done or done
correctly. Several commenters indicated that manufacturer warranties
for oxygen equipment are void if the title is transferred. Therefore,
requiring that the supplier that furnished the oxygen equipment replace
at no cost items that, under Medicare rules, did not last for the
entire reasonable useful lifetime would subject suppliers to undue
financial burden.
Response: We expect that equipment furnished by the supplier will
function for the entire period established under Medicare regulations
and program instructions as the equipment's reasonable useful lifetime.
If this is not the case, then the supplier has not furnished a quality
item of durable medical equipment for which they have been paid. If
suppliers have information or data that proves that specific types of
DME do not routinely last for 5 years, they can furnish this
information to CMS for consideration in possibly establishing a new
reasonable useful lifetime for equipment.
Comment: A commenter stated that suppliers are financially unable
to furnish additional equipment in the event it needs to be replaced
after the title is transferred. Another commenter noted that once the
title is transferred, patients may find it difficult to locate an
oxygen supplier that is willing or able to provide them with a loaner
unit on short notice.
Response: We expect that oxygen equipment and capped rental items
furnished by the supplier will function for the entire period
established under Medicare regulations and program instructions as the
reasonable useful lifetime. As long as suppliers are furnishing items
that meet this standard, they should not generally need to replace
beneficiary-owned items and should not suffer the kind of financial
hardship envisioned by the commenter. In addition, we believe that the
modifications to our maintenance and servicing policy will limit the
possibility that oxygen equipment will not be properly maintained after
the beneficiary acquires title to it. Accordingly, we are finalizing
our proposal to require that suppliers replace malfunctioning oxygen
equipment that does not last for its reasonable useful lifetime,
however, as explained more fully below, we are modifying it to allow
carriers greater discretion in determining when a supplier must replace
the item at no charge to the beneficiary or the Medicare program. We
are also finalizing the same proposal with respect to capped rental
DME. The replacement item must be equipment of equal or greater value
to the equipment being replaced. We have never encountered major
problems associated with beneficiaries obtaining servicing of
equipment. Due to the current abundance of oxygen suppliers, we believe
that this will also be the case with regard to servicing of
beneficiary-owned oxygen equipment.
Comment: A commenter noted that our current definition of ``useful
life'' exceeds the warranty that manufacturers typically provide on
most of the current oxygen technologies, and expressed concern that
forcing a supplier to be financially responsible for a device beyond
the manufacturer's warranty period would impose a significant financial
burden on suppliers. The commenter stated that Medicare should modify
its definition of ``useful life'' and develop technology or equipment-
specific definitions. Another commenter noted that it is unclear in the
rule if we are basing ``lifetime'' on manufacturer warranty or some
other basis. The commenter stated that basing our definition of
``lifetime'' on the manufacturer warranty could be problematic since an
equipment's ``lifetime'' varies widely by manufacturer and type of
equipment.
Response: Under Sec. 414.220(f) of our regulations, the reasonable
useful lifetime of durable medical equipment is either the period
established through program instructions or, in the absence of program
instructions, the period determined by our carriers (at least five
years). These periods are not based on manufacturer warranties. If
suppliers have information or data that proves that specific types of
durable medical equipment do not routinely last for five years, they
can furnish this information to CMS for consideration in possibly
establishing a new reasonable useful lifetime for equipment. In
addition, consistent with how we currently measure the reasonable
useful lifetime for capped rental items, we would measure the
reasonable useful lifetime for oxygen equipment beginning on the date
that the equipment is furnished to the beneficiary.
Comment: Several commenters requested that we not adopt the
proposal that a supplier be required to replace equipment once
accumulated repair costs exceed 60 percent of the cost to replace the
equipment. Although the commenters acknowledged that the 60 percent
threshold was based on a similar replacement provision for artificial
limbs, the commenters do not believe that the proposal is appropriate
since unlike oxygen, artificial limbs do not require regular
maintenance or additional supplies that must be regularly replaced in
order to function properly. The commenters also noted that the proposed
rule does not define ``replacement cost'' and how such cost would be
calculated in determining the 60 percent threshold. According to the
commenters, the proposal is not clear regarding whether the
``replacement cost'' is the original cost to Medicare of the equipment
being replaced, the Medicare fee schedule amount, or the fair market
value of the item. Several commenters requested that we eliminate the
60 percent analysis and reimburse at the cost of each incident of
repair rather than the accumulation of repairs. Several commenters
noted that given the 5-year useful lifetime of the equipment, the
circumstances that would require equipment to be replaced may be so far
removed from the date that title transferred that there would be no
plausible connection between the supplier's actions and a conclusion
that the supplier delivered substandard equipment. Several commenters
requested that responsibility for the equipment shift to the patient
once the title transfers because the supplier will not have any record
of routine maintenance in years four and five, placing the supplier in
the position of having to replace equipment that may not have been
properly maintained. One commenter suggested that we could establish a
supplier responsibility period of 30 days following transfer of title
that would require replacement if the repair costs were 60 percent of
the replacement cost. Some commenters indicated that we appear to be
trying to balance appropriate coverage for needed non-warranty repairs
with beneficiary protection from receiving poor quality equipment via
the proposed rule that covers repairs until they accumulate to 60
percent of the replacement cost. Some commenters indicated that some
equipment, such as semi-electric hospital beds and power wheelchairs,
have component parts that can be quite expensive to repair/replace and
that these costs could easily exceed the 60 percent trigger but still
be in the equipment's useful lifetime. Repairs of such equipment are
often a function of active use, not poor quality of defective
equipment.
One commenter remarked that there are areas of the proposed rule
that present legal concerns because Medicare does not have statutory
authority to implement these requirements. The
[[Page 65921]]
commenter is unaware of any statutory requirement for the repair or
replacement of patient-owned equipment or for the use of a 60 percent
threshold. Moreover, CMS has not conducted any independent laboratory
studies or manufacturer surveys of DME or oxygen equipment to determine
if the 5-year ``average useful life'' is accurate or current before
making it subject to such a provision.
Response: We agree with the commenters that the proposed 60 percent
threshold may not be pertinent in all cases and have revised the final
rule to reflect a more general policy. Equipment furnished must
function for the entire period established under Medicare regulations
and program instructions as the reasonable useful lifetime. We are
modifying our proposal to permit our contractors to use the 60 percent
repair threshold at their discretion when making case-by-case
determinations on whether a supplier must replace equipment that does
not function during the reasonable useful lifetime. However, we
continue to believe that the 60 percent threshold is a useful factor
for our carriers to consider because it is probative of whether the
beneficiary has been furnished with, and the Medicare program has paid
for, a substandard item.
The replacement item must be equipment of equal or greater value to
the equipment being replaced. Under Sec. 414.210(f) of our
regulations, the reasonable useful lifetime for DME is five years,
unless we determine otherwise. For a capped rental DME item, Sec.
414.229(b) of our regulations specifies that the monthly fee schedule
amount for rental of the item equals ten percent of the purchase price
for the item; therefore, the replacement cost of the item is equal to
the rental fee schedule amount multiplied by ten. For oxygen equipment,
there is no established purchase price for Medicare purposes, so the
replacement cost of an item will be established by the carrier on an
individual, case-by-case basis using information such as invoices to
determine the replacement cost of the item. With respect to
beneficiary-owned oxygen equipment, ``repair'' costs will not include
the costs of labor associated with general maintenance and servicing of
the equipment.
Comment: One commenter requested that we provide information about
how equipment failures due to beneficiary neglect or abuse will be
determined. Another commenter questioned who is responsible for
providing the replacement equipment in the event that there is more
than one supplier involved, for example, if the beneficiary moves.
Response: We are finalizing a policy that would allow CMS or the
carrier to make determinations if replacement equipment is warranted.
We will be monitoring the number of replacement equipment provided to a
beneficiary. In the case that a beneficiary is abusing or neglecting
the equipment, CMS or the carrier may determine that the supplier is
not responsible for furnishing replacement equipment.
Comment: One commenter suggested that in lieu of prohibiting the
replacement of equipment during the period of continuous use, CMS can
require that the beneficiary receive title to equipment that is of
comparable quality to the equipment delivered at the beginning of the
period of continuous use.
Response: As we explained above, we have decided to modify our
proposal and allow suppliers to furnish different equipment during the
rental period as long as the equipment is of equal or greater value as
the equipment being replaced.
Comment: Several commenters questioned that under the proposed
regulations, a new period of continuous use would begin only when
beneficiary-owned equipment is lost, stolen or irreparably damaged. The
commenter requested that a new period of continuous use begin when a
supplier furnishes replacement equipment during the period of
continuous use. Otherwise, suppliers replacing lost equipment will be
forced to transfer title to two devices, but receive payment only for
one. Alternatively, commenters suggested allowing the carriers to make
the determination whether to initiate a new period of continuous use on
a case-by-case basis. Two commenters stated that while they agree with
the proposed provision that a new period of continuous use would begin
when beneficiary-owned equipment is lost, stolen, or irreparably
damaged, they questioned our decision to apply this exception only to
beneficiary-owned equipment. The commenters noted that when equipment
is lost, stolen, or irreparably damaged during the period of continuous
use and a supplier furnishes replacement equipment, a new period of
continuous use should begin; otherwise, the regulation would impose a
patently unfair result when rented equipment is lost or damaged through
no fault of the supplier. The commenters suggested if this is the case,
CMS should allow carriers to make the determination whether to initiate
a new period of continuous use on a case-by-case basis to ensure a more
balanced application of the requirement to transfer equipment ownership
to beneficiaries.
Response: Current rules regarding replacement of capped rental
items located at Sec. 414.229(g) allow for replacement of rented items
if the carrier determines that the item is lost or irreparably damaged.
In the proposed rule, we inadvertently deleted this text when we
proposed to revise Sec. 414.229(g), although we never intended to
change this longstanding policy, which reflects our belief that
suppliers should be compensated for furnishing a new rental item if the
item is needed as a result of circumstances beyond the supplier's
control. Therefore, as part of this final rule, we will reincorporate
this policy in our regulations but will move it to Sec. 414.210(f),
the general section on replacement of equipment, so that the policy
applies to all rented items. To be consistent with what we proposed in
the context of beneficiary-owned items, we will also specify that this
policy would also apply if an item is stolen.
However, we continue to believe that a new period of continuous use
should not automatically begin whenever the beneficiary changes
equipment (that is, from equipment falling under one HCPCS code to
different but similar equipment described by another HCPCS code). This
is consistent with longstanding policy relating to payment for DME.
This policy can be found in section 30.5.4 of Chapter 20 of the
Medicare Claims Processing Manual (Pub. 100-04). In no case can a new
rental period begin for a change in equipment from one product within a
HCPCS code to another product within the same HCPCS code or from one
oxygen modality within a payment class to another oxygen modality
within a payment class. Items falling within the same HCPCS code and
paid based on the same payment rules and fee schedule amounts are
considered the same item or service for Medicare purposes. Likewise,
oxygen modalities falling under the same payment class and paid based
on the same payment rules and fee schedule amounts are considered the
same item or service for Medicare purposes. Oxygen modality changes are
generally done for the convenience of the beneficiary, and not because
they are medically necessary. The Medicare NCD and contractor LCDs
establish medical necessity criteria for oxygen and oxygen equipment,
but do not establish separate medical necessity criteria for different
types or modalities of stationary or portable oxygen equipment. We also
note that beneficiaries who wish to exchange
[[Page 65922]]
equipment or oxygen modalities during the rental period for reasons
other than medical necessity can be required to sign an ABN.
Periods of Continuous Use
Comment: Several commenters requested that we clarify how a ``break
in service'' applies to short-term or intermittent usage of home oxygen
therapy. They stated that patients that fall within the Group II oxygen
coverage guidelines may not be sufficiently hypoxemic to require
ongoing oxygen therapy and their short-term use should not be included
in the 36-month continuous rental period. They also stated that other
``breaks in service'' that should not count towards the period include
skilled nursing facility stays or acute care admissions any longer than
a month. The commenters noted that current rules at Sec. 414.230(c)
state that an interruption in the use of the equipment of not longer
than 60 consecutive days plus the days remaining in the rental month in
which use ceases is temporary, regardless of the reason for the
interruption. Current Medicare program instructions indicate that a new
rental period begins in cases where the interruption is greater than 60
days plus the days remaining in the rental month in which use ceases if
it is supported by new medical necessity documentation. The commenters
believe that there is no basis for CMS to apply different break-in-
service rules to oxygen.
One commenter stated that beneficiary enrollment/disenrollment in
Medicare managed care plans further complicates our proposals on
switching equipment and consistent assignment during the rental period.
The commenter indicated that a single beneficiary may be in traditional
Medicare, enroll in one HMO, disenroll and go back on transitional
Medicare, then enroll in a different HMO all in one rental period. The
commenter questioned how these scenarios can possibly be addressed in a
reasonable manner under the proposed rule.
Response: The rules for defining a period of continuous use for
which we make payments for DME were first adopted in an October 9, 1991
interim final rule with comment (56 FR 50821). In that rule, we stated
that we believed certain language in the House Committee Report
accompanying section 4062(b)(1) of the Omnibus Reconciliation Act of
1987 (Pub. L. 100-203) (which authorized the implementation of the DME
fee schedules) indicated that Congress did not intend for a period of
continuous use to automatically terminate each time there was a break
in service. Therefore, we stated that an interruption in the rental
period of not longer than 60 days plus the days remaining in the rental
month in which the use ceases would be considered a temporary
suspension of the period of continuous use pending resumption of
medical need. This precedent, which we finalized in a December 3, 1992
final rule (57 FR 57109), has now become longstanding Medicare policy,
has worked well throughout the years and has addressed all of the
situations highlighted by the commenters (e.g., short term use of DME,
breaks-in-service, etc.). Therefore, we believe that these rules should
continue to apply. In accordance with Sec. 414.230(c) and current
program instructions found in section 30.5.4 of Chapter 20 of the
Medicare Claims Processing Manual (Pub. 100-04), if the interruption is
less than 60 consecutive days plus the days remaining in the rental
month in which use ceases, contractors will not begin a new rental
period. Also, when an interruption continues beyond the end of the
rental month in which the use ceases, contractors will not make payment
for additional rental until use of the item resumes. Contractors will
establish a new date of service when use resumes. Unpaid months of
interruption do not count toward the 15-month limit. These policies
will apply to beneficiary-owned oxygen equipment and capped rental DME.
In addition, because Medicare makes payment for a rental item on the
date of delivery of the item, and payment for each subsequent rental
month on the same day, or ``anniversary date'' for that month, if the
break in service is short, the supplier would still be paid for that
rental month.
Comment: Several commenters were concerned about the impact and
interaction of the proposed DRA policy and payment changes and the
competitive bidding provisions. One commenter noted that certain DRA
provisions and planned competitive bidding provisions overlap and
conflict. The commenters requested that we clarify the conflicts in
both final rules. The commenter stated that, for example, a rule
conflict exists when a contract supplier is forced to accept an oxygen
patient with only 6 months rental left in the 36-month rental period.
To address this conflict, the commenter suggested that we allow the 36-
month period to start over again whenever a patient switches suppliers
if less than 36 months of continuous use have transpired.
Response: We will address issues that pertain to the Medicare
DMEPOS Competitive Bidding Program in the final rule for that program.
Comment: Several commenters requested that we clarify which
supplier's equipment transfers to the beneficiary if the beneficiary
has two residences in different areas and uses a local supplier in each
area. They stated that ``snow birds'' may face hurdles in maintaining
access to equipment unless a new period of continuous use begins when
they change suppliers. The commenters suggested that extended travel
outside of the supplier's service area should not be counted toward the
period of continuous use to the extent the supplier is not paid for
furnishing the oxygen equipment during that period. Another commenter
noted that the proposed rule does not address how suppliers that
coordinate services for patients who travel after they have purchased
the equipment will be reimbursed. Another commenter indicated that the
proposed rule was unclear on the methodology for those who have two
homes during different times of the year. The supplier in the new area
will not have the full 36 months to collect reimbursement.
Response: We expect that travel arrangements for beneficiaries with
oxygen equipment would be handled by suppliers in the same manner that
such instances are currently arranged for beneficiaries with capped
rental items. Capped rental items have been paid under these
circumstances and addressed through program instructions since 1989.
The capped rental policies that apply when a beneficiary changes
suppliers are listed in section 30.5.4 of chapter 20 of the Medicare
Claims Processing Manual (Pub. 100-04) and indicate that if a
beneficiary changes suppliers during or after the rental period, this
does not result in new rental episode. The equipment furnished to the
beneficiary at the time that transfer of title is required by the
statute and this final rule is the equipment for which the beneficiary
would receive title to.
Beneficiary Safeguards
Comment: One commenter stated that we should add an additional
safeguard to protect beneficiaries if their initial supplier decides to
discontinue service once title of the oxygen equipment transfers to the
beneficiary. The commenter recommended that we add a new paragraph in
Sec. 414.226(g) requiring the supplier that furnishes the oxygen
equipment throughout the rental period to notify the beneficiary no
later than 3 months before the end of the rental period that the
supplier will no longer continue to provide services once the transfer
of title takes place. The commenter believes this will give the
[[Page 65923]]
beneficiary adequate notice and time to find another comparable
supplier and will not leave a gap in their service once ownership takes
place. The commenter noted that current DME Quality Standards establish
certain ``consumer services,'' but they do not address this issue.
Response: We agree with this comment but believe that 2 months is a
more reasonable period of time in terms of how much advance notice
should be given to beneficiaries in these situations. We have revised
Sec. 414.226(g) to require the supplier to notify the beneficiary no
later than 2 months before the end of the rental period if the supplier
will no longer continue to maintain and service the equipment, and/or
deliver oxygen contents, once the transfer of title takes place.
Likewise, in order to be consistent with our policies, we are revising
Sec. 414.229(g) to require the supplier of a capped rental item to
disclose no later than two months before title transfers whether it
will continue to maintain and service the item. Because we recognize
that there may be isolated cases where a supplier cannot satisfy this
requirement (such as if the supplier goes out of business), we (or our
carriers) will also allow for exceptions on a case-by-case basis.
Comment: One commenter stated that we should require suppliers to
re-train beneficiaries (and/or their caregivers) on the services they
will need to perform on oxygen equipment at the time the suppliers
transfer ownership and to verify in writing that the beneficiary/
caregiver has actually performed the tasks for which they will be
responsible to ensure that they are capable of doing so. The commenter
recommended that we add an additional safeguard in Sec. 414.226(g)
that would require the supplier at the time of transfer to re-train the
beneficiary and/or caregiver with respect to information regarding
preparation of formulas, features, routine use, troubleshooting,
cleaning, maintenance, safety conditions, and infection control. The
commenter stated that although these requirements are currently
contained in the DME Quality Standards, their supplier is only required
to verify that the beneficiary received the instructions and
information at the time of setup, not that he or she understood them or
could perform them. The commenter believes that re-training and
verification in writing by the supplier that the beneficiary and/or
caregiver can actually carry out the tasks could prevent serious
injuries and life-threatening situations in the future.
Response: We do not believe that it is necessary to revise Sec.
414.226(g) as recommended. The DRA requires CMS to pay separately for
any reasonable and necessary maintenance and servicing of capped rental
or oxygen equipment after title transfers to the beneficiary. We
proposed to continue our longstanding policy of paying for reasonable
and necessary repairs and non-routine maintenance and servicing that a
beneficiary cannot perform. In response to comments, we have also
decided to add an exception in the final rule under which, beginning 6
months after title to oxygen equipment transfers to the beneficiary,
the supplier may bill for general maintenance and servicing of certain
beneficiary-owned oxygen equipment once every 6 months. As for routine
maintenance that may be necessary beyond what Medicare will pay for, we
also note, as we did in the proposed rule, that by the time title
transfers for oxygen equipment and capped rental items, beneficiaries
and/or their caregivers should be very familiar with their equipment
and the routine maintenance that is required to maintain it. In
addition, we note that we would expect that at the time of title
transfer, suppliers would provide beneficiaries with operating manuals
describing their equipment and the servicing that must be done to
maintain it. Beneficiaries could also access many of these manuals on
manufacturer Web sites.
Comment: One commenter was concerned that if the beneficiary
safeguards are imposed at the same time as reduced reimbursement, the
viability of many oxygen suppliers will be threatened, thus affecting
patient access to oxygen equipment and contents.
Response: We appreciate the comment. However, we believe that the
provisions discussed in the proposed rule and in this final rule with
respect to oxygen equipment, oxygen contents, and capped rental DME
items are necessary to ensure that our beneficiaries receive the
appropriate equipment and service both during the rental period and
after they assume title to the item. In addition, the beneficiary
safeguards that we are implementing with this final rule reflect what
we believe to be fair business practices, are consistent with our
DMEPOS Quality Standards, and should not impose undue burdens on the
suppliers. We have clarified our proposals in a number of places after
considering all of the comments received in order to reduce the burden
on suppliers.
Comment: One commenter recommended that in conjunction with this
rule, we should impose safeguards (for instance, limits on the number
of times a beneficiary can switch suppliers) that prevent beneficiaries
from gaming the system.
Response: We do not agree that having no limits on the number of
times that a beneficiary can switch suppliers will encourage gaming
because under this rule, changing suppliers does not result in a new
period of continuous use. Although we cannot envision every conceivable
gaming scenario, we believe that we have fully considered the needs of
beneficiaries in adopting this rule and that the protections we are
implementing will strongly discourage gaming by unscrupulous suppliers.
Comment: One commenter agreed with our proposed beneficiary
safeguards since suppliers should be furnishing items in good working
order and are otherwise bound by regulations at Sec. 424.57(c)(15) to
accept returns from beneficiaries of substandard items.
Response: We appreciate the support of our proposed beneficiary
safeguards. We believe that these changes in concert with the
implementation of the DMEPOS quality standards will ensure that
beneficiaries receive quality equipment and appropriate services
throughout the rental period and after title transfer.
Comment: We received numerous comments regarding our continuity of
equipment proposal. Commenters stated that our attempt to ensure that
suppliers do not substitute substandard equipment to patients just
before the required transfer of title is too restrictive. Several
commenters recommended that suppliers be allowed to exchange and/or
change a beneficiary's equipment during the period of medical need,
provided this exchange/change is documented. However, commenters were
concerned that the proposed rule does not define a change in medical
condition or provide enough detail to understand how and when patients
will be entitled to switch oxygen modalities, or how it will be
documented so that suppliers will be paid appropriately and promptly.
Commenters also asked for additional clarity regarding our
interpretation of ``modality'' and asked for specific circumstances
when patients may be changed from one type of equipment to another.
Commenters recommended that we allow suppliers to judiciously exchange
or change a patient's equipment during the period of medical need
provided that this exchange or change is sufficiently documented and
that the supplier certifies that the new equipment is not a lesser-
quality device. Commenters also recommended that we instruct our DME
[[Page 65924]]
Program Safeguard Contractor (PSC) medical directors to incorporate
specific medical necessity coverage and documentation requirements in
the revised Oxygen and Oxygen Equipment LCD before the proposed January
1, 2007 implementation date of this regulation. Specifically, the
revised LCD should address: (a) Under what circumstances or diagnoses
it is medically necessary to change from one oxygen modality or
equipment type to another; (b) how suppliers will be reimbursed for
changing equipment; and (c) specific documentation requirements for
both the supplier and the physician to ensure that the contractors can
make appropriate coverage determination.
Commenters also raised concerns about the potential impact the
continuity of equipment proposals could have on beneficiary access to
new oxygen technology. They stated that there are fairly common
circumstances where a supplier must exchange equipment in order to best
serve the beneficiary. For example, if suppliers cannot exchange
equipment, they may have to perform a complex repair in the patient's
home. Suppliers should not be placed in a situation where they have to
choose between not being able to provide service to the beneficiary at
the time of need versus providing a higher level of equipment and
taking a financial loss over the remaining rental period if they are
unable to switch to the prescribed level of equipment. Commenters
recommended that the proposed rule be modified to clarify that it is
acceptable for a supplier to exchange equipment if (a) the exchange is
for same or similar equipment; or (b) the exchange is to equipment that
better matches a physician's order.
Commenters also stated that it is unreasonable to mandate a
supplier to continue to service a beneficiary if the beneficiary is
non-compliant with the supplier's instruction on the safe and
appropriate use of the medical equipment. They recommended that the
oxygen supplier be responsible for transferring title for the total
number of liquid oxygen vessels or oxygen cylinders that would be
present in the patient's home at one time.
Response: We appreciate the concerns presented by the commenters.
Medicare pays for two classes of equipment, stationary and portable.
For the stationary class, there are three modalities that Medicare pays
the same ``modality neutral'' payment rate for: concentrator, liquid
cylinders, and gaseous tanks. For the portable class, Medicare makes a
modality neutral payment for all types of portable equipment. As we
explained above, we are finalizing our proposal to add a new payment
class for oxygen-generating portable equipment and separate classes for
delivery of stationary and portable oxygen contents. As has always been
the case, a physician may order a specific oxygen equipment modality
based on the clinical needs of the patient; and the supplier is bound
by that order. In addition, there is currently no Medicare national
coverage determination (NCD) that establishes medical necessity
criteria for different oxygen modalities. The carrier would still
maintain the ability to determine that a change in equipment is
warranted for reasons other than those described above. Instructions
for the DME PSC contractors are not part of rulemaking, and will be
handled under local carrier coverage policies.
After considering all of the comments, we are finalizing a policy
that would allow for four general exceptions to the rule that a
supplier may not exchange equipment during the rental period. We
believe that these exceptions are flexible enough to allow
beneficiaries and suppliers to exchange equipment where appropriate,
but limited enough to protect beneficiaries from a situation where
their equipment could be replaced with less valuable equipment just
prior to the date when they acquire ownership of it. In all cases, the
replacement item must be equipment of equal or greater value to the
equipment being replaced.
(1) The supplier replaces an item with the same, or equivalent,
make and model of equipment because the item initially furnished was
lost, stolen, irreparably damaged, is being repaired, or no longer
functions.
(2) The physician orders different equipment for the beneficiary.
If the need for different equipment is based on medical necessity, then
the order must indicate why the equipment initially furnished is no
longer medically necessary, and the supplier must retain this order in
the beneficiary's medical record.
(3) The beneficiary chooses to obtain a newer technology item or
upgraded item and signs an ABN.
(4) CMS or its carriers determine that a change in equipment is
warranted.
Comment: We received numerous comments regarding our proposal to
require that a supplier that furnishes rented oxygen equipment or
capped rental items to the beneficiary must continue to furnish that
item throughout the whole rental period except in certain situations.
These comments focused on varying scenarios where patients move or
choose to switch suppliers due to dissatisfaction with their service.
Commenters were concerned that patients in these situations will
experience an access-to-care issue as few suppliers will accept such a
patient if he/she has only a few months left on the rental schedule but
would be expected to provide oxygen equipment, including the back-up
and other un-reimbursed equipment. This will create inequities as a
supplier might be required to provide a brand new piece of equipment to
a beneficiary for 10 months of the 36 months, as an example, and this
de facto diminished reimbursement could deter suppliers from offering
services to Medicare beneficiaries and diminish beneficiary access to
oxygen supplies. Commenters recommended that we specify that a new 36-
month period begins in conjunction with this provision.
Response: In an October 9, 1991 interim final rule with comment
period (56 FR 50821), we first adopted our policy that precludes a new
period of continuous use from beginning when a beneficiary changes
suppliers. In adopting that policy, we looked to the House Committee
Report that accompanied the enactment of the Omnibus Budget
Reconciliation Act of 1987 (Pub. L. 100-203), which authorized
implementation of the fee schedules for DME. The House report stated
that a change in suppliers during an otherwise uninterrupted period
should be considered continuous. Therefore, we adopted Sec.
414.230(g), which provides that if the beneficiary changes suppliers
during or after the equipment rental period, that change would not
result in a new rental period. Since we first adopted this policy, we
believe that suppliers have been able to adequately accommodate
beneficiaries who change suppliers, and we see no reason to change this
policy now.
After reviewing the comments on this issue, we have maintained our
proposal requiring a supplier who furnishes rented oxygen equipment/
capped rental for the first month for which payment is made to continue
to furnish that item throughout the 36/13-month period of continuous
use for as long as it is medically necessary, except in the following
cases:
The item becomes subject to a competitive acquisition
program;
A beneficiary relocates on either a temporary or permanent
basis to an area that is outside the normal service area of the initial
supplier;
The beneficiary chooses to obtain equipment from a
different supplier; or
Other cases in which CMS or the carrier determine that an
exception is warranted.
[[Page 65925]]
We continue to believe that these policies are necessary to ensure that
beneficiaries have adequate access to oxygen equipment and capped
rental items because they protect beneficiaries from a situation in
which an unscrupulous supplier could try to take back the equipment
just before the rental period expires in order to retain title to it.
We note, however, that our rules would not require a supplier to accept
a beneficiary as a customer simply because a beneficiary chooses to
change suppliers. In addition, we note that we are considering certain
policies that would address how contract suppliers are reimbursed if
they must begin furnishing items to beneficiaries midway through the
rental period under a competitive bidding program, and we expect to
fully address this issue in the final rule that implements the Medicare
DMEPOS Competitive Bidding Program.
Comment: One commenter noted that our literal interpretation of the
DRA would require suppliers to track equipment by serial number in
order to make sure the beneficiary receives title to the equipment that
the supplier furnished originally. The commenter stated that this will
be very difficult for suppliers to accomplish and suggested that during
the period of continuous use, suppliers be permitted to continue the
current practice of simply replacing equipment in need of service or
repair with equipment of the same type that is in good working order.
This practice will allow suppliers to streamline their operations and
serve beneficiaries more efficiently equipment that must be repaired or
serviced at the supplier's facility. The commenter further stated that
we can address this issue simply by requiring that the beneficiary
receive title to equipment that is of comparable quality to the
equipment delivered at the beginning of the period of continuous use.
Another commenter stated that we should not impede service delivery by
restricting replacement of equipment during the capped rental period.
The commenter indicated the equipment requirement would limit the
ability of the new patient to try new or different equipment/enhanced
technology.
Response: Suppliers have access to and frequently use current
inventory tracking technology that allows them to easily track specific
items they take from their inventory and furnish to a patient in their
home. This is a normal part of the supplier's business. As explained
above, suppliers of oxygen tanks and cylinders do not need to track
specific tanks and cylinders belonging to beneficiaries. In addition,
as explained above, this final rule allows the suppler to replace
equipment during the rental period in certain situations.
Comment: One commenter remarked that the proposed rule states that
the current supplier or beneficiary is responsible for finding a new
supplier if a beneficiary needs to relocate from one service area to
another service area during the rental period. The commenter indicated
that this should be limited to the beneficiary since it is the choice
of the beneficiary to relocate and not that of the supplier.
Response: While the proposal states that the supplier or
beneficiary would need to arrange for another supplier in the new area
to furnish the item, it does not mandate that the supplier, rather than
the beneficiary, must make these arrangements. In cases where the
supplier elects not to provide this service to the beneficiary, the
beneficiary or caregiver for the beneficiary would need to make these
arrangements. This proposal is consistent with current practice and is
being adopted as part of this final rule.
Assignment
Comment: We received numerous comments on the Medicare assignment
proposal. Some commenters requested clarification of our notice
requirements about Medicare assignment to ensure it is consistent with
the general rule that participating suppliers agree to accept
assignment on an annual basis and can modify their status as a
participating supplier as well. They also requested clarification that
suppliers disclose to beneficiaries their intent to accept assignment
on all claims for the duration of the rental period, and stated that
the supplier should be able to clarify under what circumstances
assignment would no longer be appropriate, such as if the beneficiary
is no longer eligible for coverage. Some commenters noted that we do
not have the authority to change Medicare assignment terms and should
not require suppliers to disclose their intentions regarding assignment
for the entire duration of the rental periods. Commenters indicated
that current Medicare supplier standards require a supplier to inform
patients of whether or not it will accept assignment for one month at a
time (per claim) and that it is unreasonable for us to expect a
supplier to commit to accepting assignment for the entire rental period
when policies, payment levels or other things could change by the end
of the first year. Some commenters requested that we not adopt our
proposal to post assignment statistics for each supplier on our
website, but that if we proceed with publication, we should coordinate
this effort with suppliers to ensure correct information is distributed
to the public. Some commenters observed that we do not indicate how
often we will make web postings and how we will verify the accuracy of
postings. This could result in an inaccurate picture of a supplier's
assignment history since suppliers could choose not to accept
assignment for a variety of reasons, which a basic percentage will not
demonstrate. If we intend to post assignment information, commenters
believe that we should give suppliers 30 days notice, as well as an
opportunity to review information prior to posting and to correct
erroneous information or identify the risks posed by erroneous
information. Commenters indicated that we cannot require suppliers to
enter into private contracts for the duration of the period of
continuous use. Finally, commenters stated that we must clarify in the
final regulation whether a supplier may accept assignment for a portion
of the rental period, since allowing this type of assignment
arrangement would still further the stated intent to create a
reasonable rule for suppliers and ensure that beneficiaries have the
information necessary to make informed choices.
Response: Under Medicare, DME suppliers can accept assignment on a
claim-by-claim basis. If a supplier accepts assignment, the supplier
agrees to request direct payment from Medicare for the item, to accept
80 percent of the Medicare allowed payment amount for the item from the
carrier, and to charge the beneficiary not more than the remaining 20
percent of the Medicare approved payment amount, plus any unmet
deductible. If a supplier elects not to accept assignment, Medicare
pays the beneficiary 80 percent of the Medicare allowed payment amount,
after subtracting any unmet deductible, and there is no limit under
Title XVIII of the Act on the amount the supplier can charge the
beneficiary for rental of the DME item. The beneficiary, in these
situations, is financially responsible for the difference between 80
percent of the Medicare allowed payment amount and the amount the
supplier charges for the rental of the DME item.
Suppliers can also sign a participation agreement where they agree
voluntarily, before a calendar year, to accept assignment for all
Medicare items and services furnished to a beneficiary for the
following calendar year. Current supplier participation agreements are
renewable annually.
In the proposed rule, we did not propose to change the current
voluntary
[[Page 65926]]
participation agreement. Nor did we propose to change acceptance of
assignment on a claim-by-claim basis for suppliers who do not sign
participation agreements. However, we did point out that the calendar
year participation agreements do not coincide with a beneficiary's full
period of medical need in cases where such need extends for more than a
calendar year or where such a period overlaps calendar years. While a
supplier may renew its participation agreement annually, a beneficiary
would not know, before choosing a supplier, the intentions of the
supplier regarding acceptance of assignment of all claims during the
13-month or 36-month rental period.
We proposed to require suppliers to give beneficiaries advance
notice of the possible extent of their financial liability during the
period of medical need in which monthly rental payments are made for
the equipment so that they can use this information to make an informed
choice of supplier. We proposed that before furnishing the oxygen
equipment or a capped rental item, the supplier must disclose to the
beneficiary its intentions regarding whether it will accept assignment
of all monthly rental claims for the equipment during the period of
medical need, up to and including the 36th month of continuous use for
oxygen equipment or the 13th rental month of continuous use for capped
rental DME in which rental payments could potentially be made. We
indicated that we believe it is reasonable for the supplier to disclose
to each beneficiary its intentions regarding acceptance of assignment
as this decision has a direct financial effect on the beneficiary.
While we proposed to require an up-front declaration on assignment
intentions, a supplier would not be bound by such declaration unless
the supplier chooses to do so. For example, a supplier who routinely
signs participation agreements and intends to accept assignment for all
months during a beneficiary's period of medical need may choose to let
such information be known to the beneficiary. Such supplier might want
to use such information as a marketing advantage. A supplier's
declaration could indicate that the supplier intends to accept
assignment for a portion of the period of medical need. A beneficiary
could use such information from such supplier and compare it with the
declaration from another supplier who intends to accept assignment for
the entire period of medical need and make a selection between such two
suppliers.
While we proposed that a supplier's intentions could be expressed
in the form of a written agreement between the supplier and a
beneficiary, we did not propose to require a binding written agreement.
A supplier could select the form of the declaration. If a supplier
chose to offer a written agreement, the nature of such agreement would
be between the supplier and the beneficiary. We believe that the
required declaration is consistent with and complements the voluntary
participation agreement because they represent different things; the
former is a beneficiary-specific declaration of intentions applicable
to the beneficiary's period of medical need but is not binding, while
the latter is a voluntary agreement that applies to claims for all
beneficiaries served for a calendar year and is binding.
Assignment applies with respect to covered-Medicare services. Thus,
a supplier's declaration of assignment acceptance would only apply to
covered-Medicare services.
In the proposed rule, we indicated that in order to promote
informed beneficiary choices, we plan to post information on a CMS and/
or CMS contractor Web site(s) indicating supplier specific information
on oxygen equipment and capped rental items such as (1) the percentage
of beneficiaries for whom each supplier accepted assignment during a
prior period of time (for example, a quarter), and/or (2) the
percentage of cases in which the supplier accepted assignment during
the beneficiary's entire rental period. We do not agree with the
commenters who asked that we not post information about assignment
statistics for each supplier. We believe that such information is
necessary to promote informed beneficiary choices of suppliers. It
would not be possible to promote more informed beneficiary choices
among suppliers if we did not publish such information. Publication of
such information is consistent with the Agency's goal of promoting
transparency. We expect that the supplier-specific assignment
information that we post would be derived from Medicare paid claims
data. We plan to give suppliers the opportunity to review information
prior to posting the first time we post information. After a period of
time, we believe that the assignment information for a supplier is
likely to be relatively stable. Thus, rather than delaying the posting
of information on an ongoing basis by providing an opportunity to
review information prior to each posting, we would post the information
and allow a supplier to contact us or the carrier if a supplier
believes that erroneous information was posted. We have not decided how
often we would post assignment statistics.
Comment: One commenter asked for clarification on whether or not
in-home clinical assessments will be part of patient care after they
have received home oxygen therapy for 36 months. The commenter strongly
encouraged us to allow patients to continue to receive these
assessments according to physician orders. The commenter noted that
this activity is sustainable only if we establish a new code and an
appropriate reimbursement rate.
Response: In-home clinical assessments are the responsibility of
the physician, not the supplier and are therefore outside the scope of
the DME benefit. It is the obligation of the physician to ensure that
beneficiaries continue to be evaluated, as medically necessary.
IV. Provisions of the Final Regulations
In this final rule, we generally adopt the provisions of the August
3, 2006 proposed rule. We have, however, changed the methodology we
will use to impute a wage index for rural areas. We will calculate a
rural wage index by averaging the wage indexes from all CBSAs that we
believe are contiguous to that rural area if that rural area lacks
rural hospital wage data. In addition, we are revising the fixed-dollar
loss ratio used in the calculation of the outlier payment to reflect
the most recent available data.
We are finalizing a policy regarding change of equipment during a
rental period to allow for changes under four general scenarios: (1)
The supplier replaces an item with the same, or equivalent, make and
model of equipment because the item initially furnished was lost,
stolen, irreparably damaged, is being repaired, or no longer functions;
(2) the physician orders different equipment for the beneficiary. If
the need for different equipment is based on medical necessity, then
the order must indicate why the equipment initially furnished is no
longer medically necessary and the supplier must retain this order in
the beneficiary medical record; (3) the beneficiary chooses to obtain a
newer technology item or upgraded item and signs an advanced
beneficiary notice (ABN); or (4) CMS or the carrier determines that a
change in equipment is warranted. The Medicare contractor can also
determine that a change in equipment is warranted for additional
reasons.
We reincorporated a policy that we inadvertently deleted from
section 414.229(g) of our current regulations in the proposed rule with
regard to replacement of equipment to allow for
[[Page 65927]]
replacement of rented capped rental items in cases where the item is
lost or irreparably damaged. We stated that we would be continuing that
policy, applying it to all rented items, and also applying it to cases
where an item has been stolen. We also stated that we would move that
policy from Sec. 414.229(g) to Sec. 414.210(f) since it would now
apply to all rented items.
We have revised the policy that requires suppliers to replace
beneficiary-owned equipment that they furnished that fails to function
for the full period established as the reasonable useful lifetime for
the equipment. The need for the replacement of the equipment will not
automatically be mandated merely because the repair costs are greater
than 60 percent of the cost to replace the item. Rather, the
determination regarding the need for replacement will be made by the
Medicare contractor on an individual case-by-case basis.
We added a provision to require suppliers to provide information to
beneficiaries at the time of title transfer for oxygen equipment on how
to safely dispose of oxygen equipment that is no longer medically
necessary and advise that beneficiaries must comply with all Federal,
State, and local laws that apply to the disposal, transport, and resale
of oxygen equipment.
We have revised the policy for maintenance and servicing of
beneficiary-owned oxygen equipment so that beginning 6 months after
title to oxygen equipment transfers to the beneficiary, the supplier
may bill for general maintenance and servicing of beneficiary-owned
oxygen equipment once every 6 months. Payment for each of these general
maintenance calls would be limited to 30 minutes of labor, plus the
reasonable cost for any replacement parts. Under this policy, suppliers
could bill for general maintenance and servicing of all oxygen
equipment except liquid or gaseous oxygen equipment (stationary and
portable). We are also specifying that these general maintenance and
servicing payments would not begin until at least 6 months after the
date that title to the equipment transfers. Finally, we will make these
payments for general maintenance and servicing in addition to payment
for any non-routine repairs needed for beneficiary-owned oxygen
equipment. Suppliers would be able to bill for such non-routine
maintenance beginning immediately after the beneficiary assumes
ownership of the equipment.
We have revised the provisions regarding transfer of title for
oxygen tanks to clarify that, although Medicare payments for oxygen
equipment are limited to 36 months and the statute requires transfer of
ownership after 36 months, the arrangement between the supplier and
beneficiary allows the supplier to replace the beneficiary-owned tanks
with new or different tanks of equal or greater value when the supplier
picks up empty tanks to be refilled with oxygen contents and delivers
refilled tanks back to the beneficiary. We have also revised the
provisions to allow for a servicing payment when suppliers pick up
tanks that are no longer medically necessary. We have also made several
clarifying changes to the regulation text.
We have also added a provision that would require a supplier to
disclose at least 2 months before the date that the beneficiary will
assume ownership of oxygen equipment or a capped rental item whether
the supplier can maintain and service the item after the title
transfers and, in the case of oxygen equipment, whether the supplier
can deliver oxygen contents. We or our carriers would have discretion
to make exceptions to this requirement on a case-by-case basis.
V. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 30-day notice in the Federal Register and solicit public
comment when a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
We are soliciting public comment on each of these issues for the
following sections of this document that contain information collection
requirements:
Section 414.2267 Oxygen and Oxygen Equipment
This section requires the supplier to disclose to the beneficiary,
prior to the furnishing of oxygen equipment, whether or not it will
accept assignment of all monthly rental claims for the duration of the
rental period.
The burden associated with this requirement is the time and effort
put forth by the supplier to educate the beneficiary and to disclose
information regarding its intent to accept assignment. While this
information collection is subject to the PRA, we believe this
requirement meets the requirements of 5 CFR 1320.3(b)(2), and as such,
the burden associated with this requirement is exempt from the PRA.
This section requires a supplier to retain the physician's order
submitted for a different type of equipment in the patient's medical
record and to disclose to the beneficiary its intentions regarding
whether it will accept assignment of all monthly rental claims for the
duration of the rental period.
The burden associated with this requirement is the time and effort
put forth by the supplier to retain and disclose the required
information. While this information collection is subject to the PRA,
we believe this requirement meets the requirements of 5 CFR
1320.3(b)(2), and as such, the burden associated with this requirement
is exempt from the PRA.
Section 414.229 Other Durable Medical Equipment--Capped Rental Items
This section requires a supplier to retain the physician's order
submitted for a different type of equipment in the patient's medical
record and to disclose to the beneficiary its intentions regarding
whether it will accept assignment of all monthly rental claims for the
duration of the rental period.
The burden associated with this requirement is the time and effort
put forth by the supplier to retain and disclose the required
information. While this information collection is subject to the PRA,
we believe this requirement meets the requirements of 5 CFR
1320.3(b)(2), and as such, the burden associated with this requirement
is exempt from the PRA.
If you comment on these information collection and recordkeeping
requirements, please mail copies directly to the following:
Centers for Medicare & Medicaid Services, Office of Strategic
Operations and Regulatory Affairs, Division of Regulations Development,
Attn: Melissa Musotto, [CMS-1304-F], Room C4-26-05, 7500 Security
Boulevard, Baltimore, MD 21244-1850; and
Office of Information and Regulatory Affairs, Office of Management and
Budget, Room 10235, New Executive Office Building, Washington, DC
[[Page 65928]]
20503, Attn: Carolyn Lovett, CMS Desk Officer, CMS-1304-F,
carolyn_lovett@omb.eop.gov. Fax (202) 395-6974.
VI. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this rule as required by Executive
Order 12866 (September 1993, Regulatory Planning and Review), the
Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354),
section 1102(b) of the Social Security Act, the Unfunded Mandates
Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.
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).
This final rule will be a major rule, as defined in Title 5, United
States Code, section 804(2), because we estimate the impact to the
Medicare program, and the annual effects to the overall economy, will
be more than $100 million. The update set forth in this final rule will
apply to Medicare payments under the HH PPS in CY 2007. Accordingly,
the following analysis describes the impact in CY 2007 only. We
estimate that there will be an additional $440 million in CY 2007
expenditures attributable to the CY 2007 estimated home health market
basket update of 3.3 percent. We estimate that the effect of the wage
index update will bring CY 2007 expenditures to $410 million.
The RFA requires agencies to analyze options for regulatory relief
of small businesses. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and small government
agencies. Most hospitals and most other providers and suppliers are
small entities, either by nonprofit status or by having revenues of $6
million to $29 million in any 1 year. For purposes of the RFA,
approximately 75 percent of HHAs are considered small businesses
according to the Small Business Administration's size standards with
total revenues of $11.5 million or less in any 1 year. Individuals and
States are not included in the definition of a small entity. As stated
above, this final rule will provide an update to all HHAs for CY 2007
as required by statute. This final rule will have a significant
positive effect upon small entities that are HHAs.
Based on our analysis of 2003 claims data, we also estimate that
approximately 90 percent of registered DME suppliers are considered
small businesses according to the Small Business Administration's size
standards. The size standard for NAICS code, 532291, Home Health
Equipment Rental is $6 million. (see http://www.sba.gov/size/sizetable2002.html
, read May 9, 2005.) This final rule will reduce
payments for oxygen equipment and capped rental items and, therefore,
will have a significant negative effect upon small entities that are
DME suppliers overall. However, as explained in detail below, we
believe that Medicare payments will still be adequate for the items
affected by this rule and that suppliers whose primary line of business
involves furnishing these items will remain profitable.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 100 beds. We have determined that
this final rule will not have a significant economic impact on the
operations of a substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L.
104-4) also requires that agencies assess anticipated costs and
benefits before issuing any rule that may result in expenditures in any
1 year by State, local, or tribal governments, in the aggregate, or by
the private sector, of $120 million. We believe this final rule will
not mandate expenditures in that amount.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. We have reviewed this rule under the threshold criteria
of Executive Order 13132, Federalism. We have determined that this
final rule will not have substantial direct effects on the rights,
roles, and responsibilities of States.
B. Anticipated Effects
1. Home Health PPS
This final rule will update the HH PPS rates contained in Pub. 100-
20, One Time Notification, Transmittal 211, published February 10,
2006. We updated the rates in the CY 2006 final rule (70 FR 68132,
November 9, 2005) through Transmittal 211 to take account of the DRA
changes, specifically the 0 percent update and the rural add-on. The
impact analysis of this final rule presents the projected effects of
the change from the CY 2006 transition wage index (50/50 blend of MSA-
based and CBSA-based designations) to the CY 2007 CBSA-based
designations in determining the wage index used to calculate the HH PPS
rates for CY 2007. We estimate the effects by estimating payments while
holding all other payment variables constant. We use the best data
available, but we do not attempt to predict behavioral responses to
these changes, and we do not make adjustments for future changes in
such variables as days or case-mix.
This analysis incorporates the latest estimates of growth in
service use and payments under the Medicare home health benefit, based
on the latest available Medicare claims from 2004. 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 made by
the Congress, or changes specifically related to HHAs. In addition,
changes to the Medicare program may continue to be made as a result of
the BBA, the BBRA, the Medicare, Medicaid, and SCHIP Benefits
Improvement and Protection Act of 2000, the MMA, the DRA, or new
statutory provisions. Although these changes may not be specific to the
HH PPS, the nature of the Medicare program is such that the changes may
interact, and the complexity of the interaction of these changes could
make it difficult to predict accurately the full scope of the impact
upon HHAs.
Our discussion for this final rule will focus on the impact of
changes in the wage index, most notably the adoption of the full CBSA
designations. The impacts of the updated wage data are shown in Table
13 below. The breakdown of the various impacts displayed in the table
follows.
The rows display the estimated effect of the changes on different
categories. The first row of figures represents the
[[Page 65929]]
estimated effects on all facilities. The next 2 rows show the effect on
urban and rural facilities. This is followed, in the next 4 rows, by
impacts on urban and rural facilities based on whether they are a
hospital-based or freestanding facility. The next 20 rows show the
effect on urban and rural facilities based on the census region in
which they are located.
The first column shows the breakdown of all HHAs by urban or rural
status, hospital-based or freestanding status, and census division.
The second column in the table shows the number of facilities in
the impact database. A facility is considered urban if it is located in
a CBSA and, conversely, rural if it is not located in a CBSA.
The third column of the table shows the effect of the annual update
to the wage index. This represents the effect of using the most recent
wage data available to determine the estimated home health market
basket update. The total impact of this change is -0.2 percent;
however, there are distributional effects of the change.
The fourth column of the table shows the effect of all the changes
on the CY 2007 payments. The estimated market basket update of 3.3
percentage points is constant for all providers and is included in this
column. Although the market basket increase for CY 2007 is 3.3 percent,
fluctuations in the wage index impact the projected payments as well.
The total impact of the wage index update is -0.2 percent. Therefore,
including effects of the wage index, we project that total aggregate
payments will increase by 3.1 percent, assuming that facilities do not
change their care delivery and billing practices in response.
As can be seen from this table, the combined effects of all of the
changes, including the updated wage index and the market basket
increase of 3.3 percent, will vary by specific types of providers and
by location. For example, HHAs in the rural Pacific show the largest
estimated increase in payment at 11.0 percent, while HHAs in the rural
Mountain census division show the smallest increase in payments at 0.5
percent. Rural HHAs do somewhat better than urban HHAs, seeing an
estimated increase in payments of 3.6 percent and 3.1 percent
respectively. Amongst the different type of facility categories,
freestanding rural HHAs do best, with an estimated increase in payments
of 3.8 percent. Hospital-based urban HHAs are next with an estimated
increase in payments of 3.4 percent, followed by hospital-based rural
and freestanding urban HHAs following with estimated increases of 3.2
percent and 3.0 percent respectively.
Table 13.--Projected Impact of CY 2007 Update to the HH PPS
----------------------------------------------------------------------------------------------------------------
Updated wage Total CY 2007
Number of data change
facilities (percent) (percent)
----------------------------------------------------------------------------------------------------------------
Total........................................................... 7,370 -0.2 3.1
Urban........................................................... 5,273 -0.2 3.1
Rural........................................................... 2,097 0.3 3.6
Hospital based urban............................................ 1,988 0.1 3.4
Freestanding urban.............................................. 3,285 -0.3 3.0
Hospital based rural............................................ 1,201 -0.1 3.2
Freestanding rural.............................................. 896 0.5 3.8
----------------------------------------------------------------------------------------------------------------
Urban by Region
----------------------------------------------------------------------------------------------------------------
New England..................................................... 254 -1.2 2.1
Middle Atlantic................................................. 423 -0.2 3.1
South Atlantic.................................................. 913 -0.4 2.8
East North Central.............................................. 886 0.4 3.7
East South Central.............................................. 222 -0.6 2.7
West North Central.............................................. 304 0.1 3.4
West South Central.............................................. 1,300 -0.8 2.5
Mountain........................................................ 281 1.6 4.9
Pacific......................................................... 649 0.4 3.7
Outlying........................................................ 41 -4.2 1.0
----------------------------------------------------------------------------------------------------------------
Rural by Region
----------------------------------------------------------------------------------------------------------------
New England..................................................... 43 -1.1 2.2
Middle Atlantic................................................. 82 0.1 3.4
South Atlantic.................................................. 239 -0.7 2.6
East North Central.............................................. 284 1.6 5.0
East South Central.............................................. 215 0.1 3.4
West North Central.............................................. 488 0.2 3.5
West South Central.............................................. 475 -0.4 2.8
Mountain........................................................ 173 -2.7 0.5
Pacific......................................................... 88 7.5 11.0
Outlying........................................................ 10 8.9 12.5
----------------------------------------------------------------------------------------------------------------
The impact of the wage index for CY 2007 is shown in Addendum C to
this document. Addendum C to this document shows a side-by-side
comparison, by State and county code, of the CY 2006 transition wage
index, which was a 50/50 blend of MSA-based and CBSA-based pre-floor,
pre-reclassified hospital wage indexes, and pre-floor, pre-reclassified
hospital wage index for the CY 2007 HH PPS update. In the last column
of Addendum C to this document, we show the percentage change in the
wage index from CY 2006 to the wage index for CY 2007. We estimate that
there will be an additional $410 million in CY 2007 expenditures
attributable to the CY 2007 estimated
[[Page 65930]]
market basket increase of 3.3 percent and the wage index update of -0.2
percent. Thus, the anticipated expenditures outlined in this final rule
will exceed the $100 million annual threshold for a major rule as
defined in 5 U.S.C. section 804(2).
This final rule will have a positive effect on providers of
Medicare home health services by increasing their Medicare payment
rates. We anticipate that very few HHAs will not submit the quality
data required by section 1895(b)(3)(B)(v)(II) of the Act necessary to
receive the full market basket percentage increase. Submission of OASIS
data is a Medicare condition of participation for HHAs. Therefore, we
expect that very few HHAs would be subject to the 2 percent reduction
in payments in CY 2007. As indicated in the rule, most HHAs that do not
report OASIS provide pediatric, non-Medicare, or personal care only.
However, CMS is aware of instances of non-compliance among a very small
portion of HHAs with regard to OASIS submission.
For the purposes of the CY 2007 impact analysis, we anticipate that
less than 1 percent of HHAs, involving less than 1 percent of total
Medicare HH payments, would fail to submit quality data and hence will
be subject to the 2 percent reduction. This is not enough to impact the
estimated $410 million in additional expenditures. Finally, we do not
believe there is a differential impact due to the aggregate nature of
the update. We do not anticipate specific effects on other providers.
2. Oxygen and Oxygen Equipment Provisions
As mandated by the DRA of 2005, this final rule limits to 36 months
the total number of continuous months for which Medicare will pay for
oxygen equipment, after which the title to the oxygen equipment will be
transferred from the supplier to the beneficiary. Since Medicare
currently pays for oxygen equipment on a monthly basis for as long as
it is medically necessary, this change will result in savings to
Medicare. In addition, the DRA mandates that Medicare continue to make
monthly payments for furnishing contents for beneficiary-owned oxygen
equipment, as well as payments for reasonable and necessary maintenance
and servicing of beneficiary-owned oxygen equipment.
Approximately one million beneficiaries now receive oxygen therapy.
Although monthly rental payments already have been reduced by 30
percent by section 4552 of the Balanced Budget Act of 1997 and
approximately 10 percent by section 302(c)(2) of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003, Medicare
allowed charges rose to $2.72 billion by 2005, a 68 percent increase
since 1998 that reflects the growing use. Before the amendments to
section 1834(a)(5) of the Act made by the DRA, Medicare continued to
make rental payments for as long as medical necessity continued, even
when the total payments greatly exceeded the cost of purchasing the
equipment and the supplier retained title to the equipment. We believe
the DRA amendments to the Act will result in a loss of revenue to
suppliers that will no longer receive payments for oxygen equipment
after the 36th month of continuous use.
Based on data for items furnished in calendar year 2005, oxygen
concentrators accounted for approximately 94 percent of Medicare
utilization for stationary oxygen systems, in terms of both allowed
charges and allowed services. Since oxygen concentrators can typically
be purchased for $1,000 or less, we believe that 36 months of payment
at approximately $200 per month will ensure the supplier is reimbursed
for its cost for furnishing the equipment. The $200 allowed payment
amount may be re-adjusted in the future to assure that payments are
adequate, but not excessive. This could be accomplished though the
competitive acquisition programs mandated by section 1847 of the Act or
in accordance with our authority for adjusting fee schedule amounts at
section 1842(b)(8) and (9) of the Act. Based on data gathered by the
OIG in the course of developing their September 2006 report (OEI-09-04-
00420), approximately 22 percent of Medicare beneficiaries rented
oxygen equipment for 36 months or longer and approximately 16 percent
of Medicare beneficiaries rented oxygen equipment for 48 months or
longer. In section IV, ``Provisions of the Final Regulation'' section
of this preamble, we are allowing beneficiaries to obtain replacement
oxygen equipment in cases where their equipment has been in continuous
use for the reasonable useful lifetime of the equipment. Unless CMS or
its carriers establish a specific reasonable useful lifetime for oxygen
equipment, the default lifetime for DME of 5 years will apply. The main
effect of this rule on suppliers is that they will not be able to
receive payment for the equipment beyond 36 months for approximately 22
percent of Medicare patients. They will also not be able to receive
payment for furnishing the same item to subsequent patients in these
cases since they lose title to the equipment. In the case of oxygen
concentrator systems and portable oxygen transfilling systems, delivery
of oxygen contents is not necessary, and therefore, payment will not be
made for the furnishing of contents for these types of beneficiary
owned equipment. Under the old payment rules, payment for oxygen
concentrators used for stationary equipment purposes would have
continued at approximately $200 per month for the entire period of
medical need. Section 5101(b) of the DRA mandates that payment for
oxygen equipment end and that title to the equipment transfer after 36
months of continuous use.
In the case of liquid and gaseous oxygen systems, suppliers will
continue to be paid for furnishing oxygen contents for beneficiary-
owned systems. The current statewide monthly payment amounts for oxygen
and oxygen equipment that would be paid during the 36-month period of
continuous use for beneficiaries who only use stationary equipment
range from $194.48 to $200.41, with the weighted average statewide fee
being $199.84. The current statewide monthly payment amount for
furnishing oxygen contents for beneficiary owned equipment range from
$137.54 to $198.12, with the weighted average statewide fee being
$154.90. The average decrease in Medicare fee schedule amounts that may
result from the DRA changes for liquid and gaseous systems after the
36-month period (that is, shift from monthly payments for equipment and
contents to monthly payments for contents only), is expected to be
$44.94 ($199.84-$154.90). Therefore, this is the level of monthly
reimbursement that would be lost after the 36-month period for
suppliers that furnish oxygen and oxygen equipment to beneficiaries in
these situations and who continue to furnish contents to these
beneficiaries. Based on current fee schedule amounts for all oxygen and
oxygen equipment, this equates to an average reduction in payment (from
$199.84 to $154.90) of approximately 22 percent.
At the current monthly statewide fee schedule rates, which range
from $194.48 to $200.41, suppliers of oxygen equipment are expected to
be paid from $7,001.28 to $7,214.76 over 36 months. By comparison, a
medical center operated by the Department of Veterans Affairs (VA) in
Tampa, Florida, is the largest VA center in terms of number of veterans
on oxygen therapy and services approximately 1,000 patients on oxygen
by contracting with a locally based manufacturer to purchase the oxygen
concentrators for $895 each. The medical center contracts with a local
[[Page 65931]]
supplier for $90 to deliver and set up the concentrator to the
patient's home. This local supplier also provides service and
maintenance of the equipment at any time throughout the year for $48
per service episode. If the equipment needs to be replaced, the local
supplier will furnish another concentrator for a $90 fee. The VA total
payments over 5 years for an oxygen concentrator used by a veteran in
this center plus payment for 10 episodes of maintenance and servicing,
assuming servicing every 6 months, will be $1,435, compared to total
Medicare allowed charges of $7,164, on average, for a Medicare
beneficiary. Based on this comparison, the Medicare payment amounts and
methodology appear to be more than adequate.
We do not anticipate that transfer of ownership for oxygen
equipment to the beneficiary after 36 months of continuous use will be
a significant financial burden to suppliers because the effect is
limited to a maximum of 36 percent of a supplier's Medicare business
and because suppliers of oxygen equipment primarily furnish lower cost
oxygen concentrators. We also do not anticipate a significant change in
the rate of assignment of claims for oxygen equipment based on our
belief that suppliers will be adequately reimbursed for furnishing the
oxygen equipment.
In accordance with the statute and this final rule, suppliers will
also receive payments for reasonable and necessary maintenance and
servicing of beneficiary-owned oxygen equipment, including a general
maintenance and servicing payment for certain oxygen equipment every 6
months, beginning 6 months after the date that the beneficiary assumes
ownership of the equipment.
Finally, the new oxygen and oxygen equipment classes and national
payment amounts that are established as part of this final rule, will
likely result in a shift in utilization between the various oxygen
equipment modalities, which could impact supplier revenues and sales
volume for certain oxygen equipment manufacturers. However, since the
payment amounts will be budget-neutral in accordance with section
1834(a)(9)(D)(ii) of the Act, there will not be a significant impact on
overall Medicare payments to suppliers.
3. Capped Rental DME
This final rule, which limits to 13 months the total number of
continuous months for which Medicare would pay for capped rental DME,
after which the ownership of the capped rental item would be
transferred from the supplier to the beneficiary, will result in
significant savings for the Medicare program. Savings will be realized
through: (1) The gradual elimination of rental payments for the 14th
and 15th months of continuous use; and (2) changing the semi-annual
payment for maintenance and servicing to payment only when reasonable
and necessary maintenance and servicing is needed. We anticipate that
suppliers may lose money due to the loss of 1 to 2 months rental in
cases where beneficiaries need the item for more than 13 months and
would not have otherwise selected the purchase option currently
described in Sec. 414.229(d). The average of the 2006 fee schedule
amounts for all capped rental items for months 14 and 15 is
approximately $152. We do not believe suppliers will suffer financially
as a result of this provision based on data which show that in 2004, 97
percent of suppliers accepted assignment for beneficiaries who chose
the purchase option (Sec. 414.229(d)) in the 10th month of a capped
rental period. This is an indication that suppliers were willing to
accept the Medicare payment as payment in full for the capped rental
item, even though they had been informed that the beneficiary will take
over ownership of the item after the 13th month of continuous use.
Therefore, we do not anticipate that transfer of ownership for capped
rental equipment to the beneficiary after 13 months of continuous use
will be a significant financial burden to suppliers.
For items for which the first rental payment falls on or after
January 1, 2006, Medicare will only pay for maintenance and servicing
as necessary. In a June 2002 report (OEI-03-00-00410), the Office of
Inspector General (OIG) indicated that only 9 percent of the capped
rental equipment with a June 2000 service date actually received any
servicing between June and December 2000. Out of the $7.3 million
Medicare paid for maintenance services from June 2000, OIG estimated
that $6.5 million was paid for equipment that received no actual
servicing. The OIG recommended to CMS in 2002 that we eliminate the
semi-annual maintenance payment currently allowed for capped rental
equipment and pay only for repairs when needed.
The combination of these two factors provides strong evidence that
the Medicare rules for paying for maintenance and servicing of capped
rental equipment furnished before January 1, 2006, were not cost-
effective.
Impact on Beneficiaries
The DRA provisions and this final rule will result in savings for
Medicare beneficiaries using oxygen equipment and capped rental items.
For capped rental items, Medicare payments will be made for 13
continuous months and for oxygen equipment, payments will be made for
36 continuous months. After the rental period for each category of
equipment expires, ownership of the equipment will transfer from the
suppliers to the beneficiaries. Beneficiaries will continue to be
financially responsible for a 20 percent coinsurance payment during the
13- or 36-month rental periods for capped rental items and oxygen
equipment, respectively. However, even though beneficiaries will still
be required to make a 20 percent coinsurance payment in connection with
each maintenance and servicing call, beneficiaries will no longer have
to make a monthly 20 percent coinsurance payment for oxygen equipment
after they own it, or a 20 percent coinsurance payment every 6 months
for maintenance and servicing of beneficiary-owned capped rental items,
even if maintenance and servicing is not needed. This will result in
significant savings to beneficiaries.
For example, before the DRA, Medicare and the beneficiary made
continuous payments for the rental of oxygen equipment that totaled
about $200 per month. Of this amount, the beneficiary paid coinsurance
of $40 which will equal $480 for a single year's rental, $1,440 over 36
months, and $2,400 over 5 years. After the DRA, beneficiaries will only
pay a coinsurance amount for up to 36 months for the rental of oxygen
equipment, after which time they will own the equipment. Thus, the DRA
oxygen provisions result in savings of approximately $480 if
beneficiaries use the equipment for 4 years, and $960 if they use the
equipment for 5 years. As a result of the provision of this final rule
that allows for a general maintenance and servicing call every 6
months, beneficiaries could pay approximately $6 in coinsurance
payments for assigned claims, and more for unassigned claims for
supplier labor associated with these services. However, the beneficiary
can elect not to have these services performed if they feel that their
equipment is not in need of servicing.
For capped rental items, beneficiaries will save coinsurance by not
being responsible for any equipment payment after the 13th rental month
or the automatic semi-annual maintenance and servicing payment that was
approximately equal to 10 percent of the
[[Page 65932]]
purchase price for the equipment. Before the DRA, Medicare and the
beneficiary would pay up to 15 months for capped rental items, and
Medicare and the beneficiary would also pay for maintenance and
servicing every 6 months. Thus, beneficiaries will save coinsurance
payments related to both the equipment itself and the maintenance and
servicing of that equipment.
This final rule will assure beneficiaries that unless certain
prescribed exceptions apply, suppliers that furnish the equipment for
the first month will continue to furnish the equipment for the entire
36-month period of continuous use for oxygen equipment or the 13-month
period of continuous use for capped rental.
Beneficiaries will also be assured that their oxygen and capped
rental equipment would not be impermissibly swapped by the supplier at
any time during the rental period. Under the final rule, we require
that a supplier may not provide different rented equipment to the
beneficiary at any time during the 36 rental months for oxygen
equipment or the 13 rental months for capped rental DME unless one of
the following three exceptions apply: (1) The supplier replaces an item
with the same, or equivalent, make and model of equipment because the
item initially furnished was lost, stolen, irreparably damaged, is
being repaired, or no longer functions; (2) The physician orders a
different equipment for the beneficiary. If the need for different
equipment is based on medical necessity, the order must indicate why
the equipment initially furnished is no longer appropriate or medically
necessary, and the supplier must retain this order in the beneficiary's
medical record; (3) The beneficiary chooses to obtain a newer
technology item or upgraded item and signs an ABN; or (4) CMS or the
carrier determines that a change in equipment is warranted.
We are requiring that suppliers inform beneficiaries whether they
intend to accept or not accept assignment on all monthly rental claims
during the 13-month rental period for capped rental items or the 36-
month rental period for oxygen equipment in an upfront manner.
This final rule will also assure beneficiaries that following the
transfer of title, the supplier must replace an item at no cost to the
beneficiary in cases where the carrier determines that the item
furnished by the supplier will not last for the entire reasonable
useful lifetime established for the equipment. In making this
determination, the carrier may consider whether the accumulated costs
of repair exceed 60 percent of the cost to replace the item.
C. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf
), in Table 14 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this final rule. This
table provides our best estimate of the increase in Medicare payments
under the HH PPS as a result of the changes presented in this final
rule based on the data for 7,370 HHAs in our database. All expenditures
are classified as transfers to Medicare providers (that is, HHAs).
Table 14.--Accounting Statement: Classification of Estimated
Expenditures, From CY 2006 to CY 2007
[In millions]
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $410
From Whom to Whom?........................ Federal Government to HHAs.
------------------------------------------------------------------------
In Table 15 below, we have prepared an accounting statement showing
the classification of the expenditures associated with the DME
provisions of this final rule. This table provides our best estimate of
the decrease in Medicare payments under the DME benefit as a result of
the changes presented in this final rule based on the 2004 allowed
charge data for oxygen and capped rental DME in our database. All
expenditures are classified as transfers to the Medicare program and
its beneficiaries.
Table 15.--Accounting Statement: Classification of Estimated
Expenditures
[In millions]
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Monetized Transfers in FY 2007............ $80
Monetized Transfers in FY 2008............ $130
Monetized Transfers in FY 2009............ $170
Monetized Transfers in FY 2010............ $220
Monetized Transfers in FY 2011............ $280
From Whom to Whom?........................ Suppliers to Federal
Government and
beneficiaries.
------------------------------------------------------------------------
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects
42 CFR Part 414
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements.
42 CFR Part 484
Health facilities, Health professions, Medicare, Reporting and
recordkeeping requirements.
0
For the reasons set forth in the preamble, the Centers for Medicare &
Medicaid Services amends 42 CFR chapter IV as set forth below:
PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
Subpart D--Payment for Durable Medical Equipment and Prosthetic and
Orthotic Devices
0
1. The authority citation for part 414 continues to read as follows:
Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social
Security Act (42 U.S.C. 1302, 1395(hh), and 1395rr(b)(1)).
0
2. Amend Sec. 414.210 as follows:
0
A. Revise paragraph (e).
0
B. Revise the introductory text to paragraph (f).
0
C. Revise paragraph (f)(2).
0
D. Add new paragraphs (f)(3) and (f)(4).
The revisions read as follows:
Sec. 414.210 General payment rules.
* * * * *
(e) Maintenance and servicing--(1) General rule. Except as provided
in paragraph (e)(2) of this section, the carrier pays the reasonable
and necessary charges for maintenance and servicing of beneficiary-
owned equipment. Reasonable and necessary charges are those made for
parts and labor not otherwise covered under a manufacturer's or
supplier's warranty. Payment is made for replacement parts in a lump
sum based on the carrier's consideration of the item. The carrier
establishes a reasonable fee for labor associated with repairing,
maintaining, and servicing the item. Payment is not made for
maintenance and servicing of a rented item other than the maintenance
and servicing fee for other durable medical equipment as described in
Sec. 414.229(e).
(2) Additional maintenance and servicing payment for certain
[[Continued on page 65933]]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
]
[[pp. 65933-65982]] Medicare Program; Home Health Prospective Payment System Rate
Update for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes
to Medicare Payment for Oxygen Equipment and Capped Rental Durable
Medical Equipment; Final Rule
[[Continued from page 65932]]
[[Page 65933]]
beneficiary-owned oxygen equipment. In addition to the maintenance and
servicing payments described in paragraph (e)(1) of this section, the
carrier makes a maintenance and servicing payment for oxygen equipment
other than liquid and gaseous equipment (stationary and portable) as
follows:
(i) For the first 6-month period following the date on which title
to the equipment transfers to the beneficiary in accordance with Sec.
414.226(f), no payments are to be made.
(ii) During each succeeding 6-month period, payment may be made for
30 minutes of labor for general maintenance and servicing of the
equipment.
(3) Additional payment for picking up oxygen tanks and cylinders.
The carrier pays the reasonable and necessary charges for a supplier to
pick up and store or dispose of beneficiary-owned oxygen tanks and
cylinders that are no longer medically necessary.
(4) Exception to Maintenance and Servicing Payments. For items
purchased on or after June 1, 1989, no payment is made under the
provisions of paragraph (e)(1) of this section for the maintenance and
servicing of:
(i) Items requiring frequent and substantial servicing, as defined
in Sec. 414.222(a);
(ii) Capped rental items, as defined in Sec. 414.229(a), that are
not beneficiary-owned in accordance with Sec. 414.229(d), Sec.
414.229(f)(2), or Sec. 414.229(h); and
(iii) Oxygen equipment, as described in Sec. 414.226, that is not
beneficiary-owned in accordance with Sec. 414.226(f).
(5) Supplier replacement of beneficiary-owned equipment based on
accumulated repair costs. A supplier that transfers title to oxygen
equipment or a capped rental item to a beneficiary in accordance with
Sec. 414.226(f) or Sec. 414.229(f)(2) is responsible for furnishing
replacement equipment at no cost to the beneficiary or to the Medicare
program if the carrier determines that the item furnished by the
supplier will not last for the entire reasonable useful lifetime
established for the equipment in accordance with Sec. 414.210(f)(1).
In making this determination, the carrier may consider whether the
accumulated costs of repair exceed 60 percent of the cost to replace
the item.
(f) Payment for replacement of equipment. If an item of DME or a
prosthetic or orthotic device paid for under this subpart has been in
continuous use by the patient for the equipment's reasonable useful
lifetime or if the carrier determines that the item is lost, stolen, or
irreparably damaged, the patient may elect to obtain a new piece of
equipment.
* * * * *
(2) If the beneficiary elects to obtain replacement oxygen
equipment, payment is made in accordance with Sec. 414.226(a).
(3) If the beneficiary elects to obtain a replacement capped rental
item, payment is made in accordance with Sec. 414.229(a)(2) or (a)(3).
(4) For all other beneficiary-owned items, if the beneficiary
elects to obtain replacement equipment, payment is made on a purchase
basis.
0
3. Amend Sec. 414.226 by--
0
A. Revising paragraph (a) and the heading of paragraph (b).
0
B. Revising paragraph (b)(3).
0
C. Adding paragraphs (b)(4) and (b)(5).
0
D. Redesignating paragraph (d) as paragraph (e).
0
E. Redesignating paragraph (c) as paragraph (d).
0
F. Revising newly redesignated paragraph (d).
0
G. Adding a new paragraph (c).
0
H. Revising newly redesignated paragraph (e)(1) introductory text.
0
I. Revising newly redesignated paragraph (e)(1)(i).
0
J. Revising newly redesignated paragraph (e)(2)(i).
0
K. Revising newly redesignated paragraph (e)(2)(ii).
0
L. Adding new paragraphs (f) and (g).
The revisions and additions read as follows:
Sec. 414.226 Oxygen and oxygen equipment.
(a) Payment rules--(1) Oxygen equipment. Payment for rental of
oxygen equipment is made based on a monthly fee schedule amount during
the period of medical need, but for no longer than a period of
continuous use of 36 months. A period of continuous use is determined
under the provisions in Sec. 414.230.
(2) Oxygen contents. Payment for purchase of oxygen contents is
made based on a monthly fee schedule amount until medical necessity
ends.
(b) Monthly fee schedule amount for items furnished prior to 2007.
* * * * *
(3) For 1991 through 2006, the fee schedule amounts for items
described in paragraphs (b)(1)(iii) and (iv) of this section are
determined using the methodology contained in Sec. 414.220(d), (e),
and (f).
(4) For 1991 through 2006, the fee schedule amounts for items
described in paragraphs (b)(1)(i) and (ii) of this section are
determined using the methodology contained in Sec. 414.220(d), (e),
and (f).
(5) For 2005 and 2006, the fee schedule amounts determined under
paragraph (b)(4) of this section are reduced using the methodology
described in section 1834(a)(21)(A) of the Act.
(c) Monthly fee schedule amount for items furnished for years after
2006. (1) For 2007, national limited monthly payment rates are
calculated and paid as the monthly fee schedule amounts for the
following classes of items:
(i) Stationary oxygen equipment (including stationary
concentrators) and oxygen contents (stationary and portable).
(ii) Portable equipment only (gaseous or liquid tanks).
(iii) Oxygen generating portable equipment only.
(iv) Stationary oxygen contents only.
(v) Portable oxygen contents only.
(2) The national limited monthly payment rate for items described
in paragraph (c)(1)(i) of this section is equal to the weighted average
fee schedule amount established under paragraph (b)(5) of this section
reduced by $1.44.
(3) The national limited monthly payment rate for items described
in paragraph (c)(1)(ii) of this section is equal to the weighted
average of the fee schedule amounts established under paragraph (b)(5)
of this section.
(4) The national limited monthly payment rate for items described
in paragraph (c)(1)(iii) of this section is equal to the national
limited monthly payment rate established under paragraph (c)(5) of this
section, multiplied by 24, and divided by 36.
(5) The national limited monthly payment rate for items described
in paragraphs (c)(1)(iv) and (c)(1)(v) of this section is equal to 50
percent of the weighted average fee schedule amounts established under
paragraph (b)(3) of this section for items described in paragraph
(b)(1)(iii) of this section.
(6) Beginning in 2008, CMS makes an annual adjustment to the
national limited monthly payment rates for each class of items
described in paragraph (c)(1) of this section to ensure that such
payment rates do not result in expenditures for any year that are more
or less than the expenditures that would have been made if such classes
had not been established.
(d) Application of monthly fee schedule amounts. (1) The fee
schedule amount for items described in paragraph (c)(1)(i) of this
section is paid when the beneficiary rents stationary oxygen equipment.
(2) Subject to the limitation set forth in paragraph (e)(2) of this
section, the fee schedule amount for items described
[[Page 65934]]
in paragraphs (c)(1)(ii) and (c)(1)(iii) of this section is paid when
the beneficiary rents portable oxygen equipment.
(3) The fee schedule amount for items described in paragraph
(c)(1)(iv) of this section is paid when the beneficiary owns stationary
oxygen equipment that requires delivery of gaseous or liquid oxygen
contents.
(4) The fee schedule amount for items described in paragraph
(c)(1)(v) of this section is paid when the beneficiary owns portable
oxygen equipment described in paragraph (c)(1)(ii) of this section, or
rents portable oxygen equipment described in paragraph (c)(1)(ii) of
this section and does not rent stationary oxygen equipment.
(e) Volume adjustments. (1) The fee schedule amount for an item
described in paragraph (c)(1)(i) of this section is adjusted as
follows:
(i) If the attending physician prescribes an oxygen flow rate
exceeding four liters per minute, the fee schedule amount is increased
by 50 percent, subject to the limit in paragraph (e)(2) of this
section.
* * * * *
(2) * * *
(i) The sum of the monthly fee schedule amount for the items
described in paragraphs (c)(1)(i) and (c)(1)(ii) or (c)(1)(iii) of this
section; or
(ii) The adjusted fee schedule amount described in paragraph
(e)(1)(i) of this section.
* * * * *
(f) Ownership of equipment. On the first day that begins after the
36th continuous month in which payment is made for oxygen equipment
under paragraph (a)(1) of this section, the supplier must transfer
title to the oxygen equipment to the beneficiary. At the time of title
transfer, the supplier must provide information to the beneficiary on
how to safely dispose of oxygen equipment that is no longer medically
necessary and advise that the beneficiary must comply with all Federal,
State, and local laws that apply to the disposal, transport, and resale
of oxygen equipment.
(g) Additional supplier requirements for rentals that begin on or
after January 1, 2007. (1) The supplier that furnishes oxygen equipment
for the first month during which payment is made under this section
must continue to furnish the equipment until medical necessity ends, or
the 36-month period of continuous use ends, whichever is earlier,
unless--
(i) The item becomes subject to a competitive acquisition program
implemented in accordance with section 1847(a) of the Act;
(ii) The beneficiary relocates to an area that is outside the
normal service area of the supplier that initially furnished the
equipment;
(iii) The beneficiary elects to obtain oxygen equipment from a
different supplier prior to the expiration of the 36-month rental
period; or
(iv) CMS or the carrier determines that an exception should apply
in an individual case based on the circumstances.
(2) Oxygen equipment furnished under this section may not be
replaced by the supplier prior to the expiration of the 36-month rental
period unless:
(i) The supplier replaces an item with the same, or equivalent,
make and model of equipment because the item initially furnished was
lost, stolen, irreparably damaged, is being repaired, or no longer
functions;
(ii) A physician orders different equipment for the beneficiary. If
the order is based on medical necessity, then the order must indicate
why the equipment initially furnished is no longer medically necessary
and the supplier must retain this order in the beneficiary's medical
record;
(iii) The beneficiary chooses to obtain a newer technology item or
upgraded item and signs an advanced beneficiary notice (ABN); or
(iv) CMS or the carrier determines that a change in equipment is
warranted.
(3) Before furnishing oxygen equipment, the supplier must disclose
to the beneficiary its intentions regarding whether it will accept
assignment of all monthly rental claims for the duration of the rental
period. A supplier's intentions could be expressed in the form of a
written agreement between the supplier and the beneficiary.
(4) No later than two months before the date on which the supplier
must transfer title to oxygen equipment to the beneficiary, the
supplier must disclose to the beneficiary--
(i) Whether it can maintain and service the equipment after the
beneficiary acquires title to it; and
(ii) Whether it can continue to deliver oxygen contents to the
beneficiary after the beneficiary acquires title to the equipment.
0
4. Amend Sec. 414.229 by--
0
A. Revising paragraphs (a), (f) and (g).
0
B. Adding paragraph (h).
The revisions and additions read as follows:
Sec. 414.229 Other durable medical equipment-capped rental items.
(a) General payment rule. Payment is made for other durable medical
equipment that is not subject to the payment provisions set forth in
Sec. 414.220 through Sec. 414.228 as follows:
(1) For items furnished prior to January 1, 2006, payment is made
on a rental or purchase option basis in accordance with the rules set
forth in paragraphs (b) through (e) of this section.
(2) For items other than power-driven wheelchairs furnished on or
after January 1, 2006, payment is made in accordance with the rules set
forth in paragraph (f) of this section.
(3) For power-driven wheelchairs furnished on or after January 1,
2006, payment is made in accordance with the rules set forth in
paragraphs (f) or (h) of this section.
* * * * *
(f) Rules for capped rental items furnished beginning on or after
January 1, 2006. (1) For items furnished on or after January 1, 2006,
payment is made based on a monthly rental fee schedule amount during
the period of medical need, but for no longer than a period of
continuous use of 13 months. A period of continuous use is determined
under the provisions in Sec. 414.230.
(2) The supplier must transfer title to the item to the beneficiary
on the first day that begins after the 13th continuous month in which
payments are made under paragraph (f)(1) of this section.
(3) Payment for maintenance and servicing of beneficiary-owned
equipment is made in accordance with Sec. 414.210(e).
(g) Additional supplier requirements for capped rental items that
are furnished beginning on or after January 1, 2007. (1) The supplier
that furnishes an item for the first month during which payment is made
using the methodology described in paragraph (f)(1) of this section
must continue to furnish the equipment until medical necessity ends, or
the 13-month period of continuous use ends, whichever is earlier,
unless--
(i) The item becomes subject to a competitive acquisition program
implemented in accordance with section 1847(a) of the Act;
(ii) The beneficiary relocates to an area that is outside the
normal service area of the supplier that initially furnished the
equipment;
(iii) The beneficiary elects to obtain the equipment from a
different supplier prior to the expiration of the 13-month rental
period; or
(iv) CMS or the carrier determines that an exception should apply
in an individual case based on the circumstances.
(2) A capped rental item furnished under this section may not be
replaced by the supplier prior to the expiration of the 13-month rental
period unless:
[[Page 65935]]
(i) The supplier replaces an item with the same, or equivalent,
make and model of equipment because the item initially furnished was
lost, stolen, irreparably damaged, is being repaired, or no longer
functions;
(ii) A physician orders different equipment for the beneficiary. If
the need for different equipment is based on medical necessity, then
the order must indicate why the equipment initially furnished is no
longer medically necessary and the supplier must retain this order in
the beneficiary's medical record;
(iii) The beneficiary chooses to obtain a newer technology item or
upgraded item and signs an advanced beneficiary notice (ABN); or
(iv) CMS or the carrier determines that a change in equipment is
warranted.
(3) Before furnishing a capped rental item, the supplier must
disclose to the beneficiary its intentions regarding whether it will
accept assignment of all monthly rental claims for the duration of the
rental period. A supplier's intentions could be expressed in the form
of a written agreement between the supplier and the beneficiary.
(4) No later than two months before the date on which the supplier
must transfer title to a capped rental item to the beneficiary, the
supplier must disclose to the beneficiary whether it can maintain and
service the item after the beneficiary acquires title to it. CMS or its
carriers may make exceptions to this requirement on a case-by-case
basis.
(h) Purchase of power-driven wheelchairs furnished on or after
January 1, 2006. Suppliers must offer beneficiaries the option to
purchase power-driven wheelchairs at the time the equipment is
initially furnished. Payment is made on a lump-sum purchase basis if
the beneficiary chooses this option.
0
5. Amend Sec. 414.230 by--
0
A. Revising paragraph (b).
0
B. Revising paragraph (f).
The revisions read as follows:
Sec. 414.230 Determining a period of continuous use.
* * * * *
(b) Continuous use. (1) A period of continuous use begins with the
first month of medical need and lasts until a beneficiary's medical
need for a particular item of durable medical equipment ends.
(2) In the case of a beneficiary receiving oxygen equipment on
December 31, 2005, the period of continuous use for the equipment
begins on January 1, 2006.
* * * * *
(f) New equipment. (1) If a beneficiary changes equipment or
requires additional equipment based on a physician's prescription, and
the new or additional equipment is found to be necessary, a new period
of continuous use begins for the new or additional equipment. A new
period of continuous use does not begin for base equipment that is
modified by an addition.
(2) A new period of continuous use does not begin when a
beneficiary changes from one stationary oxygen equipment modality to
another or from one portable oxygen equipment modality to another.
* * * * *
PART 484--HOME HEALTH SERVICES
0
6. The authority citation for part 484 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395(hh)) unless otherwise indicated.
0
7. Amend Sec. 484.225 as follows:
0
A. Revise paragraph (f).
0
B. Redesignate paragraph (g) as paragraph (h).
0
C. Add new paragraph (g).
0
D. Revise newly redesignated paragraph (h).
0
E. Add new paragraph (i).
The revisions and additions read as follows:
Sec. 484.225 Annual update of the unadjusted national prospective 60-
day episode payment rate.
* * * * *
(f) For calendar year 2005, the unadjusted national prospective 60-
day episode payment rate is equal to the rate from the previous
calendar year, increased by the applicable home health market basket
minus 0.8 percentage points.
(g) For calendar year 2006, the unadjusted national prospective 60-
day episode payment rate is equal to the rate from calendar year 2005.
(h) For 2007 and subsequent calendar years, in the case of a home
health agency that submits home health quality data, as specified by
the Secretary, the unadjusted national prospective 60-day episode rate
is equal to the rate for the previous calendar year increased by the
applicable home health market basket index amount.
(i) For 2007 and subsequent calendar years, in the case of a home
health agency that does not submit home health quality data, as
specified by the Secretary, the unadjusted national prospective 60-day
episode rate is equal to the rate for the previous calendar year
increased by the applicable home health market basket index amount
minus 2 percentage points. Any reduction of the percentage change will
apply only to the calendar year involved and will not be taken into
account in computing the prospective payment amount for a subsequent
calendar year.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: October 20, 2006.
Leslie V. Norwalk,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: October 31, 2006.
Michael O. Leavitt,
Secretary.
Note: The following addenda will not be published in the Code of
Federal Regulations.
[[Page 65936]]
Addendum A.--CY 2007 Wage Index for Rural Areas by CBSA; Applicable Pre-
Floor and Pre-Reclassified Hospital Wage Index
------------------------------------------------------------------------
Wage
CBSA code Nonurban area index
------------------------------------------------------------------------
01.......................... Alabama......................... 0.7591
02.......................... Alaska.......................... 1.0661
03.......................... Arizona......................... 0.8908
04.......................... Arkansas........................ 0.7307
05.......................... California...................... 1.1454
06.......................... Colorado........................ 0.9325
07.......................... Connecticut..................... 1.1709
08.......................... Delaware........................ 0.9705
10.......................... Florida......................... 0.8594
11.......................... Georgia......................... 0.7593
12.......................... Hawaii.......................... 1.0448
13.......................... Idaho........................... 0.8120
14.......................... Illinois........................ 0.8320
15.......................... Indiana......................... 0.8538
16.......................... Iowa............................ 0.8681
17.......................... Kansas.......................... 0.7998
18.......................... Kentucky........................ 0.7768
19.......................... Louisiana....................... 0.7438
20.......................... Maine........................... 0.8443
21.......................... Maryland........................ 0.8926
22.......................... Massachusetts \1\............... 1.1661
23.......................... Michigan........................ 0.9062
24.......................... Minnesota....................... 0.9153
25.......................... Mississippi..................... 0.7738
26.......................... Missouri........................ 0.7927
27.......................... Montana......................... 0.8590
28.......................... Nebraska........................ 0.8677
29.......................... Nevada.......................... 0.8944
30.......................... New Hampshire................... 1.0853
31.......................... New Jersey \2\.................. ........
32.......................... New Mexico...................... 0.8332
33.......................... New York........................ 0.8232
34.......................... North Carolina.................. 0.8588
35.......................... North Dakota.................... 0.7215
36.......................... Ohio............................ 0.8658
37.......................... Oklahoma........................ 0.7629
38.......................... Oregon.......................... 0.9753
39.......................... Pennsylvania.................... 0.8320
40.......................... Puerto Rico \3\................. 0.4047
41.......................... Rhode Island \2\................ ........
42.......................... South Carolina.................. 0.8566
43.......................... South Dakota.................... 0.8480
44.......................... Tennessee....................... 0.7827
45.......................... Texas........................... 0.7965
46.......................... Utah............................ 0.8140
47.......................... Vermont......................... 0.9744
48.......................... Virgin Islands.................. 0.8467
49.......................... Virginia........................ 0.7940
50.......................... Washington...................... 1.0263
51.......................... West Virginia................... 0.7607
52.......................... Wisconsin....................... 0.9553
53.......................... Wyoming......................... 0.9295
65.......................... Guam............................ 0.9611
------------------------------------------------------------------------
\1\ There are no short-term, acute care hospitals located in rural areas
in Massachusetts from which to calculate a wage index for CY07.
Therefore, the rural wage index for Massachusetts will be imputed
using the methodology discussed in Section III of this rule.
\2\ All counties within the State are classified as urban.
\3\ There are no short-term, acute care hospitals located in rural areas
in Puerto Rico from which to calculate a wage index for CY07.
Therefore, we will continue to use the wage index from CY05 which was
the last year in which we had ``rural'' hospital data.
Addendum B.--CY 2007 Wage Index for Urban Areas by CBSA; Applicable Pre-
Floor and Pre-Reclassified Hospital Wage Index
------------------------------------------------------------------------
Urban area (constituent Wage
CBSA code counties) index
------------------------------------------------------------------------
10180....................... Abilene, TX.................... 0.8000
Callahan County, TX
Jones County, TX
Taylor County, TX
10380....................... Aguadilla-Isabela-San 0.3915
Sebastian, PR.
Aguada Municipio, PR
Aguadilla Municipio, PR
Anasco Municipio, PR
Isabela Municipio, PR
Lares Municipio, PR
Moca Municipio, PR
Rincon Municipio, PR
San Sebastian Municipio, PR
10420....................... Akron, OH...................... 0.8654
Portage County, OH
Summit County, OH
10500....................... Albany, GA..................... 0.8991
Baker County, GA
Dougherty County, GA
Lee County, GA
Terrell County, GA
Worth County, GA
10580....................... Albany-Schenectady-Troy, NY.... 0.8720
Albany County, NY
Rensselaer County, NY
Saratoga County, NY
Schenectady County, NY
Schoharie County, NY
10740....................... Albuquerque, NM................ 0.9458
Bernalillo County, NM
Sandoval County, NM
Torrance County, NM
Valencia County, NM
10780....................... Alexandria, LA................. 0.8006
Grant Parish, LA
Rapides Parish, LA
10900....................... Allentown-Bethlehem-Easton, PA- 0.9947
NJ.
[[Page 65937]]
Warren County, NJ
Carbon County, PA
Lehigh County, PA
Northampton County, PA
11020....................... Altoona, PA.................... 0.8812
Blair County, PA
11100....................... Amarillo, TX................... 0.9169
Armstrong County, TX
Carson County, TX
Potter County, TX
Randall County, TX
11180....................... Ames, IA....................... 0.9760
Story County, IA
111260...................... Anchorage, AK.................. 1.2023
Anchorage Municipality, AK
Matanuska-Susitna Borough, AK
11300....................... Anderson, IN................... 0.8681
Madison County, IN
11340....................... Anderson, SC................... 0.9017
Anderson County, SC
11460....................... Ann Arbor, MI.................. 1.0826
Washtenaw County, MI
11500....................... Anniston-Oxford, AL............ 0.7770
Calhoun County, AL
11540....................... Appleton, WI................... 0.9455
Calumet County, WI
Outagamie County, WI
11700....................... Asheville, NC.................. 0.9216
Buncombe County, NC
Haywood County, NC
Henderson County, NC
Madison County, NC
2020........................ Athens-Clarke County, GA....... 0.9856
Clarke County, GA
Madison County, GA
Oconee County, GA
Oglethorpe County, GA
12060....................... Atlanta-Sandy Springs-Marietta, 0.9762
GA.
Barrow County, GA
Bartow County, GA
Butts County, GA
Carroll County, GA
Cherokee County, GA
Clayton County, GA
Cobb County, GA
Coweta County, GA
Dawson County, GA
DeKalb County, GA
Douglas County, GA
Fayette County, GA
Forsyth County, GA
Fulton County, GA
Gwinnett County, GA
Haralson County, GA
Heard County, GA
Henry County, GA
Jasper County, GA
Lamar County, GA
Meriwether County, GA
Newton County, GA
Paulding County, GA
Pickens County, GA
Pike County, GA
Rockdale County, GA
Spalding County, GA
Walton County, GA
12100....................... Atlantic City, NJ.............. 1.1831
Atlantic County, NJ
2220........................ Auburn-Opelika, AL............. 0.8096
Lee County, AL
[[Page 65938]]
12260....................... Augusta-Richmond County, GA-SC. 0.9667
Burke County, GA
Columbia County, GA
McDuffie County, GA
Richmond County, GA
Aiken County, SC
Edgefield County, SC
12420....................... Austin-Round Rock, TX.......... 0.9344
Bastrop County, TX
Caldwell County, TX
Hays County, TX
Travis County, TX
Williamson County, TX
12540....................... Bakersfield, CA................ 1.0725
Kern County, CA
12580....................... Baltimore-Towson, MD........... 1.0088
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..................... 0.9711
Penobscot County, ME
12700....................... Barnstable Town, MA............ 1.2539
Barnstable County, MA
12940....................... Baton Rouge, LA................ 0.8084
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............... 0.9762
Calhoun County, MI
13020....................... Bay City, MI................... 0.9251
Bay County, MI
13140....................... Beaumont-Port Arthur, TX....... 0.8595
Hardin County, TX
Jefferson County, TX
Orange County, TX
13380....................... Bellingham, WA................. 1.1104
Whatcom County, WA
13460....................... Bend, OR....................... 1.0743
Deschutes County, OR
13644....................... Bethesda-Frederick- 1.0903
Gaithersburg, MD.
Frederick County, MD
Montgomery County, MD
13740....................... Billings, MT................... 0.8712
Carbon County, MT
Yellowstone County, MT
13780....................... Binghamton, NY................. 0.8786
Broome County, NY
Tioga County, NY
13820....................... Birmingham-Hoover, AL.......... 0.8894
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................... 0.7240
Burleigh County, ND
Morton County, ND
13980....................... Blacksburg-Christiansburg- 0.8213
Radford, VA.
[[Page 65939]]
Giles County, VA
Montgomery County, VA
Pulaski County, VA
Radford City, VA
14020....................... Bloomington, IN................ 0.8533
Greene County, IN
Monroe County, IN
Owen County, IN
14060....................... Bloomington-Normal, IL......... 0.8944
McLean County, IL
14260....................... Boise City-Nampa, ID........... 0.9401
Ada County, ID
Boise County, ID
Canyon County, ID
Gem County, ID
Owyhee County, ID
14484....................... Boston-Quincy, MA.............. 1.1679
Norfolk County, MA
Plymouth County, MA
Suffolk County, MA
14500....................... Boulder, CO.................... 1.0350
Boulder County, CO
14540....................... Bowling Green, KY.............. 0.8148
Edmonson County, KY
Warren County, KY
14740....................... Bremerton-Silverdale, WA....... 1.0913
Kitsap County, WA
14860....................... Bridgeport-Stamford-Norwalk, CT 1.2659
Fairfield County, CT
15180....................... Brownsville-Harlingen, TX...... 0.9430
Cameron County, TX
15260....................... Brunswick, GA.................. 1.0164
Brantley County, GA
Glynn County, GA
McIntosh County, GA
15380....................... Buffalo-Niagara Falls, NY...... 0.9424
Erie County, NY
Niagara County, NY
15500....................... Burlington, NC................. 0.8674
Alamance County, NC
15540....................... Burlington-South Burlington, VT 0.9474
Chittenden County, VT
Franklin County, VT
Grand Isle County, VT
15764....................... Cambridge-Newton-Framingham, MA 1.0970
Middlesex County, MA
5804........................ Camden, NJ..................... 1.0392
Burlington County, NJ
Camden County, NJ
Gloucester County, NJ
15940....................... Canton-Massillon, OH........... 0.9031
Carroll County, OH
Stark County, OH
15980....................... Cape Coral-Fort Myers, FL...... 0.9342
Lee County, FL
16180....................... Carson City, NV................ 1.0025
Carson City, NV
16220....................... Casper, WY..................... 0.9145
Natrona County, WY
16300....................... Cedar Rapids, IA............... 0.8888
Benton County, IA
Jones County, IA
Linn County, IA
16580....................... Champaign-Urbana, IL........... 0.9644
Champaign County, IL
Ford County, IL
Piatt County, IL
16620....................... Charleston, WV................. 0.8542
Boone County, WV
Clay County, WV
[[Page 65940]]
Kanawha County, WV
Lincoln County, WV
Putnam County, WV
16700....................... Charleston-North Charleston, SC 0.9145
Berkeley County, SC
Charleston County, SC
Dorchester County, SC
16740....................... Charlotte-Gastonia-Concord, NC- 0.9554
SC.
Anson County, NC
Cabarrus County, NC
Gaston County, NC
Mecklenburg County, NC
Union County, NC
York County, SC
16820....................... Charlottesville, VA............ 1.0125
Albemarle County, VA
Fluvanna County, VA
Greene County, VA
Nelson County, VA
Charlottesville City, VA
16860....................... Chattanooga, TN-GA............. 0.8948
Catoosa County, GA
Dade County, GA
Walker County, GA
Hamilton County, TN
Marion County, TN
Sequatchie County, TN
16940....................... Cheyenne, WY................... 0.9060
Laramie County, WY
16974....................... Chicago-Naperville-Joliet, IL.. 1.0751
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...................... 1.1053
Butte County, CA
17140....................... Cincinnati-Middletown, OH-KY-IN 0.9601
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............. 0.8436
Christian County, KY
Trigg County, KY
Montgomery County, TN
Stewart County, TN
17420....................... Cleveland, TN.................. 0.8109
Bradley County, TN
Polk County, TN
17460....................... Cleveland-Elyria-Mentor, OH.... 0.9400
Cuyahoga County, OH
Geauga County, OH
Lake County, OH
Lorain County, OH
Medina County, OH
[[Page 65941]]
17660....................... Coeur d'Alene, ID.............. 0.9344
Kootenai County, ID
17780....................... College Station-Bryan, TX...... 0.9045
Brazos County, TX
Burleson County, TX
Robertson County, TX
17820....................... Colorado Springs, CO........... 0.9701
El Paso County, CO
Teller County, CO
17860....................... Columbia, MO................... 0.8542
Boone County, MO
Howard County, MO
17900....................... Columbia, SC................... 0.8933
Calhoun County, SC
Fairfield County, SC
Kershaw County, SC
Lexington County, SC
Richland County, SC
Saluda County, SC
17980....................... Columbus, GA-AL................ 0.8239
Russell County, AL
Chattahoochee County, GA
Harris County, GA
Marion County, GA
Muscogee County, GA
18020....................... Columbus, IN................... 0.9318
Bartholomew County, IN
18140....................... Columbus, OH................... 1.0107
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............. 0.8564
Aransas County, TX
Nueces County, TX
San Patricio County, TX
18700....................... Corvallis, OR.................. 1.1546
Benton County, OR
19060....................... Cumberland, MD-WV.............. 0.8446
Allegany County, MD
Mineral County, WV
19124....................... Dallas-PlanoIrving, TX......... 1.0075
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..................... 0.9093
Murray County, GA
Whitfield County, GA
19180....................... Danville, IL................... 0.9266
Vermilion County, IL
19260....................... Danville, VA................... 0.8451
Pittsylvania County, VA
Danville City, VA
19340....................... Davenport-Moline-Rock Island, 0.8846
IA-IL.
Henry County, IL
Mercer County, IL
Rock Island County, IL
Scott County, IA
19380....................... Dayton, OH..................... 0.9037
Greene County, OH
Miami County, OH
[[Page 65942]]
Montgomery County, OH
Preble County, OH
19460....................... Decatur, AL.................... 0.8159
Lawrence County, AL
Morgan County, AL
19500....................... Decatur, IL.................... 0.8172
Macon County, IL
19660....................... Deltona-Daytona Beach-Ormond 0.9263
Beach, FL.
Volusia County, FL
19740....................... Denver-Aurora, CO.............. 1.0930
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................. 0.9214
Dallas County, IA
Guthrie County, IA
Madison County, IA
Polk County, IA
Warren County, IA
19804....................... Detroit-Livonia-Dearborn, MI... 1.0281
Wayne County, MI
20020....................... Dothan, AL..................... 0.7381
Geneva County, AL
Henry County, AL
Houston County, AL
20100....................... Dover, DE...................... 0.9847
Kent County, DE
20220....................... Dubuque, IA.................... 0.9133
Dubuque County, IA
20260....................... Duluth, MN-WI.................. 1.0042
Carlton County, MN
St. Louis County, MN
Douglas County, WI
20500....................... Durham, NC..................... 0.9826
Chatham County, NC
Durham County, NC
Orange County, NC
Person County, NC
20740....................... Eau Claire, WI................. 0.9630
Chippewa County, WI
Eau Claire County, WI
20764....................... Edison, NJ..................... 1.1190
Middlesex County, NJ
Monmouth County, NJ
Ocean County, NJ
Somerset County, NJ
20940....................... El Centro, CA.................. 0.9076
Imperial County, CA
21060....................... Elizabethtown, KY.............. 0.8697
Hardin County, KY
Larue County, KY
21140....................... Elkhart-Goshen, IN............. 0.9426
Elkhart County, IN
21300....................... Elmira, NY..................... 0.8240
Chemung County, NY
21340....................... El Paso, TX.................... 0.9053
El Paso County, TX
21500....................... Erie, PA....................... 0.8827
Erie County, PA
21604....................... Essex County, MA............... 1.0418
Essex County, MA
21660....................... Eugene-Springfield, OR......... 1.0876
Lane County, OR
[[Page 65943]]
21780....................... Evansville, IN-KY.............. 0.9071
Gibson County, IN
Posey County, IN
Vanderburgh County, IN
Warrick County, IN
Henderson County, KY
Webster County, KY
21820....................... Fairbanks, AK.................. 1.1059
Fairbanks North Star Borough,
AK
21940....................... Fajardo, PR.................... 0.4036
Ceiba Municipio, PR
Fajardo Municipio, PR
Luquillo Municipio, PR
22020....................... Fargo, ND-MN................... 0.8250
Cass County, ND
Clay County, MN
22140....................... Farmington, NM................. 0.8589
San Juan County, NM
22180....................... Fayetteville, NC............... 0.8945
Cumberland County, NC
Hoke County, NC
22220....................... Fayetteville-Springdale-Rogers, 0.8865
AR-MO.
Benton County, AR
Madison County, AR
Washington County, AR
McDonald County, MO
22380....................... Flagstaff, AZ.................. 1.1601
Coconino County, AZ
22420....................... Flint, MI...................... 1.0969
Genesee County, MI
22500....................... Florence, SC................... 0.8388
Darlington County, SC
Florence County, SC
22520....................... Florence-Muscle Shoals, AL..... 0.7843
Colbert County, AL
Lauderdale County, AL
22540....................... Fond du Lac, WI................ 1.0063
Fond du Lac County, WI
22660....................... Fort Collins-Loveland, CO...... 0.9544
Larimer County, CO
22744....................... Fort Lauderdale-Pompano Beach- 1.0133
Deerfield Beach, FL.
Broward County, FL
22900....................... Fort Smith, AR-OK.............. 0.7731
Crawford County, AR
Franklin County, AR
Sebastian County, AR
Le Flore County, OK
Sequoyah County, OK
23020....................... Fort Walton Beach-Crestview- 0.8643
Destin, FL.
Okaloosa County, FL
23060....................... Fort Wayne, IN................. 0.9517
Allen County, IN
Wells County, IN
Whitley County, IN
23104....................... Fort Worth-Arlington, TX....... 0.9569
Johnson County, TX
Parker County, TX
Tarrant County, TX
Wise County, TX
23420....................... Fresno, CA..................... 1.0943
Fresno County, CA
23460....................... Gadsden, AL.................... 0.8066
Etowah County, AL
23540....................... Gainesville, FL................ 0.9277
Alachua County, FL
Gilchrist County, FL
23580....................... Gainesville, GA................ 0.8958
Hall County, GA
23844....................... Gary, IN....................... 0.9334
Jasper County, IN
[[Page 65944]]
Lake County, IN
Newton County, IN
Porter County, IN
24020....................... Glens Falls, NY................ 0.8324
Warren County, NY
Washington County, NY
24140....................... Goldsboro, NC.................. 0.9171
Wayne County, NC
24220....................... Grand Forks, ND-MN............. 0.7949
Polk County, MN
Grand Forks County, ND
24300....................... Grand Junction, CO............. 0.9668
Mesa County, CO
24340....................... Grand Rapids-Wyoming, MI....... 0.9455
Barry County, MI
Ionia County, MI
Kent County, MI
Newaygo County, MI
24500....................... Great Falls, MT................ 0.8598
Cascade County, MT
24540....................... Greeley, CO.................... 0.9602
Weld County, CO
24580....................... Green Bay, WI.................. 0.9787
Brown County, WI
Kewaunee County, WI
Oconto County, WI
24660....................... Greensboro-High Point, NC...... 0.8866
Guilford County, NC
Randolph County, NC
Rockingham County, NC
24780....................... Greenville, NC................. 0.9432
Greene County, NC
Pitt County, NC
24860....................... Greenville, SC................. 0.9804
Greenville County, SC
Laurens County, SC
Pickens County, SC
25020....................... Guayama, PR.................... 0.3235
Arroyo Municipio, PR
Guayama Municipio, PR
Patillas Municipio, PR
25060....................... Gulfport-Biloxi, MS............ 0.8915
Hancock County, MS
Harrison County, MS
Stone County, MS
25180....................... Hagerstown-Martinsburg, MD-WV.. 0.9038
Washington County, MD
Berkeley County, WV
Morgan County, WV
25260....................... Hanford-Corcoran, CA........... 1.0282
Kings County, CA
25420....................... Harrisburg-Carlisle, PA........ 0.9402
Cumberland County, PA
Dauphin County, PA
Perry County, PA
25500....................... Harrisonburg, VA............... 0.9073
Rockingham County, VA
Harrisonburg City, VA
25540....................... Hartford-West Hartford-East 1.0894
Hartford, CT.
Hartford County, CT
Litchfield County, CT
Middlesex County, CT
Tolland County, CT
25620....................... Hattiesburg, MS................ 0.7430
Forrest County, MS
Lamar County, MS
Perry County, MS
25860....................... Hickory-Lenoir-Morganton, NC... 0.9010
Alexander County, NC
Burke County, NC
[[Page 65945]]
Caldwell County, NC
Catawba County, NC
25980\1\.................... Hinesville-Fort Stewart, GA.... 0.9178
Liberty County, GA
Long County, GA
26100....................... Holland-Grand Haven, MI........ 0.9163
Ottawa County, MI
26180....................... Honolulu, HI................... 1.1096
Honolulu County, HI
26300....................... Hot Springs, AR................ 0.8782
Garland County, AR
26380....................... Houma-Bayou Cane-Thibodaux, LA. 0.8082
Lafourche Parish, LA
Terrebonne Parish, LA
26420....................... Houston-Baytown-Sugar Land, TX. 1.0008
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, WVKYOH..... 0.8997
Boyd County, KY
Greenup County, KY
Lawrence County, OH
Cabell County, WV
Wayne County, WV
26620....................... Huntsville, AL................. 0.9007
Limestone County, AL
Madison County, AL
26820....................... Idaho Falls, ID................ 0.9088
Bonneville County, ID
Jefferson County, ID
26900....................... Indianapolis, IN............... 0.9895
Boone County, IN
Brown County, IN
Hamilton County, IN
Hancock County, IN
Hendricks County, IN
Johnson County, IN
Marion County, IN
Morgan County, IN
Putnam County, IN
Shelby County, IN
26980....................... Iowa City, IA.................. 0.9714
Johnson County, IA
Washington County, IA
27060....................... Ithaca, NY..................... 0.9928
Tompkins County, NY
27100....................... Jackson, MI.................... 0.9560
Jackson County, MI
27140....................... Jackson, MS.................... 0.8271
Copiah County, MS
Hinds County, MS
Madison County, MS
Rankin County, MS
Simpson County, MS
27180....................... Jackson, TN.................... 0.8853
Chester County, TN
Madison County, TN
27260....................... Jacksonville, FL............... 0.9165
Baker County, FL
Clay County, FL
Duval County, FL
Nassau County, FL
St. Johns County, FL
[[Page 65946]]
27340....................... Jacksonville, NC............... 0.8231
Onslow County, NC
27500....................... Janesville, WI................. 0.9655
Rock County, WI
27620....................... Jefferson City, MO............. 0.8332
Callaway County, MO
Cole County, MO
Moniteau County, MO
Osage County, MO
>27740...................... Johnson City, TN............... 0.8043
Carter County, TN
Unicoi County, TN
Washington County, TN
27780....................... Johnstown, PA.................. 0.8620
Cambria County, PA
27860....................... Jonesboro, AR.................. 0.7662
Craighead County, AR
Poinsett County, AR
27900....................... Joplin, MO..................... 0.8605
Jasper County, MO
Newton County, MO
28020....................... Kalamazoo-Portage, MI.......... 1.0704
Kalamazoo County, MI
Van Buren County, MI
28100....................... Kankakee-Bradley, IL........... 1.0083
Kankakee County, IL
28140....................... Kansas City, MOKS.............. 0.9495
Franklin County, KS
Johnson County, KS
Leavenworth County, KS
Linn County, KS
Miami County, KS
Wyandotte County, KS
Bates County, MO
Caldwell County, MO
Cass County, MO
Clay County, MO
Clinton County, MO
Jackson County, MO
Lafayette County, MO
Platte County, MO
Ray County, MO
28420....................... Kennewick-Richland-Pasco, WA... 1.0343
Benton County, WA
Franklin County, WA
28660....................... Killeen-TempleFort Hood, TX.... 0.8901
Bell County, TX
Coryell County, TX
Lampasas County, TX
28700....................... Kingsport-Bristol-Bristol, TNVA 0.7985
Hawkins County, TN
Sullivan County, TN
Bristol City, VA
Scott County, VA
Washington County, VA
28740....................... Kingston, NY................... 0.9367
Ulster County, NY
28940....................... Knoxville, TN.................. 0.8249
Anderson County, TN
Blount County, TN
Knox County, TN
Loudon County, TN
Union County, TN
29020....................... Kokomo, IN..................... 0.9669
Howard County, IN
Tipton County, IN
29100....................... La Crosse, WIMN................ 0.9426
Houston County, MN
La Crosse County, WI
29140....................... Lafayette, IN.................. 0.8931
[[Page 65947]]
Benton County, IN
Carroll County, IN
Tippecanoe County, IN
29180....................... Lafayette, LA.................. 0.8289
Lafayette Parish, LA
St. Martin Parish, LA
29340....................... Lake Charles, LA............... 0.7914
Calcasieu Parish, LA
Cameron Parish, LA
29404....................... Lake County-Kenosha County, IL- 1.0570
WI.
Lake County, IL
Kenosha County, WI
29460....................... Lakeland, FL................... 0.8879
Polk County, FL
29540....................... Lancaster, PA.................. 0.9589
Lancaster County, PA
29620....................... Lansing-East Lansing, MI....... 1.0088
Clinton County, MI
Eaton County, MI
Ingham County, MI
29700....................... Laredo, TX..................... 0.7811
Webb County, TX
29740....................... Las Cruces, NM................. 0.9273
Dona Ana County, NM
29820....................... Las Vegas-Paradise, NV......... 1.1430
Clark County, NV
29940....................... Lawrence, KS................... 0.8365
Douglas County, KS
30020....................... Lawton, OK..................... 0.8065
Comanche County, OK
30140....................... Lebanon, PA.................... 0.8679
Lebanon County, PA
30300....................... Lewiston, ID-WA................ 0.9853
Nez Perce County, ID
Asotin County, WA
30340....................... LewistonAuburn, ME............. 0.9126
Androscoggin County, ME
30460....................... Lexington-Fayette, KY.......... 0.9181
Bourbon County, KY
Clark County, KY
Fayette County, KY
Jessamine County, KY
Scott County, KY
Woodford County, KY
30620....................... Lima, OH....................... 0.9042
Allen County, OH
30700....................... Lincoln, NE.................... 1.0092
Lancaster County, NE
Seward County, NE
30780....................... Little Rock-North Little Rock, 0.8890
AR.
Faulkner County, AR
Grant County, AR
Lonoke County, AR
Perry County, AR
Pulaski County, AR
Saline County, AR
30860....................... Logan, UT-ID................... 0.9022
Franklin County, ID
Cache County, UT
30980....................... Longview, TX................... 0.8788
Gregg County, TX
Rusk County, TX
Upshur County, TX
31020....................... Longview, WA................... 1.0011
Cowlitz County, WA
31084....................... Los Angeles-Long Beach- 1.1760
Glendale, CA.
Los Angeles County, CA
31140....................... Louisville, KY-IN.............. 0.9118
Clark County, IN
Floyd County, IN
[[Page 65948]]
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.................... 0.8613
Crosby County, TX
Lubbock County, TX
31340....................... Lynchburg, VA.................. 0.8694
Amherst County, VA
Appomattox County, VA
Bedford County, VA
Campbell County, VA
Bedford City, VA
Lynchburg City, VA
31420....................... Macon, GA...................... 0.9519
Bibb County, GA
Crawford County, GA
Jones County, GA
Monroe County, GA
Twiggs County, GA
31460....................... Madera, CA..................... 0.8154
Madera County, CA
31540....................... Madison, WI.................... 1.0840
Columbia County, WI
Dane County, WI
Iowa County, WI
31700....................... Manchester-Nashua, NH.......... 1.0243
Hillsborough County, NH
Merrimack County, NH
31900....................... Mansfield, OH.................. 0.9271
Richland County, OH
32420....................... Mayaguez, PR................... 0.3848
Hormigueros Municipio, PR
Mayaguez Municipio, PR
32580....................... McAllen-Edinburg-Pharr, TX..... 0.8773
Hidalgo County, TX
32780....................... Medford, OR.................... 1.0818
Jackson County, OR
32820....................... Memphis, TN-MS-AR.............. 0.9373
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..................... 1.1471
Merced County, CA
33124....................... Miami-Miami Beach-Kendall, FL.. 0.9812
Miami-Dade County, FL
33140....................... Michigan City-La Porte, IN..... 0.9118
LaPorte County, IN
33260....................... Midland, TX.................... 0.9786
Midland County, TX
33340....................... Milwaukee-Waukesha-West Allis, 1.0218
WI.
Milwaukee County, WI
Ozaukee County, WI
Washington County, WI
Waukesha County, WI
33460....................... Minneapolis-St. Paul- 1.0946
Bloomington, MN-WI.
Anoka County, MN
Carver County, MN
[[Page 65949]]
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................... 0.8928
Missoula County, MT
33660....................... Mobile, AL..................... 0.7913
Mobile County, AL
33700....................... Modesto, CA.................... 1.1729
Stanislaus County, CA
33740....................... Monroe, LA..................... 0.7997
Ouachita Parish, LA
Union Parish, LA
33780....................... Monroe, MI..................... 0.9707
Monroe County, MI
33860....................... Montgomery, AL................. 0.8009
Autauga County, AL
Elmore County, AL
Lowndes County, AL
Montgomery County, AL
34060....................... Morgantown, WV................. 0.8423
Monongalia County, WV
Preston County, WV
34100....................... Morristown, TN................. 0.7933
Grainger County, TN
Hamblen County, TN
Jefferson County, TN
34580....................... Mount Vernon-Anacortes, WA..... 1.0517
Skagit County, WA
34620....................... Muncie, IN..................... 0.8562
Delaware County, IN
34740....................... Muskegon-Norton Shores, MI..... 0.9941
Muskegon County, MI
34820....................... Myrtle Beach-Conway-North 0.8810
Myrtle Beach, SC.
Horry County, SC
34900....................... Napa, CA....................... 1.3374
Napa County, CA
34940....................... Naples-Marco Island, FL........ 0.9941
Collier County, FL
34980....................... Nashville-Davidson- 0.9847
Murfreesboro, TN.
Cannon County, TN
Cheatham County, TN
Davidson County, TN
Dickson County, TN
Hickman County, TN
Macon County, TN
Robertson County, TN
Rutherford County, TN
Smith County, TN
Sumner County, TN
Trousdale County, TN
Williamson County, TN
Wilson County, TN
35004....................... Nassau-Suffolk, NY............. 1.2662
Nassau County, NY
Suffolk County, NY
35084....................... Newark-Union, NJ-PA............ 1.1892
Essex County, NJ
Hunterdon County, NJ
Morris County, NJ
Sussex County, NJ
Union County, NJ
Pike County, PA
[[Page 65950]]
35300....................... New Haven-Milford, CT.......... 1.1953
New Haven County, CT
35380....................... New Orleans-Metairie-Kenner, LA 0.8831
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- 1.3177
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........ 0.8915
Berrien County, MI
35980....................... Norwich-New London, CT......... 1.1932
New London County, CT
36084....................... Oakland-Fremont-Hayward, CA.... 1.5819
Alameda County, CA
Contra Costa County, CA
36100....................... Ocala, FL...................... 0.8867
Marion County, FL
36140....................... Ocean City, NJ................. 1.0472
Cape May County, NJ
36220....................... Odessa, TX..................... 1.0073
Ector County, TX
36260....................... Ogden-Clearfield, UT........... 0.8995
Davis County, UT
Morgan County, UT
Weber County, UT
36420....................... Oklahoma City, OK.............. 0.8843
Canadian County, OK
Cleveland County, OK
Grady County, OK
Lincoln County, OK
Logan County, OK
McClain County, OK
Oklahoma County, OK
36500....................... Olympia, WA.................... 1.1081
Thurston County, WA
36540....................... Omaha-Council Bluffs, NE-IA.... 0.9450
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.................... 0.9452
Lake County, FL
Orange County, FL
Osceola County, FL
Seminole County, FL
36780....................... Oshkosh-Neenah, WI............. 0.9315
Winnebago County, WI
36980....................... Owensboro, KY.................. 0.8748
Daviess County, KY
Hancock County, KY
McLean County, KY
37100....................... Oxnard-Thousand Oaks-Ventura, 1.1546
CA.
[[Page 65951]]
Ventura County, CA
37340....................... Palm Bay-Melbourne-Titusville, 0.9443
FL.
Brevard County, FL
37460....................... Panama City-Lynn Haven, FL..... 0.8027
Bay County, FL
37620....................... Parkersburg-Marietta, WV-OH.... 0.7977
Washington County, OH
Pleasants County, WV
Wirt County, WV
Wood County, WV
37700....................... Pascagoula, MS................. 0.8215
George County, MS
Jackson County, MS
37860....................... Pensacola-Ferry Pass-Brent, FL. 0.8000
Escambia County, FL
Santa Rosa County, FL
37900....................... Peoria, IL..................... 0.8982
Marshall County, IL
Peoria County, IL
Stark County, IL
Tazewell County, IL
Woodford County, IL
37964....................... Philadelphia, PA............... 1.0996
Bucks County, PA
Chester County, PA
Delaware County, PA
Montgomery County, PA
Philadelphia County, PA
38060....................... Phoenix-Mesa-Scottsdale, AZ.... 1.0287
Maricopa County, AZ
Pinal County, AZ
38220....................... Pine Bluff, AR................. 0.8383
Cleveland County, AR
Jefferson County, AR
Lincoln County, AR
38300....................... Pittsburgh, PA................. 0.8674
Allegheny County, PA
Armstrong County, PA
Beaver County, PA
Butler County, PA
Fayette County, PA
Washington County, PA
Westmoreland County, PA
38340....................... Pittsfield, MA................. 1.0266
Berkshire County, MA
38540....................... Pocatello, ID.................. 0.9400
Bannock County, ID
Power County, ID
38660....................... Ponce, PR...................... 0.4842
Juana Diaz Municipio, PR
Ponce Municipio, PR
Villalba Municipio, PR
38860....................... Portland-South Portland- 0.9908
Biddeford, ME.
Cumberland County, ME
Sagadahoc County, ME
York County, ME
38900....................... Portland-Vancouver-Beaverton, 1.1416
OR-WA.
Clackamas County, OR
Columbia County, OR
Multnomah County, OR
Washington County, OR
Yamhill County, OR
Clark County, WA
Skamania County, WA
38940....................... Port St. Lucie-Fort Pierce, FL. 0.9833
Martin County, FL
St. Lucie County, FL
39100....................... Poughkeepsie-Newburgh- 1.0911
Middletown, NY.
Dutchess County, NY
Orange County, NY
[[Page 65952]]
39140....................... Prescott, AZ................... 0.9836
Yavapai County, AZ
39300....................... Providence-New Bedford-Fall 1.0783
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................. 0.9537
Juab County, UT
Utah County, UT
39380....................... Pueblo, CO..................... 0.8753
Pueblo County, CO
39460....................... Punta Gorda, FL................ 0.9405
Charlotte County, FL
39540....................... Racine, WI..................... 0.9356
Racine County, WI
39580....................... Raleig-hCary, NC............... 0.9864
Franklin County, NC
Johnston County, NC
Wake County, NC
39660....................... Rapid City, SD................. 0.8833
Meade County, SD
Pennington County, SD
39740....................... Reading, PA.................... 0.9622
Berks County, PA
39820....................... Redding, CA.................... 1.3198
Shasta County, CA
39900....................... Reno-Sparks, NV................ 1.1963
Storey County, NV
Washoe County, NV
40060....................... Richmond, VA................... 0.9177
Amelia County, VA
Caroline County, VA
Charles City County, VA
Chesterfield County, VA
Cumberland County, VA
Dinwiddie County, VA
Goochland County, VA
Hanover County, VA
Henrico County, VA
King and Queen County, VA
King William County, VA
Louisa County, VA
New Kent County, VA
Powhatan County, VA
Prince George County, VA
Sussex County, VA
Colonial Heights City, VA
Hopewell City, VA
Petersburg City, VA
Richmond City, VA
40140....................... Riverside-San Bernardino- 1.0904
Ontario, CA.
Riverside County, CA
San Bernardino County, CA
40220....................... Roanoke, VA.................... 0.8647
Botetourt County, VA
Craig County, VA
Franklin County, VA
Roanoke County, VA
Roanoke City, VA
Salem City, VA
40340....................... Rochester, MN.................. 1.1408
Dodge County, MN
Olmsted County, MN
Wabasha County, MN
40380....................... Rochester, NY.................. 0.8994
Livingston County, NY
Monroe County, NY
[[Page 65953]]
Ontario County, NY
Orleans County, NY
Wayne County, NY
40420....................... Rockford, IL................... 0.9989
Boone County, IL
Winnebago County, IL
40484....................... Rockingham County-Strafford 1.0159
County, NH.
Rockingham County, NH
Strafford County, NH
40580....................... Rocky Mount, NC................ 0.8854
Edgecombe County, NC
Nash County, NC
40660....................... Rome, GA....................... 0.9193
Floyd County, GA
40900....................... Sacramento--Arden-Arcade-- 1.3372
Roseville, CA.
El Dorado County, CA
Placer County, CA
Sacramento County, CA
Yolo County, CA
40980....................... Saginaw-Saginaw Township North, 0.8874
MI.
Saginaw County, MI
41060....................... St. Cloud, MN.................. 1.0362
Benton County, MN
Stearns County, MN
41100....................... St. George, UT................. 0.9265
Washington County, UT
41140....................... St. Joseph, MO-KS.............. 1.0118
Doniphan County, KS
Andrew County, MO
Buchanan County, MO
DeKalb County, MO
41180....................... St. Louis, MO-IL............... 0.9005
Bond County, IL
Calhoun County, IL
Clinton County, IL
Jersey County, IL
Macoupin County, IL
Madison County, IL
Monroe County, IL
St. Clair County, IL
Crawford County, MO
Franklin County, MO
Jefferson County, MO
Lincoln County, MO
St. Charles County, MO
St. Louis County, MO
Warren County, MO
Washington County, MO
St. Louis City, MO
41420....................... Salem, OR...................... 1.0438
Marion County, OR
Polk County, OR
41500....................... Salinas, CA.................... 1.4337
Monterey County, CA
41540....................... Salisbury, MD.................. 0.8953
Somerset County, MD
Wicomico County, MD
41620....................... Salt Lake City, UT............. 0.9402
Salt Lake County, UT
Summit County, UT
Tooele County, UT
41660....................... San Angelo, TX................. 0.8362
Irion County, TX
Tom Green County, TX
41700....................... San Antonio, TX................ 0.8844
Atascosa County, TX
Bandera County, TX
Bexar County, TX
Comal County, TX
Guadalupe County, TX
[[Page 65954]]
Kendall County, TX
Medina County, TX
Wilson County, TX
41740....................... San Diego-Carlsbad-San Marcos, 1.1354
CA.
San Diego County, CA
41780....................... Sandusky, OH................... 0.9302
Erie County, OH
41884....................... San Francisco-San Mateo-Redwood 1.5165
City, CA.
Marin County, CA
San Francisco County, CA
San Mateo County, CA
41900....................... San German-Cabo Rojo, PR....... 0.4885
Cabo Rojo Municipio, PR
Lajas Municipio, PR
Sabana Grande Municipio, PR
San German Municipio, PR
41940....................... San Jose-Sunnyvale-Santa Clara, 1.5543
CA.
San Benito County, CA
Santa Clara County, CA
41980....................... San Juan-Caguas-Guaynabo, PR... 0.4452
Aguas Buenas Municipio, PR
Aibonito Municipio, PR
Arecibo Municipio, PR
Barceloneta Municipio, PR
Barranquitas Municipio, PR
Bayamon Municipio, PR
Caguas Municipio, PR
Camuy Municipio, PR
Canovanas Municipio, PR
Carolina Municipio, PR
Catano Municipio, PR
Cayey Municipio, PR
Ciales Municipio, PR
Cidra Municipio, PR
Comerio Municipio, PR
Corozal Municipio, PR
Dorado Municipio, PR
Florida Municipio, PR
Guaynabo Municipio, PR
Gurabo Municipio, PR
Hatillo Municipio, PR
Humacao Municipio, PR
Juncos Municipio, PR
Las Piedras Municipio, PR
Loiza Municipio, PR
Manati Municipio, PR
Maunabo Municipio, PR
Morovis Municipio, PR
Naguabo Municipio, PR
Naranjito Municipio, PR
Orocovis Municipio, PR
Quebradillas Municipio, PR
Rio 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 1.1598
San Luis Obispo County, CA
42044....................... Santa Ana-Anaheim-Irvine, CA... 1.1473
Orange County, CA
42060....................... Santa Barbara-Santa Maria- 1.1091
Goleta, CA.
Santa Barbara County, CA
42100....................... Santa Cruz-Watsonville, CA..... 1.5457
Santa Cruz County, CA
42140....................... Santa Fe, NM................... 1.0824
[[Page 65955]]
Santa Fe County, NM
42220....................... Santa Rosa-Petaluma, CA........ 1.4464
Sonoma County, CA
42260....................... Sarasota-Bradenton-Venice, FL.. 0.9868
Manatee County, FL
Sarasota County, FL
42340....................... Savannah, GA................... 0.9351
Bryan County, GA
Chatham County, GA
Effingham County, GA
42540....................... Scranton-Wilkes-Barre, PA...... 0.8347
Lackawanna County, PA
Luzerne County, PA
Wyoming County, PA
42644....................... Seattle-Bellevue-Everett, WA... 1.1434
King County, WA
Snohomish County, WA
42680....................... Sebastian-Vero Beach, FL....... 0.9573
43100....................... Sheboygan, WI.................. 0.9026
Sheboygan County, WI
43300....................... Sherman-Denison, TX............ 0.8502
Grayson County, TX
43340....................... Shreveport-Bossier City, LA.... 0.8865
Bossier Parish, LA
Caddo Parish, LA
De Soto Parish, LA
43580....................... Sioux City, IA-NE-SD........... 0.9200
Woodbury County, IA
Dakota County, NE
Dixon County, NE
Union County, SD
43620....................... Sioux Falls, SD................ 0.9559
Lincoln County, SD
McCook County, SD
Minnehaha County, SD
Turner County, SD
43780....................... South Bend-Mishawaka, IN-MI.... 0.9842
St. Joseph County, IN
Cass County, MI
43900....................... Spartanburg, SC................ 0.9174
Spartanburg County, SC
44060....................... Spokane, WA.................... 1.0447
Spokane County, WA
44100....................... Springfield, IL................ 0.8890
Menard County, IL
Sangamon County, IL
44140....................... Springfield, MA................ 1.0079
Franklin County, MA
Hampden County, MA
Hampshire County, MA
44180....................... Springfield, MO................ 0.8469
Christian County, MO
Dallas County, MO
Greene County, MO
Polk County, MO
Webster County, MO
44220....................... Springfield, OH................ 0.8593
Clark County, OH
44300....................... State College, PA.............. 0.8784
Centre County, PA
44700....................... Stockton, CA................... 1.1442
San Joaquin County, CA
44940....................... Sumter, SC..................... 0.8083
Sumter County, SC
45060....................... Syracuse, NY................... 0.9691
Madison County, NY
Onondaga County, NY
Oswego County, NY
45104....................... Tacoma, WA..................... 1.0789
Pierce County, WA
[[Page 65956]]
45220....................... Tallahassee, FL................ 0.8942
Gadsden County, FL
Jefferson County, FL
Leon County, FL
Wakulla County, FL
45300....................... Tampa-St. Petersburg- 0.9144
Clearwater, FL.
Hernando County, FL
Hillsborough County, FL
Pasco County, FL
Pinellas County, FL
45460....................... Terre Haute, IN................ 0.8765
Clay County, IN
Sullivan County, IN
Vermillion County, IN
Vigo County, IN
45500....................... Texarkana, TX-Texarkana, AR.... 0.8104
Miller County, AR
Bowie County, TX
45780....................... Toledo, OH..................... 0.9586
Fulton County, OH
Lucas County, OH
Ottawa County, OH
Wood County, OH
45820....................... Topeka, KS..................... 0.8730
Jackson County, KS
Jefferson County, KS
Osage County, KS
Shawnee County, KS
Wabaunsee County, KS
45940....................... Trenton-Ewing, NJ.............. 1.0835
Mercer County, NJ
46060....................... Tucson, AZ..................... 0.9202
Pima County, AZ
46140....................... Tulsa, OK...................... 0.8103
Creek County, OK
Okmulgee County, OK
Osage County, OK
Pawnee County, OK
Rogers County, OK
Tulsa County, OK
Wagoner County, OK
46220....................... Tuscaloosa, AL................. 0.8542
Greene County, AL
Hale County, AL
Tuscaloosa County, AL
46340....................... Tyler, TX...................... 0.8811
Smith County, TX
46540....................... Utica-Rome, NY................. 0.8396
Herkimer County, NY
Oneida County, NY
46660....................... Valdosta, GA................... 0.8369
Brooks County, GA
Echols County, GA
Lanier County, GA
Lowndes County, GA
46700....................... Vallejo-Fairfield, CA.......... 1.5137
Solano County, CA
47020....................... Victoria, TX................... 0.8560
Calhoun County, TX
Goliad County, TX
Victoria County, TX
47220....................... Vineland-Millville-Bridgeton, 0.9832
NJ.
Cumberland County, NJ
47260....................... Virginia Beach-Norfolk-Newport 0.8790
News, VA-NC.
Currituck County, NC
Gloucester County, VA
Isle of Wight County, VA
James City County, VA
Mathews County, VA
Surry County, VA
[[Page 65957]]
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........ 0.9968
Tulare County, CA
47380....................... Waco, TX....................... 0.8633
McLennan County, TX
47580....................... Warner Robins, GA.............. 0.8380
Houston County, GA
47644....................... Warren-Farmington Hills-Troy, 1.0054
MI.
Lapeer County, MI
Livingston County, MI
Macomb County, MI
Oakland County, MI
St. Clair County, MI
47894....................... Washington-Arlington- 1.1054
Alexandria, DC-VA-MD-WV.
District of Columbia, DC
Calvert County, MD
Charles County, MD
Prince George's County, MD
Arlington County, VA
Clarke County, VA
Fairfax County, VA
Fauquier County, VA
Loudoun County, VA
Prince William County, VA
Spotsylvania County, VA
Stafford County, VA
Warren County, VA
Alexandria City, VA
Fairfax City, VA
Falls Church City, VA
Fredericksburg City, VA
Manassas City, VA
Manassas Park City, VA
Jefferson County, WV
47940....................... Waterloo-Cedar Falls, IA....... 0.8408
Black Hawk County, IA
Bremer County, IA
Grundy County, IA
48140....................... Wausau, WI..................... 0.9722
Marathon County, WI
48260....................... Weirton-Steubenville, WV-OH.... 0.8063
Jefferson County, OH
Brooke County, WV
Hancock County, WV
48300....................... Wenatchee, WA.................. 1.0346
Chelan County, WA
Douglas County, WA
48424....................... West Palm Beach-Boca Raton- 0.9649
Boynton Beach, FL.
Palm Beach County, FL
48540....................... Wheeling, WV-OH................ 0.7010
Belmont County, OH
Marshall County, WV
Ohio County, WV
48620....................... Wichita, KS.................... 0.9063
Butler County, KS
Harvey County, KS
Sedgwick County, KS
Sumner County, KS
48660....................... Wichita Falls, TX.............. 0.8311
Archer County, TX
Clay County, TX
[[Page 65958]]
Wichita County, TX
48700....................... Williamsport, PA............... 0.8139
Lycoming County, PA
48864....................... Wilmington, DE-MD-NJ........... 1.0684
New Castle County, DE
Cecil County, MD
Salem County, NJ
48900....................... Wilmington, NC................. 0.9835
Brunswick County, NC
New Hanover County, NC
Pender County, NC
49020....................... Winchester, VA-WV.............. 1.0091
Frederick County, VA
Winchester City, VA
Hampshire County, WV
49180....................... Winston-Salem, NC.............. 0.9276
Davie County, NC
Forsyth County, NC
Stokes County, NC
Yadkin County, NC
49340....................... Worcester, MA.................. 1.0722
Worcester County, MA
49420....................... Yakima, WA..................... 0.9847
Yakima County, WA
49500....................... Yauco, PR...................... 0.3854
Guanica Municipio, PR
Guayanilla Municipio, PR
Penuelas Municipio, PR
Yauco Municipio, PR
49620....................... York-Hanover, PA............... 0.9397
York County, PA
49660....................... Youngstown-Warren-Boardman, OH- 0.8802
PA.
Mahoning County, OH
Trumbull County, OH
Mercer County, PA
49700....................... Yuba City, CA.................. 1.0730
Sutter County, CA
Yuba County, CA
49740....................... Yuma, AZ....................... 0.9109
Yuma County, AZ
------------------------------------------------------------------------
\1\ At this time, there are no hospitals in these urban areas on which
to base a wage index. Therefore, the urban wage index value is based
on the average wage index of all urban areas within the State.
Addendum C.--Comparison of HH PPS Transition Wage Index for CY 2006 and Pre-Floor and Pre-Reclassified Hospital
Wage Index For CY 2007
----------------------------------------------------------------------------------------------------------------
CY 2006 HH
PPS CY2007 CBSA- Percent
SSA state/county code County name CBSA No. transition based wage change CY2006-
wage index index CY2007
----------------------------------------------------------------------------------------------------------------
01000........................... Autauga County, Alabama. 33860 0.8618 0.8009 -7.07
01010........................... Baldwin County, Alabama. 99901 0.7654 0.7591 -0.82
01020........................... Barbour County, Alabama. 99901 0.7439 0.7591 2.04
01030........................... Bibb County, Alabama.... 13820 0.8196 0.8894 8.52
01040........................... Blount County, Alabama.. 13820 0.8980 0.8894 -0.96
01050........................... Bullock County, Alabama. 99901 0.7439 0.7591 2.04
01060........................... Butler County, Alabama.. 99901 0.7439 0.7591 2.04
01070........................... Calhoun County, Alabama. 11500 0.7682 0.7770 1.15
01080........................... Chambers County, Alabama 99901 0.7439 0.7591 2.04
01090........................... Cherokee County, Alabama 99901 0.7439 0.7591 2.04
01100........................... Chilton County, Alabama. 13820 0.8196 0.8894 8.52
01110........................... Choctaw County, Alabama. 99901 0.7439 0.7591 2.04
01120........................... Clarke County, Alabama.. 99901 0.7439 0.7591 2.04
01130........................... Clay County, Alabama.... 99901 0.7439 0.7591 2.04
01140........................... Cleburne County, Alabama 99901 0.7439 0.7591 2.04
01150........................... Coffee County, Alabama.. 99901 0.7439 0.7591 2.04
01160........................... Colbert County, Alabama. 22520 0.8272 0.7843 -5.19
01170........................... Conecuh County, Alabama. 99901 0.7439 0.7591 2.04
[[Page 65959]]
01180........................... Coosa County, Alabama... 99901 0.7439 0.7591 2.04
01190........................... Covington County, 99901 0.7439 0.7591 2.04
Alabama.
01200........................... Crenshaw County, Alabama 99901 0.7439 0.7591 2.04
01210........................... Cullman County, Alabama. 99901 0.7439 0.7591 2.04
01220........................... Dale County, Alabama.... 99901 0.7574 0.7591 0.22
01230........................... Dallas County, Alabama.. 99901 0.7439 0.7591 2.04
01240........................... De Kalb County, Alabama. 99901 0.7439 0.7591 2.04
01250........................... Elmore County, Alabama.. 33860 0.8618 0.8009 -7.07
01260........................... Escambia County, Alabama 99901 0.7439 0.7591 2.04
01270........................... Etowah County, Alabama.. 23460 0.7938 0.8066 1.61
01280........................... Fayette County, Alabama. 99901 0.7439 0.7591 2.04
01290........................... Franklin County, Alabama 99901 0.7439 0.7591 2.04
01300........................... Geneva County, Alabama.. 20020 0.7577 0.7381 -2.59
01310........................... Greene County, Alabama.. 46220 0.8039 0.8542 6.26
01320........................... Hale County, Alabama.... 46220 0.8039 0.8542 6.26
01330........................... Henry County, Alabama... 20020 0.7577 0.7381 -2.59
01340........................... Houston County, Alabama. 20020 0.7711 0.7381 -4.28
01350........................... Jackson County, Alabama. 99901 0.7439 0.7591 2.04
01360........................... Jefferson County, 13820 0.8980 0.8894 -0.96
Alabama.
01370........................... Lamar County, Alabama... 99901 0.7439 0.7591 2.04
01380........................... Lauderdale County, 22520 0.8272 0.7843 -5.19
Alabama.
01390........................... Lawrence County, Alabama 19460 0.8469 0.8159 -3.66
01400........................... Lee County, Alabama..... 12220 0.8100 0.8096 -0.05
01410........................... Limestone County, 26620 0.9146 0.9007 -1.52
Alabama.
01420........................... Lowndes County, Alabama. 33860 0.8025 0.8009 -0.20
01430........................... Macon County, Alabama... 99901 0.7439 0.7591 2.04
01440........................... Madison County, Alabama. 26620 0.9146 0.9007 -1.52
01450........................... Marengo County, Alabama. 99901 0.7439 0.7591 2.04
01460........................... Marion County, Alabama.. 99901 0.7439 0.7591 2.04
01470........................... Marshall County, Alabama 99901 0.7439 0.7591 2.04
01480........................... Mobile County, Alabama.. 33660 0.7876 0.7913 0.47
01490........................... Monroe County, Alabama.. 99901 0.7439 0.7591 2.04
01500........................... Montgomery County, 33860 0.8618 0.8009 -7.07
Alabama.
01510........................... Morgan County, Alabama.. 19460 0.8469 0.8159 -3.66
01520........................... Perry County, Alabama... 99901 0.7439 0.7591 2.04
01530........................... Pickens County, Alabama. 99901 0.7439 0.7591 2.04
01540........................... Pike County, Alabama.... 99901 0.7439 0.7591 2.04
01550........................... Randolph County, Alabama 99901 0.7439 0.7591 2.04
01560........................... Russell County, Alabama. 17980 0.8560 0.8239 -3.75
01570........................... St Clair County, Alabama 13820 0.8980 0.8894 -0.96
01580........................... Shelby County, Alabama.. 13820 0.8980 0.8894 -0.96
01590........................... Sumter County, Alabama.. 99901 0.7439 0.7591 2.04
01600........................... Talladega County, 99901 0.7439 0.7591 2.04
Alabama.
01610........................... Tallapoosa County, 99901 0.7439 0.7591 2.04
Alabama.
01620........................... Tuscaloosa County, 46220 0.8705 0.8542 -1.87
Alabama.
01630........................... Walker County, Alabama.. 13820 0.8196 0.8894 8.52
01640........................... Washington County, 99901 0.7439 0.7591 2.04
Alabama.
01650........................... Wilcox County, Alabama.. 99901 0.7439 0.7591 2.04
01660........................... Winston County, Alabama. 99901 0.7439 0.7591 2.04
02013........................... Aleutians County East, 99902 1.1933 1.0661 -10.66
Alaska.
02016........................... Aleutians County West, 99902 1.1933 1.0661 -10.66
Alaska.
02020........................... Anchorage County, Alaska 11260 1.1840 1.2023 1.55
02030........................... Angoon County, Alaska... 99902 1.1933 1.0661 -10.66
02040........................... Barrow-North Slope 99902 1.1933 1.0661 -10.66
County, Alaska.
02050........................... Bethel County, Alaska... 99902 1.1933 1.0661 -10.66
02060........................... Bristol Bay Borough 99902 1.1933 1.0661 -10.66
County, Alaska.
02068........................... Denali County, Alaska... 99902 1.1933 1.0661 -10.66
02070........................... Bristol Bay County, 99902 1.1933 1.0661 -10.66
Alaska.
02080........................... Cordova-Mc Carthy 99902 1.1933 1.0661 -10.66
County, Alaska.
02090........................... Fairbanks County, Alaska 21820 1.1648 1.1059 -5.06
02100........................... Haines County, Alaska... 99902 1.1933 1.0661 -10.66
02110........................... Juneau County, Alaska... 99902 1.1933 1.0661 -10.66
02120........................... Kenai-Cook Inlet County, 99902 1.1933 1.0661 -10.66
Alaska.
02122........................... Kenai Peninsula Borough, 99902 1.1933 1.0661 -10.66
Alaska.
02130........................... Ketchikan County, Alaska 99902 1.1933 1.0661 -10.66
02140........................... Kobuk County, Alaska.... 99902 1.1933 1.0661 -10.66
02150........................... Kodiak County, Alaska... 99902 1.1933 1.0661 -10.66
02160........................... Kuskokwin County, Alaska 99902 1.1933 1.0661 -10.66
[[Page 65960]]
02164........................... Lake and Peninsula 99902 1.1933 1.0661 -10.66
Borough, Alaska.
02170........................... Matanuska County, Alaska 11260 1.1892 1.2023 1.10
02180........................... Nome County, Alaska..... 99902 1.1933 1.0661 -10.66
02185........................... North Slope Borough, 99902 1.1933 1.0661 -10.66
Alaska.
02188........................... Northwest Arctic 99902 1.1933 1.0661 -10.66
Borough, Alaska.
02190........................... Outer Ketchikan County, 99902 1.1933 1.0661 -10.66
Alaska.
02200........................... Prince Of Wales County, 99902 1.1933 1.0661 -10.66
Alaska.
02201........................... Prince of Wales-Outer 99902 1.1933 1.0661 -10.66
Ketchikan Census
Area,AK.
02210........................... Seward County, Alaska... 99902 1.1933 1.0661 -10.66
02220........................... Sitka County, Alaska.... 99902 1.1933 1.0661 -10.66
02230........................... Skagway-Yakutat County, 99902 1.1933 1.0661 -10.66
Alaska.
02231........................... Skagway-Yakutat-Angoon 99902 1.1933 1.0661 -10.66
Census Area, Alaska.
02232........................... Skagway-Hoonah-Angoon 99902 1.1933 1.0661 -10.66
Census Area, Alaska.
02240........................... Southeast Fairbanks 99902 1.1933 1.0661 -10.66
County, Alaska.
02250........................... Upper Yukon County, 99902 1.1933 1.0661 -10.66
Alaska.
02260........................... Valdz-Chitna-Whitier 99902 1.1933 1.0661 -10.66
County, Alaska.
02261........................... Valdex-Cordove Census 99902 1.1933 1.0661 -10.66
Area, Alaska.
02270........................... Wade Hampton County, 99902 1.1933 1.0661 -10.66
Alaska.
02280........................... Wrangell-Petersburg 99902 1.1933 1.0661 -10.66
County, Alaska.
02282........................... Yakutat Borough, Alaska. 99902 1.1933 1.0661 -10.66
02290........................... Yukon-Koyukuk County, 99902 1.1933 1.0661 -10.66
Alaska.
03000........................... Apache County, Arizona.. 99903 0.8907 0.8908 0.01
03010........................... Cochise County, Arizona. 99903 0.8907 0.8908 0.01
03020........................... Coconino County, Arizona 22380 1.1969 1.1601 -3.07
03030........................... Gila County, Arizona.... 99903 0.8907 0.8908 0.01
03040........................... Graham County, Arizona.. 99903 0.8907 0.8908 0.01
03050........................... Greenlee County, Arizona 99903 0.8907 0.8908 0.01
03055........................... La Paz County, Arizona.. 99903 0.8907 0.8908 0.01
03060........................... Maricopa County, Arizona 38060 1.0127 1.0287 1.58
03070........................... Mohave County, Arizona.. 99903 0.9962 0.8908 -10.58
03080........................... Navajo County, Arizona.. 99903 0.8907 0.8908 0.01
03090........................... Pima County, Arizona.... 46060 0.9007 0.9202 2.16
03100........................... Pinal County, Arizona... 38060 1.0127 1.0287 1.58
03110........................... Santa Cruz County, 99903 0.8907 0.8908 0.01
Arizona.
03120........................... Yavapai County, Arizona. 39140 0.9457 0.9836 4.01
03130........................... Yuma County, Arizona.... 49740 0.9126 0.9109 -0.19
04000........................... Arkansas County, 99904 0.7605 0.7307 -3.92
Arkansas.
04010........................... Ashley County, Arkansas. 99904 0.7605 0.7307 -3.92
04020........................... Baxter County, Arkansas. 99904 0.7605 0.7307 -3.92
04030........................... Benton County, Arkansas. 22220 0.8661 0.8865 2.36
04040........................... Boone County, Arkansas.. 99904 0.7605 0.7307 -3.92
04050........................... Bradley County, Arkansas 99904 0.7605 0.7307 -3.92
04060........................... Calhoun County, Arkansas 99904 0.7605 0.7307 -3.92
04070........................... Carroll County, Arkansas 99904 0.7605 0.7307 -3.92
04080........................... Chicot County, Arkansas. 99904 0.7605 0.7307 -3.92
04090........................... Clark County, Arkansas.. 99904 0.7605 0.7307 -3.92
04100........................... Clay County, Arkansas... 99904 0.7605 0.7307 -3.92
04110........................... Cleburne County, 99904 0.7605 0.7307 -3.92
Arkansas.
04120........................... Cleveland County, 38220 0.8212 0.8383 2.08
Arkansas.
04130........................... Columbia County, 99904 0.7605 0.7307 -3.92
Arkansas.
04140........................... Conway County, Arkansas. 99904 0.7605 0.7307 -3.92
04150........................... Craighead County, 27860 0.7911 0.7662 -3.15
Arkansas.
04160........................... Crawford County, 22900 0.8238 0.7731 -6.15
Arkansas.
04170........................... Crittenden County, 32820 0.9407 0.9373 -0.36
Arkansas.
04180........................... Cross County, Arkansas.. 99904 0.7605 0.7307 -3.92
04190........................... Dallas County, Arkansas. 99904 0.7605 0.7307 -3.92
04200........................... Desha County, Arkansas.. 99904 0.7605 0.7307 -3.92
04210........................... Drew County, Arkansas... 99904 0.7605 0.7307 -3.92
04220........................... Faulkner County, 30780 0.8747 0.8890 1.63
Arkansas.
04230........................... Franklin County, 22900 0.7987 0.7731 -3.21
Arkansas.
04240........................... Fulton County, Arkansas. 99904 0.7605 0.7307 -3.92
04250........................... Garland County, Arkansas 26300 0.8375 0.8782 4.86
04260........................... Grant County, Arkansas.. 30780 0.8246 0.8890 7.81
04270........................... Greene County, Arkansas. 99904 0.7605 0.7307 -3.92
04280........................... Hempstead County, 99904 0.7605 0.7307 -3.92
Arkansas.
04290........................... Hot Spring County, 99904 0.7605 0.7307 -3.92
Arkansas.
04300........................... Howard County, Arkansas. 99904 0.7605 0.7307 -3.92
04310........................... Independence County, 99904 0.7605 0.7307 -3.92
Arkansas.
[[Page 65961]]
04320........................... Izard County, Arkansas.. 99904 0.7605 0.7307 -3.92
04330........................... Jackson County, Arkansas 99904 0.7605 0.7307 -3.92
04340........................... Jefferson County, 38220 0.8680 0.8383 -3.42
Arkansas.
04350........................... Johnson County, Arkansas 99904 0.7605 0.7307 -3.92
04360........................... Lafayette County, 99904 0.7605 0.7307 -3.92
Arkansas.
04370........................... Lawrence County, 99904 0.7605 0.7307 -3.92
Arkansas.
04380........................... Lee County, Arkansas.... 99904 0.7605 0.7307 -3.92
04390........................... Lincoln County, Arkansas 38220 0.8212 0.8383 2.08
04400........................... Little River County, 99904 0.7605 0.7307 -3.92
Arkansas.
04410........................... Logan County, Arkansas.. 99904 0.7605 0.7307 -3.92
04420........................... Lonoke County, Arkansas. 30780 0.8747 0.8890 1.63
04430........................... Madison County, Arkansas 22220 0.8203 0.8865 8.07
04440........................... Marion County, Arkansas. 99904 0.7605 0.7307 -3.92
04450........................... Miller County, Arkansas. 45500 0.8283 0.8104 -2.16
04460........................... Mississippi County, 99904 0.7605 0.7307 -3.92
Arkansas.
04470........................... Monroe County, Arkansas. 99904 0.7605 0.7307 -3.92
04480........................... Montgomery County, 99904 0.7605 0.7307 -3.92
Arkansas.
04490........................... Nevada County, Arkansas. 99904 0.7605 0.7307 -3.92
04500........................... Newton County, Arkansas. 99904 0.7605 0.7307 -3.92
04510........................... Ouachita County, 99904 0.7605 0.7307 -3.92
Arkansas.
04520........................... Perry County, Arkansas.. 30780 0.8246 0.8890 7.81
04530........................... Phillips County, 99904 0.7605 0.7307 -3.92
Arkansas.
04540........................... Pike County, Arkansas... 99904 0.7605 0.7307 -3.92
04550........................... Poinsett County, 27860 0.7828 0.7662 -2.12
Arkansas.
04560........................... Polk County, Arkansas... 99904 0.7605 0.7307 -3.92
04570........................... Pope County, Arkansas... 99904 0.7605 0.7307 -3.92
04580........................... Prairie County, Arkansas 99904 0.7605 0.7307 -3.92
04590........................... Pulaski County, Arkansas 30780 0.8747 0.8890 1.63
04600........................... Randolph County, 99904 0.7605 0.7307 -3.92
Arkansas.
04610........................... St Francis County, 99904 0.7605 0.7307 -3.92
Arkansas.
04620........................... Saline County, Arkansas. 30780 0.8747 0.8890 1.63
04630........................... Scott County, Arkansas.. 99904 0.7605 0.7307 -3.92
04640........................... Searcy County, Arkansas. 99904 0.7605 0.7307 -3.92
04650........................... Sebastian County, 22900 0.8238 0.7731 -6.15
Arkansas.
04660........................... Sevier County, Arkansas. 99904 0.7605 0.7307 -3.92
04670........................... Sharp County, Arkansas.. 99904 0.7605 0.7307 -3.92
04680........................... Stone County, Arkansas.. 99904 0.7605 0.7307 -3.92
04690........................... Union County, Arkansas.. 99904 0.7605 0.7307 -3.92
04700........................... Van Buren County, 99904 0.7605 0.7307 -3.92
Arkansas.
04710........................... Washington County, 22220 0.8661 0.8865 2.36
Arkansas.
04720........................... White County, Arkansas.. 99904 0.7605 0.7307 -3.92
04730........................... Woodruff County, 99904 0.7605 0.7307 -3.92
Arkansas.
04740........................... Yell County, Arkansas... 99904 0.7605 0.7307 -3.92
05000........................... Alameda County, 36084 1.5346 1.5819 3.08
California.
05010........................... Alpine County, 99905 1.0915 1.1454 4.94
California.
05020........................... Amador County, 99905 1.0915 1.1454 4.94
California.
05030........................... Butte County, California 17020 1.0511 1.1053 5.16
05040........................... Calaveras County, 99905 1.0915 1.1454 4.94
California.
05050........................... Colusa County, 99905 1.0915 1.1454 4.94
California.
05060........................... Contra Costa County, 36084 1.5346 1.5819 3.08
California.
05070........................... Del Norte County, 99905 1.0915 1.1454 4.94
California.
05080........................... Eldorado County, 40900 1.3056 1.3372 2.42
California.
05090........................... Fresno County, 23420 1.0483 1.0943 4.39
California.
05100........................... Glenn County, California 99905 1.0915 1.1454 4.94
05110........................... Humboldt County, 99905 1.0915 1.1454 4.94
California.
05120........................... Imperial County, 20940 0.9841 0.9076 -7.77
California.
05130........................... Inyo County, California. 99905 1.0915 1.1454 4.94
05140........................... Kern County, California. 12540 1.0470 1.0725 2.44
05150........................... Kings County, California 25260 1.0406 1.0282 -1.19
05160........................... Lake County, California. 99905 1.0915 1.1454 4.94
05170........................... Lassen County, 99905 1.0915 1.1454 4.94
California.
05200........................... Los Angeles County, 31084 1.1783 1.1760 -0.20
California.
05210........................... Los Angeles County, 31084 1.1783 1.1760 -0.20
California.
05300........................... Madera County, 31460 0.9571 0.8154 -14.81
California.
05310........................... Marin County, California 41884 1.4994 1.5165 1.14
05320........................... Mariposa County, 99905 1.0915 1.1454 4.94
California.
05330........................... Mendocino County, 99905 1.0915 1.1454 4.94
California.
05340........................... Merced County, 32900 1.1109 1.1471 3.26
California.
[[Page 65962]]
05350........................... Modoc County, California 99905 1.0915 1.1454 4.94
05360........................... Mono County, California. 99905 1.0915 1.1454 4.94
05370........................... Monterey County, 41500 1.4128 1.4337 1.48
California.
05380........................... Napa County, California. 34900 1.3313 1.3374 0.46
05390........................... Nevada County, 99905 1.0915 1.1454 4.94
California.
05400........................... Orange County, 42044 1.1559 1.1473 -0.74
California.
05410........................... Placer County, 40900 1.3056 1.3372 2.42
California.
05420........................... Plumas County, 99905 1.0915 1.1454 4.94
California.
05430........................... Riverside County, 40140 1.1027 1.0904 -1.12
California.
05440........................... Sacramento County, 40900 1.3056 1.3372 2.42
California.
05450........................... San Benito County, 41940 1.2937 1.5543 20.14
California.
05460........................... San Bernardino County, 40140 1.1027 1.0904 -1.12
California.
05470........................... San Diego County, 41740 1.1413 1.1354 -0.52
California.
05480........................... San Francisco County, 41884 1.4994 1.5165 1.14
California.
05490........................... San Joaquin County, 44700 1.1307 1.1442 1.19
California.
05500........................... San Luis Obispo County, 42020 1.1349 1.1598 2.19
California.
05510........................... San Mateo County, 41884 1.4994 1.5165 1.14
California.
05520........................... Santa Barbara County, 42060 1.1694 1.1091 -5.16
California.
05530........................... Santa Clara County, 41940 1.5109 1.5543 2.87
California.
05540........................... Santa Cruz County, 42100 1.5166 1.5457 1.92
California.
05550........................... Shasta County, 39820 1.2203 1.3198 8.15
California.
05560........................... Sierra County, 99905 1.0915 1.1454 4.94
California.
05570........................... Siskiyou County, 99905 1.0915 1.1454 4.94
California.
05580........................... Solano County, 46700 1.4460 1.5137 4.68
California.
05590........................... Sonoma County, 42220 1.3493 1.4464 7.20
California.
05600........................... Stanislaus County, 33700 1.1885 1.1729 -1.31
California.
05610........................... Sutter County, 49700 1.0921 1.0730 -1.75
California.
05620........................... Tehama County, 99905 1.0915 1.1454 4.94
California.
05630........................... Trinity County, 99905 1.0915 1.1454 4.94
California.
05640........................... Tulare County, 47300 1.0123 0.9968 -1.53
California.
05650........................... Tuolumne County, 99905 1.0915 1.1454 4.94
California.
05660........................... Ventura County, 37100 1.1622 1.1546 -0.65
California.
05670........................... Yolo County, California. 40900 1.1460 1.3372 16.68
05680........................... Yuba County, California. 49700 1.0921 1.0730 -1.75
06000........................... Adams County, Colorado.. 19740 1.0723 1.0930 1.93
06010........................... Alamosa County, Colorado 99906 0.9380 0.9325 -0.59
06020........................... Arapahoe County, 19740 1.0723 1.0930 1.93
Colorado.
06030........................... Archuleta County, 99906 0.9380 0.9325 -0.59
Colorado.
06040........................... Baca County, Colorado... 99906 0.9380 0.9325 -0.59
06050........................... Bent County, Colorado... 99906 0.9380 0.9325 -0.59
06060........................... Boulder County, Colorado 14500 0.9734 1.0350 6.33
06070........................... Chaffee County, Colorado 99906 0.9380 0.9325 -0.59
06080........................... Cheyenne County, 99906 0.9380 0.9325 -0.59
Colorado.
06090........................... Clear Creek County, 19740 1.0052 1.0930 8.73
Colorado.
06100........................... Conejos County, Colorado 99906 0.9380 0.9325 -0.59
06110........................... Costilla County, 99906 0.9380 0.9325 -0.59
Colorado.
06120........................... Crowley County, Colorado 99906 0.9380 0.9325 -0.59
06130........................... Custer County, Colorado. 99906 0.9380 0.9325 -0.59
06140........................... Delta County, Colorado.. 99906 0.9380 0.9325 -0.59
06150........................... Denver County, Colorado. 19740 1.0723 1.0930 1.93
06160........................... Dolores County, Colorado 99906 0.9380 0.9325 -0.59
06170........................... Douglas County, Colorado 19740 1.0723 1.0930 1.93
06180........................... Eagle County, Colorado.. 99906 0.9380 0.9325 -0.59
06190........................... Elbert County, Colorado. 19740 1.0052 1.0930 8.73
06200........................... El Paso County, Colorado 17820 0.9468 0.9701 2.46
06210........................... Fremont County, Colorado 99906 0.9380 0.9325 -0.59
06220........................... Garfield County, 99906 0.9380 0.9325 -0.59
Colorado.
06230........................... Gilpin County, Colorado. 19740 1.0052 1.0930 8.73
06240........................... Grand County, Colorado.. 99906 0.9380 0.9325 -0.59
06250........................... Gunnison County, 99906 0.9380 0.9325 -0.59
Colorado.
06260........................... Hinsdale County, 99906 0.9380 0.9325 -0.59
Colorado.
06270........................... Huerfano County, 99906 0.9380 0.9325 -0.59
Colorado.
06280........................... Jackson County, Colorado 99906 0.9380 0.9325 -0.59
06290........................... Jefferson County, 19740 1.0723 1.0930 1.93
Colorado.
06300........................... Kiowa County, Colorado.. 99906 0.9380 0.9325 -0.59
06310........................... Kit Carson County, 99906 0.9380 0.9325 -0.59
Colorado.
06320........................... Lake County, Colorado... 99906 0.9380 0.9325 -0.59
06330........................... La Plata County, 99906 0.9380 0.9325 -0.59
Colorado.
[[Page 65963]]
06340........................... Larimer County, Colorado 22660 1.0122 0.9544 -5.71
06350........................... Las Animas County, 99906 0.9380 0.9325 -0.59
Colorado.
06360........................... Lincoln County, Colorado 99906 0.9380 0.9325 -0.59
06370........................... Logan County, Colorado.. 99906 0.9380 0.9325 -0.59
06380........................... Mesa County, Colorado... 24300 0.9550 0.9668 1.24
06390........................... Mineral County, Colorado 99906 0.9380 0.9325 -0.59
06400........................... Moffat County, Colorado. 99906 0.9380 0.9325 -0.59
06410........................... Montezuma County, 99906 0.9380 0.9325 -0.59
Colorado.
06420........................... Montrose County, 99906 0.9380 0.9325 -0.59
Colorado.
06430........................... Morgan County, Colorado. 99906 0.9380 0.9325 -0.59
06440........................... Otero County, Colorado.. 99906 0.9380 0.9325 -0.59
06450........................... Ouray County, Colorado.. 99906 0.9380 0.9325 -0.59
06460........................... Park County, Colorado... 19740 1.0052 1.0930 8.73
06470........................... Phillips County, 99906 0.9380 0.9325 -0.59
Colorado.
06480........................... Pitkin County, Colorado. 99906 0.9380 0.9325 -0.59
06490........................... Prowers County, Colorado 99906 0.9380 0.9325 -0.59
06500........................... Pueblo County, Colorado. 39380 0.8623 0.8753 1.51
06510........................... Rio Blanco County, 99906 0.9380 0.9325 -0.59
Colorado.
06520........................... Rio Grande County, 99906 0.9380 0.9325 -0.59
Colorado.
06530........................... Routt County, Colorado.. 99906 0.9380 0.9325 -0.59
06540........................... Saguache County, 99906 0.9380 0.9325 -0.59
Colorado.
06550........................... San Juan County, 99906 0.9380 0.9325 -0.59
Colorado.
06560........................... San Miguel County, 99906 0.9380 0.9325 -0.59
Colorado.
06570........................... Sedgwick County, 99906 0.9380 0.9325 -0.59
Colorado.
06580........................... Summit County, Colorado. 99906 0.9380 0.9325 -0.59
06590........................... Teller County, Colorado. 17820 0.9424 0.9701 2.94
06600........................... Washington County, 99906 0.9380 0.9325 -0.59
Colorado.
06610........................... Weld County, Colorado... 24540 0.9570 0.9602 0.33
06620........................... Yuma County, Colorado... 99906 0.9380 0.9325 -0.59
06630........................... Broomfield County, 19740 1.0723 1.0930 1.93
Colorado.
07000........................... Fairfield County, 14860 1.2394 1.2659 2.14
Connecticut.
07010........................... Hartford County, 25540 1.1073 1.0894 -1.62
Connecticut.
07020........................... Litchfield County, 25540 1.1073 1.0894 -1.62
Connecticut.
07030........................... Middlesex County, 25540 1.1073 1.0894 -1.62
Connecticut.
07040........................... New Haven County, 35300 1.2042 1.1953 -0.74
Connecticut.
07050........................... New London County, 35980 1.1345 1.1932 5.17
Connecticut.
07060........................... Tolland County, 25540 1.1073 1.0894 -1.62
Connecticut.
07070........................... Windham County, 99907 1.1730 1.1709 -0.18
Connecticut.
08000........................... Kent County, Delaware... 20100 0.9776 0.9847 0.73
08010........................... New Castle County, 48864 1.0499 1.0684 1.76
Delaware.
08020........................... Sussex County, Delaware. 99908 0.9579 0.9705 1.32
09000........................... Washington DC County, 47894 1.0951 1.1054 0.94
Dist Of Col.
10000........................... Alachua County, Florida. 23540 0.9388 0.9277 -1.18
10010........................... Baker County, Florida... 27260 0.8984 0.9165 2.01
10020........................... Bay County, Florida..... 37460 0.8005 0.8027 0.27
10030........................... Bradford County, Florida 99910 0.8623 0.8594 -0.34
10040........................... Brevard County, Florida. 37340 0.9839 0.9443 -4.02
10050........................... Broward County, Florida. 22744 1.0432 1.0133 -2.87
10060........................... Calhoun County, Florida. 99910 0.8623 0.8594 -0.34
10070........................... Charlotte County, 39460 0.9255 0.9405 1.62
Florida.
10080........................... Citrus County, Florida.. 99910 0.8623 0.8594 -0.34
10090........................... Clay County, Florida.... 27260 0.9295 0.9165 -1.40
10100........................... Collier County, Florida. 34940 1.0139 0.9941 -1.95
10110........................... Columbia County, Florida 99910 0.8623 0.8594 -0.34
10120........................... Dade County, Florida.... 33124 0.9750 0.9812 0.64
10130........................... De Soto County, Florida. 99910 0.8623 0.8594 -0.34
10140........................... Dixie County, Florida... 99910 0.8623 0.8594 -0.34
10150........................... Duval County, Florida... 27260 0.9295 0.9165 -1.40
10160........................... Escambia County, Florida 37860 0.8096 0.8000 -1.19
10170........................... Flagler County, Florida. 99910 0.8947 0.8594 -3.95
10180........................... Franklin County, Florida 99910 0.8623 0.8594 -0.34
10190........................... Gadsden County, Florida. 45220 0.8688 0.8942 2.92
10200........................... Gilchrist County, 23540 0.9033 0.9277 2.70
Florida.
10210........................... Glades County, Florida.. 99910 0.8623 0.8594 -0.34
10220........................... Gulf County, Florida.... 99910 0.8623 0.8594 -0.34
10230........................... Hamilton County, Florida 99910 0.8623 0.8594 -0.34
10240........................... Hardee County, Florida.. 99910 0.8623 0.8594 -0.34
10250........................... Hendry County, Florida.. 99910 0.8623 0.8594 -0.34
[[Page 65964]]
10260........................... Hernando County, Florida 45300 0.9233 0.9144 -0.96
10270........................... Highlands County, 99910 0.8623 0.8594 -0.34
Florida.
10280........................... Hillsborough County, 45300 0.9233 0.9144 -0.96
Florida.
10290........................... Holmes County, Florida.. 99910 0.8623 0.8594 -0.34
10300........................... Indian River County, 42680 0.9056 0.9573 5.71
Florida.
10310........................... Jackson County, Florida. 99910 0.8623 0.8594 -0.34
10320........................... Jefferson County, 45220 0.8683 0.8942 2.98
Florida.
10330........................... Lafayette County, 99910 0.8623 0.8594 -0.34
Florida.
10340........................... Lake County, Florida.... 36740 0.9464 0.9452 -0.13
10350........................... Lee County, Florida..... 15980 0.9356 0.9342 -0.15
10360........................... Leon County, Florida.... 45220 0.8688 0.8942 2.92
10370........................... Levy County, Florida.... 99910 0.8623 0.8594 -0.34
10380........................... Liberty County, Florida. 99910 0.8623 0.8594 -0.34
10390........................... Madison County, Florida. 99910 0.8623 0.8594 -0.34
10400........................... Manatee County, Florida. 42260 0.9639 0.9868 2.38
10410........................... Marion County, Florida.. 36100 0.8925 0.8867 -0.65
10420........................... Martin County, Florida.. 38940 1.0123 0.9833 -2.86
10430........................... Monroe County, Florida.. 99910 0.8623 0.8594 -0.34
10440........................... Nassau County, Florida.. 27260 0.9295 0.9165 -1.40
10450........................... Okaloosa County, Florida 23020 0.8872 0.8643 -2.58
10460........................... Okeechobee County, 99910 0.8623 0.8594 -0.34
Florida.
10470........................... Orange County, Florida.. 36740 0.9464 0.9452 -0.13
10480........................... Osceola County, Florida. 36740 0.9464 0.9452 -0.13
10490........................... Palm Beach County, 48424 1.0067 0.9649 -4.15
Florida.
10500........................... Pasco County, Florida... 45300 0.9233 0.9144 -0.96
10510........................... Pinellas County, Florida 45300 0.9233 0.9144 -0.96
10520........................... Polk County, Florida.... 29460 0.8912 0.8879 -0.37
10530........................... Putnam County, Florida.. 99910 0.8623 0.8594 -0.34
10540........................... Johns County, Florida... 27260 0.9295 0.9165 -1.40
10550........................... St Lucie County, Florida 38940 1.0123 0.9833 -2.86
10560........................... Santa Rosa County, 37860 0.8096 0.8000 -1.19
Florida.
10570........................... Sarasota County, Florida 42260 0.9639 0.9868 2.38
10580........................... Seminole County, Florida 36740 0.9464 0.9452 -0.13
10590........................... Sumter County, Florida.. 99910 0.8623 0.8594 -0.34
10600........................... Suwannee County, Florida 99910 0.8623 0.8594 -0.34
10610........................... Taylor County, Florida.. 99910 0.8623 0.8594 -0.34
10620........................... Union County, Florida... 99910 0.8623 0.8594 -0.34
10630........................... Volusia County, Florida. 19660 0.9312 0.9263 -0.53
10640........................... Wakulla County, Florida. 45220 0.8683 0.8942 2.98
10650........................... Walton County, Florida.. 99910 0.8623 0.8594 -0.34
10660........................... Washington County, 99910 0.8623 0.8594 -0.34
Florida.
11000........................... Appling County, Georgia. 99911 0.7914 0.7593 -4.06
11010........................... Atkinson County, Georgia 99911 0.7914 0.7593 -4.06
11011........................... Bacon County, Georgia... 99911 0.7914 0.7593 -4.06
11020........................... Baker County, Georgia... 10500 0.8397 0.8991 7.07
11030........................... Baldwin County, Georgia. 99911 0.7914 0.7593 -4.06
11040........................... Banks County, Georgia... 99911 0.7914 0.7593 -4.06
11050........................... Barrow County, Georgia.. 12060 0.9793 0.9762 -0.32
11060........................... Bartow County, Georgia.. 12060 0.9793 0.9762 -0.32
11070........................... Ben Hill County, Georgia 99911 0.7914 0.7593 -4.06
11080........................... Berrien County, Georgia. 99911 0.7914 0.7593 -4.06
11090........................... Bibb County, Georgia.... 31420 0.9360 0.9519 1.70
11100........................... Bleckley County, Georgia 99911 0.7914 0.7593 -4.06
11110........................... Brantley County, Georgia 15260 0.8739 1.0164 16.31
11120........................... Brooks County, Georgia.. 46660 0.8516 0.8369 -1.73
11130........................... Bryan County, Georgia... 42340 0.9461 0.9351 -1.16
11140........................... Bulloch County, Georgia. 99911 0.7914 0.7593 -4.06
11150........................... Burke County, Georgia... 12260 0.8957 0.9667 7.93
11160........................... Butts County, Georgia... 12060 0.8980 0.9762 8.71
11161........................... Calhoun County, Georgia. 99911 0.7914 0.7593 -4.06
11170........................... Camden County, Georgia.. 99911 0.7914 0.7593 -4.06
11180........................... Candler County, Georgia. 99911 0.7914 0.7593 -4.06
11190........................... Carroll County, Georgia. 12060 0.9793 0.9762 -0.32
11200........................... Catoosa County, Georgia. 16860 0.9088 0.8948 -1.54
11210........................... Charlton County, Georgia 99911 0.7914 0.7593 -4.06
11220........................... Chatham County, Georgia. 42340 0.9461 0.9351 -1.16
11230........................... Chattahoochee County, 17980 0.8560 0.8239 -3.75
Georgia.
11240........................... Chattooga County, 99911 0.7914 0.7593 -4.06
Georgia.
[[Page 65965]]
11250........................... Cherokee County, Georgia 12060 0.9793 0.9762 -0.32
11260........................... Clarke County, Georgia.. 12020 0.9855 0.9856 0.01
11270........................... Clay County, Georgia.... 99911 0.7914 0.7593 -4.06
11280........................... Clayton County, Georgia. 12060 0.9793 0.9762 -0.32
11281........................... Clinch County, Georgia.. 99911 0.7914 0.7593 -4.06
11290........................... Cobb County, Georgia.... 12060 0.9793 0.9762 -0.32
11291........................... Coffee County, Georgia.. 99911 0.7914 0.7593 -4.06
11300........................... Colquitt County, Georgia 99911 0.7914 0.7593 -4.06
11310........................... Columbia County, Georgia 12260 0.9778 0.9667 -1.14
11311........................... Cook County, Georgia.... 99911 0.7914 0.7593 -4.06
11320........................... Coweta County, Georgia.. 12060 0.9793 0.9762 -0.32
11330........................... Crawford County, Georgia 31420 0.8805 0.9519 8.11
11340........................... Crisp County, Georgia... 99911 0.7914 0.7593 -4.06
11341........................... Dade County, Georgia.... 16860 0.9088 0.8948 -1.54
11350........................... Dawson County, Georgia.. 12060 0.8980 0.9762 8.71
11360........................... Decatur County, Georgia. 99911 0.7914 0.7593 -4.06
11370........................... De Kalb County, Georgia. 12060 0.9793 0.9762 -0.32
11380........................... Dodge County, Georgia... 99911 0.7914 0.7593 -4.06
11381........................... Dooly County, Georgia... 99911 0.7914 0.7593 -4.06
11390........................... Dougherty County, 10500 0.8628 0.8991 4.21
Georgia.
11400........................... Douglas County, Georgia. 12060 0.9793 0.9762 -0.32
11410........................... Early County, Georgia... 99911 0.7914 0.7593 -4.06
11420........................... Echols County, Georgia.. 46660 0.8516 0.8369 -1.73
11421........................... Effingham County, 42340 0.9461 0.9351 -1.16
Georgia.
11430........................... Elbert County, Georgia.. 99911 0.7914 0.7593 -4.06
11440........................... Emanuel County, Georgia. 99911 0.7914 0.7593 -4.06
11441........................... Evans County, Georgia... 99911 0.7914 0.7593 -4.06
11450........................... Fannin County, Georgia.. 99911 0.7914 0.7593 -4.06
11451........................... Fayette County, Georgia. 12060 0.9793 0.9762 -0.32
11460........................... Floyd County, Georgia... 40660 0.8790 0.9193 4.58
11461........................... Forsyth County, Georgia. 12060 0.9793 0.9762 -0.32
11462........................... Franklin County, Georgia 99911 0.7914 0.7593 -4.06
11470........................... Fulton County, Georgia.. 12060 0.9793 0.9762 -0.32
11471........................... Gilmer County, Georgia.. 99911 0.7914 0.7593 -4.06
11480........................... Glascock County, Georgia 99911 0.7914 0.7593 -4.06
11490........................... Glynn County, Georgia... 15260 0.8739 1.0164 16.31
11500........................... Gordon County, Georgia.. 99911 0.7914 0.7593 -4.06
11510........................... Grady County, Georgia... 99911 0.7914 0.7593 -4.06
11520........................... Greene County, Georgia.. 99911 0.7914 0.7593 -4.06
11530........................... Gwinnett County, Georgia 12060 0.9793 0.9762 -0.32
11540........................... Habersham County, 99911 0.7914 0.7593 -4.06
Georgia.
11550........................... Hall County, Georgia.... 23580 0.8520 0.8958 5.14
11560........................... Hancock County, Georgia. 99911 0.7914 0.7593 -4.06
11570........................... Haralson County, Georgia 12060 0.8980 0.9762 8.71
11580........................... Harris County, Georgia.. 17980 0.8560 0.8239 -3.75
11581........................... Hart County, Georgia.... 99911 0.7914 0.7593 -4.06
11590........................... Heard County, Georgia... 12060 0.8980 0.9762 8.71
11591........................... Henry County, Georgia... 12060 0.9793 0.9762 -0.32
11600........................... Houston County, Georgia. 47580 0.8961 0.8380 -6.48
11601........................... Irwin County, Georgia... 99911 0.7914 0.7593 -4.06
11610........................... Jackson County, Georgia. 99911 0.7914 0.7593 -4.06
11611........................... Jasper County, Georgia.. 12060 0.8980 0.9762 8.71
11612........................... Jeff Davis County, 99911 0.7914 0.7593 -4.06
Georgia.
11620........................... Jefferson County, 99911 0.7914 0.7593 -4.06
Georgia.
11630........................... Jenkins County, Georgia. 99911 0.7914 0.7593 -4.06
11640........................... Johnson County, Georgia. 99911 0.7914 0.7593 -4.06
11650........................... Jones County, Georgia... 31420 0.9360 0.9519 1.70
11651........................... Lamar County, Georgia... 12060 0.8980 0.9762 8.71
11652........................... Lanier County, Georgia.. 46660 0.8516 0.8369 -1.73
11660........................... Laurens County, Georgia. 99911 0.7914 0.7593 -4.06
11670........................... Lee County, Georgia..... 10500 0.8628 0.8991 4.21
11680........................... Liberty County, Georgia. 25980 0.8973 0.9178 2.28
11690........................... Lincoln County, Georgia. 99911 0.7914 0.7593 -4.06
11691........................... Long County, Georgia.... 25980 0.8973 0.9178 2.28
11700........................... Lowndes County, Georgia. 46660 0.8516 0.8369 -1.73
11701........................... Lumpkin County, Georgia. 99911 0.7914 0.7593 -4.06
11702........................... Mc Duffie County, 12260 0.9778 0.9667 -1.14
Georgia.
11703........................... Mc Intosh County, 15260 0.8739 1.0164 16.31
Georgia.
[[Page 65966]]
11710........................... Macon County, Georgia... 99911 0.7914 0.7593 -4.06
11720........................... Madison County, Georgia. 12020 0.9855 0.9856 0.01
11730........................... Marion County, Georgia.. 17980 0.8363 0.8239 -1.48
11740........................... Meriwether County, 12060 0.8980 0.9762 8.71
Georgia.
11741........................... Miller County, Georgia.. 99911 0.7914 0.7593 -4.06
11750........................... Mitchell County, Georgia 99911 0.7914 0.7593 -4.06
11760........................... Monroe County, Georgia.. 31420 0.8805 0.9519 8.11
11770........................... Montgomery County, 99911 0.7914 0.7593 -4.06
Georgia.
11771........................... Morgan County, Georgia.. 99911 0.7914 0.7593 -4.06
11772........................... Murray County, Georgia.. 19140 0.8623 0.9093 5.45
11780........................... Muscogee County, Georgia 17980 0.8560 0.8239 -3.75
11790........................... Newton County, Georgia.. 12060 0.9793 0.9762 -0.32
11800........................... Oconee County, Georgia.. 12020 0.9855 0.9856 0.01
11801........................... Oglethorpe County, 12020 0.9011 0.9856 9.38
Georgia.
11810........................... Paulding County, Georgia 12060 0.9793 0.9762 -0.32
11811........................... Peach County, Georgia... 99911 0.8470 0.7593 -10.35
11812........................... Pickens County, Georgia. 12060 0.9793 0.9762 -0.32
11820........................... Pierce County, Georgia.. 99911 0.7914 0.7593 -4.06
11821........................... Pike County, Georgia.... 12060 0.8980 0.9762 8.71
11830........................... Polk County, Georgia.... 99911 0.7914 0.7593 -4.06
11831........................... Pulaski County, Georgia. 99911 0.7914 0.7593 -4.06
11832........................... Putnam County, Georgia.. 99911 0.7914 0.7593 -4.06
11833........................... Quitman County, Georgia. 99911 0.7914 0.7593 -4.06
11834........................... Rabun County, Georgia... 99911 0.7914 0.7593 -4.06
11835........................... Randolph County, Georgia 99911 0.7914 0.7593 -4.06
11840........................... Richmond County, Georgia 12260 0.9778 0.9667 -1.14
11841........................... Rockdale County, Georgia 12060 0.9793 0.9762 -0.32
11842........................... Schley County, Georgia.. 99911 0.7914 0.7593 -4.06
11850........................... Screven County, Georgia. 99911 0.7914 0.7593 -4.06
11851........................... Seminole County, Georgia 99911 0.7914 0.7593 -4.06
11860........................... Spalding County, Georgia 12060 0.9793 0.9762 -0.32
11861........................... Stephens County, Georgia 99911 0.7914 0.7593 -4.06
11862........................... Stewart County, Georgia. 99911 0.7914 0.7593 -4.06
11870........................... Sumter County, Georgia.. 99911 0.7914 0.7593 -4.06
11880........................... Talbot County, Georgia.. 99911 0.7914 0.7593 -4.06
11881........................... Taliaferro County, 99911 0.7914 0.7593 -4.06
Georgia.
11882........................... Tattnall County, Georgia 99911 0.7914 0.7593 -4.06
11883........................... Taylor County, Georgia.. 99911 0.7914 0.7593 -4.06
11884........................... Telfair County, Georgia. 99911 0.7914 0.7593 -4.06
11885........................... Terrell County, Georgia. 10500 0.8397 0.8991 7.07
11890........................... Thomas County, Georgia.. 99911 0.7914 0.7593 -4.06
11900........................... Tift County, Georgia.... 99911 0.7914 0.7593 -4.06
11901........................... Toombs County, Georgia.. 99911 0.7914 0.7593 -4.06
11902........................... Towns County, Georgia... 99911 0.7914 0.7593 -4.06
11903........................... Treutlen County, Georgia 99911 0.7914 0.7593 -4.06
11910........................... Troup County, Georgia... 99911 0.7914 0.7593 -4.06
11911........................... Turner County, Georgia.. 99911 0.7914 0.7593 -4.06
11912........................... Twiggs County, Georgia.. 31420 0.9360 0.9519 1.70
11913........................... Union County, Georgia... 99911 0.7914 0.7593 -4.06
11920........................... Upson County, Georgia... 99911 0.7914 0.7593 -4.06
11921........................... Walker County, Georgia.. 16860 0.9088 0.8948 -1.54
11930........................... Walton County, Georgia.. 12060 0.9793 0.9762 -0.32
11940........................... Ware County, Georgia.... 99911 0.7914 0.7593 -4.06
11941........................... Warren County, Georgia.. 99911 0.7914 0.7593 -4.06
11950........................... Washington County, 99911 0.7914 0.7593 -4.06
Georgia.
11960........................... Wayne County, Georgia... 99911 0.7914 0.7593 -4.06
11961........................... Webster County, Georgia. 99911 0.7914 0.7593 -4.06
11962........................... Wheeler County, Georgia. 99911 0.7914 0.7593 -4.06
11963........................... White County, Georgia... 99911 0.7914 0.7593 -4.06
11970........................... Whitfield County, 19140 0.8623 0.9093 5.45
Georgia.
11971........................... Wilcox County, Georgia.. 99911 0.7914 0.7593 -4.06
11972........................... Wilkes County, Georgia.. 99911 0.7914 0.7593 -4.06
11973........................... Wilkinson County, 99911 0.7914 0.7593 -4.06
Georgia.
11980........................... Worth County, Georgia... 10500 0.8397 0.8991 7.07
12005........................... Kalawao County, Hawaii.. 99912 1.0551 1.0448 -0.98
12010........................... Hawaii County, Hawaii... 99912 1.0551 1.0448 -0.98
12020........................... Honolulu County, Hawaii. 26180 1.1214 1.1096 -1.05
12040........................... Kauai County, Hawaii.... 99912 1.0551 1.0448 -0.98
[[Page 65967]]
12050........................... Maui County, Hawaii..... 99912 1.0551 1.0448 -0.98
13000........................... Ada County, Idaho....... 14260 0.9052 0.9401 3.86
13010........................... Adams County, Idaho..... 99913 0.8567 0.8120 -5.22
13020........................... Bannock County, Idaho... 38540 0.9351 0.9400 0.52
13030........................... Bear Lake County, Idaho. 99913 0.8567 0.8120 -5.22
13040........................... Benewah County, Idaho... 99913 0.8567 0.8120 -5.22
13050........................... Bingham County, Idaho... 99913 0.8567 0.8120 -5.22
13060........................... Blaine County, Idaho.... 99913 0.8567 0.8120 -5.22
13070........................... Boise County, Idaho..... 14260 0.9075 0.9401 3.59
13080........................... Bonner County, Idaho.... 99913 0.8567 0.8120 -5.22
13090........................... Bonneville County, Idaho 26820 0.9259 0.9088 -1.85
13100........................... Boundary County, Idaho.. 99913 0.8567 0.8120 -5.22
13110........................... Butte County, Idaho..... 99913 0.8567 0.8120 -5.22
13120........................... Camas County, Idaho..... 99913 0.8567 0.8120 -5.22
13130........................... Canyon County, Idaho.... 14260 0.9052 0.9401 3.86
13140........................... Caribou County, Idaho... 99913 0.8567 0.8120 -5.22
13150........................... Cassia County, Idaho.... 99913 0.8567 0.8120 -5.22
13160........................... Clark County, Idaho..... 99913 0.8567 0.8120 -5.22
13170........................... Clearwater County, Idaho 99913 0.8567 0.8120 -5.22
13180........................... Custer County, Idaho.... 99913 0.8567 0.8120 -5.22
13190........................... Elmore County, Idaho.... 99913 0.8567 0.8120 -5.22
13200........................... Franklin County, Idaho.. 30860 0.9131 0.9022 -1.19
13210........................... Fremont County, Idaho... 99913 0.8567 0.8120 -5.22
13220........................... Gem County, Idaho....... 14260 0.9075 0.9401 3.59
13230........................... Gooding County, Idaho... 99913 0.8567 0.8120 -5.22
13240........................... Idaho County, Idaho..... 99913 0.8567 0.8120 -5.22
13250........................... Jefferson County, Idaho. 26820 0.9259 0.9088 -1.85
13260........................... Jerome County, Idaho.... 99913 0.8567 0.8120 -5.22
13270........................... Kootenai County, Idaho.. 17660 0.9372 0.9344 -0.30
13280........................... Latah County, Idaho..... 99913 0.8567 0.8120 -5.22
13290........................... Lemhi County, Idaho..... 99913 0.8567 0.8120 -5.22
13300........................... Lewis County, Idaho..... 99913 0.8567 0.8120 -5.22
13310........................... Lincoln County, Idaho... 99913 0.8567 0.8120 -5.22
13320........................... Madison County, Idaho... 99913 0.8567 0.8120 -5.22
13330........................... Minidoka County, Idaho.. 99913 0.8567 0.8120 -5.22
13340........................... Nez Perce County, Idaho. 30300 0.9492 0.9853 3.80
13350........................... Oneida County, Idaho.... 99913 0.8567 0.8120 -5.22
13360........................... Owyhee County, Idaho.... 14260 0.9075 0.9401 3.59
13370........................... Payette County, Idaho... 99913 0.8567 0.8120 -5.22
13380........................... Power County, Idaho..... 38540 0.9224 0.9400 1.91
13390........................... Shoshone County, Idaho.. 99913 0.8567 0.8120 -5.22
13400........................... Teton County, Idaho..... 99913 0.8567 0.8120 -5.22
13410........................... Twin Falls County, Idaho 99913 0.8567 0.8120 -5.22
13420........................... Valley County, Idaho.... 99913 0.8567 0.8120 -5.22
13430........................... Washington County, Idaho 99913 0.8567 0.8120 -5.22
14000........................... Adams County, Illinois.. 99914 0.8286 0.8320 0.41
14010........................... Alexander County, 99914 0.8286 0.8320 0.41
Illinois.
14020........................... Bond County, Illinois... 41180 0.8628 0.9005 4.37
14030........................... Boone County, Illinois.. 40420 0.9984 0.9989 0.05
14040........................... Brown County, Illinois.. 99914 0.8286 0.8320 0.41
14050........................... Bureau County, Illinois. 99914 0.8286 0.8320 0.41
14060........................... Calhoun County, Illinois 41180 0.8628 0.9005 4.37
14070........................... Carroll County, Illinois 99914 0.8286 0.8320 0.41
14080........................... Cass County, Illinois... 99914 0.8286 0.8320 0.41
14090........................... Champaign County, 16580 0.9594 0.9644 0.52
Illinois.
14100........................... Christian County, 99914 0.8286 0.8320 0.41
Illinois.
14110........................... Clark County, Illinois.. 99914 0.8286 0.8320 0.41
14120........................... Clay County, Illinois... 99914 0.8286 0.8320 0.41
14130........................... Clinton County, Illinois 41180 0.8958 0.9005 0.52
14140........................... Coles County, Illinois.. 99914 0.8286 0.8320 0.41
14141........................... Cook County, Illinois... 16974 1.0787 1.0751 -0.33
14150........................... Crawford County, 99914 0.8286 0.8320 0.41
Illinois.
14160........................... Cumberland County, 99914 0.8286 0.8320 0.41
Illinois.
14170........................... De Kalb County, Illinois 16974 1.0787 1.0751 -0.33
14180........................... De Witt County, Illinois 99914 0.8286 0.8320 0.41
14190........................... Douglas County, Illinois 99914 0.8286 0.8320 0.41
14250........................... Du Page County, Illinois 16974 1.0787 1.0751 -0.33
14310........................... Edgar County, Illinois.. 99914 0.8286 0.8320 0.41
[[Page 65968]]
14320........................... Edwards County, Illinois 99914 0.8286 0.8320 0.41
14330........................... Effingham County, 99914 0.8286 0.8320 0.41
Illinois.
14340........................... Fayette County, Illinois 99914 0.8286 0.8320 0.41
14350........................... Ford County, Illinois... 16580 0.8948 0.9644 7.78
14360........................... Franklin County, 99914 0.8286 0.8320 0.41
Illinois.
14370........................... Fulton County, Illinois. 99914 0.8286 0.8320 0.41
14380........................... Gallatin County, 99914 0.8286 0.8320 0.41
Illinois.
14390........................... Greene County, Illinois. 99914 0.8286 0.8320 0.41
14400........................... Grundy County, Illinois. 16974 1.0787 1.0751 -0.33
14410........................... Hamilton County, 99914 0.8286 0.8320 0.41
Illinois.
14420........................... Hancock County, Illinois 99914 0.8286 0.8320 0.41
14421........................... Hardin County, Illinois. 99914 0.8286 0.8320 0.41
14440........................... Henderson County, 99914 0.8286 0.8320 0.41
Illinois.
14450........................... Henry County, Illinois.. 19340 0.8724 0.8846 1.40
14460........................... Iroquois County, 99914 0.8286 0.8320 0.41
Illinois.
14470........................... Jackson County, Illinois 99914 0.8286 0.8320 0.41
14480........................... Jasper County, Illinois. 99914 0.8286 0.8320 0.41
14490........................... Jefferson County, 99914 0.8286 0.8320 0.41
Illinois.
14500........................... Jersey County, Illinois. 41180 0.8958 0.9005 0.52
14510........................... Jo Daviess County, 99914 0.8286 0.8320 0.41
Illinois.
14520........................... Johnson County, Illinois 99914 0.8286 0.8320 0.41
14530........................... Kane County, Illinois... 16974 1.0787 1.0751 -0.33
14540........................... Kankakee County, 28100 1.0721 1.0083 -5.95
Illinois.
14550........................... Kendall County, Illinois 16974 1.0787 1.0751 -0.33
14560........................... Knox County, Illinois... 99914 0.8286 0.8320 0.41
14570........................... Lake County, Illinois... 29404 1.0606 1.0570 -0.34
14580........................... La Salle County, 99914 0.8286 0.8320 0.41
Illinois.
14590........................... Lawrence County, 99914 0.8286 0.8320 0.41
Illinois.
14600........................... Lee County, Illinois.... 99914 0.8286 0.8320 0.41
14610........................... Livingston County, 99914 0.8286 0.8320 0.41
Illinois.
14620........................... Logan County, Illinois.. 99914 0.8286 0.8320 0.41
14630........................... Mc Donough County, 99914 0.8286 0.8320 0.41
Illinois.
14640........................... Mc Henry County, 16974 1.0787 1.0751 -0.33
Illinois.
14650........................... Mclean County, Illinois. 14060 0.9075 0.8944 -1.44
14660........................... Macon County, Illinois.. 19500 0.8067 0.8172 1.30
14670........................... Macoupin County, 41180 0.8628 0.9005 4.37
Illinois.
14680........................... Madison County, Illinois 41180 0.8958 0.9005 0.52
14690........................... Marion County, Illinois. 99914 0.8286 0.8320 0.41
14700........................... Marshall County, 37900 0.8586 0.8982 4.61
Illinois.
14710........................... Mason County, Illinois.. 99914 0.8286 0.8320 0.41
14720........................... Massac County, Illinois. 99914 0.8286 0.8320 0.41
14730........................... Menard County, Illinois. 44100 0.8792 0.8890 1.11
14740........................... Mercer County, Illinois. 19340 0.8513 0.8846 3.91
14750........................... Monroe County, Illinois. 41180 0.8958 0.9005 0.52
14760........................... Montgomery County, 99914 0.8286 0.8320 0.41
Illinois.
14770........................... Morgan County, Illinois. 99914 0.8286 0.8320 0.41
14780........................... Moultrie County, 99914 0.8286 0.8320 0.41
Illinois.
14790........................... Ogle County, Illinois... 99914 0.9128 0.8320 -8.85
14800........................... Peoria County, Illinois. 37900 0.8870 0.8982 1.26
14810........................... Perry County, Illinois.. 99914 0.8286 0.8320 0.41
14820........................... Piatt County, Illinois.. 16580 0.8948 0.9644 7.78
14830........................... Pike County, Illinois... 99914 0.8286 0.8320 0.41
14831........................... Pope County, Illinois... 99914 0.8286 0.8320 0.41
14850........................... Pulaski County, Illinois 99914 0.8286 0.8320 0.41
14860........................... Putnam County, Illinois. 99914 0.8286 0.8320 0.41
14870........................... Randolph County, 99914 0.8286 0.8320 0.41
Illinois.
14880........................... Richland County, 99914 0.8286 0.8320 0.41
Illinois.
14890........................... Rock Island County, 19340 0.8724 0.8846 1.40
Illinois.
14900........................... St Clair County, 41180 0.8958 0.9005 0.52
Illinois.
14910........................... Saline County, Illinois. 99914 0.8286 0.8320 0.41
14920........................... Sangamon County, 44100 0.8792 0.8890 1.11
Illinois.
14921........................... Schuyler County, 99914 0.8286 0.8320 0.41
Illinois.
14940........................... Scott County, Illinois.. 99914 0.8286 0.8320 0.41
14950........................... Shelby County, Illinois. 99914 0.8286 0.8320 0.41
14960........................... Stark County, Illinois.. 37900 0.8586 0.8982 4.61
14970........................... Stephenson County, 99914 0.8286 0.8320 0.41
Illinois.
14980........................... Tazewell County, 37900 0.8870 0.8982 1.26
Illinois.
14981........................... Union County, Illinois.. 99914 0.8286 0.8320 0.41
[[Page 65969]]
14982........................... Vermilion County, 19180 0.8665 0.9266 6.94
Illinois.
14983........................... Wabash County, Illinois. 99914 0.8286 0.8320 0.41
14984........................... Warren County, Illinois. 99914 0.8286 0.8320 0.41
14985........................... Washington County, 99914 0.8286 0.8320 0.41
Illinois.
14986........................... Wayne County, Illinois.. 99914 0.8286 0.8320 0.41
14987........................... White County, Illinois.. 99914 0.8286 0.8320 0.41
14988........................... Whiteside County, 99914 0.8286 0.8320 0.41
Illinois.
14989........................... Will County, Illinois... 16974 1.0787 1.0751 -0.33
14990........................... Williamson County, 99914 0.8286 0.8320 0.41
Illinois.
14991........................... Winnebago County, 40420 0.9984 0.9989 0.05
Illinois.
14992........................... Woodford County, 37900 0.8870 0.8982 1.26
Illinois.
15000........................... Adams County, Indiana... 99915 0.9165 0.8538 -6.84
15010........................... Allen County, Indiana... 23060 0.9750 0.9517 -2.39
15020........................... Bartholomew County, 18020 0.9164 0.9318 1.68
Indiana.
15030........................... Benton County, Indiana.. 29140 0.8738 0.8931 2.21
15040........................... Blackford County, 99915 0.8682 0.8538 -1.66
Indiana.
15050........................... Boone County, Indiana... 26900 0.9893 0.9895 0.02
15060........................... Brown County, Indiana... 26900 0.9330 0.9895 6.06
15070........................... Carroll County, Indiana. 29140 0.8738 0.8931 2.21
15080........................... Cass County, Indiana.... 99915 0.8682 0.8538 -1.66
15090........................... Clark County, Indiana... 31140 0.9272 0.9118 -1.66
15100........................... Clay County, Indiana.... 45460 0.8321 0.8765 5.34
15110........................... Clinton County, Indiana. 99915 0.8680 0.8538 -1.64
15120........................... Crawford County, Indiana 99915 0.8682 0.8538 -1.66
15130........................... Daviess County, Indiana. 99915 0.8682 0.8538 -1.66
15140........................... Dearborn County, Indiana 17140 0.9675 0.9601 -0.76
15150........................... Decatur County, Indiana. 99915 0.8682 0.8538 -1.66
15160........................... De Kalb County, Indiana. 99915 0.9165 0.8538 -6.84
15170........................... Delaware County, Indiana 34620 0.8930 0.8562 -4.12
15180........................... Dubois County, Indiana.. 99915 0.8682 0.8538 -1.66
15190........................... Elkhart County, Indiana. 21140 0.9627 0.9426 -2.09
15200........................... Fayette County, Indiana. 99915 0.8682 0.8538 -1.66
15210........................... Floyd County, Indiana... 31140 0.9272 0.9118 -1.66
15220........................... Fountain County, Indiana 99915 0.8682 0.8538 -1.66
15230........................... Franklin County, Indiana 17140 0.9177 0.9601 4.62
15240........................... Fulton County, Indiana.. 99915 0.8682 0.8538 -1.66
15250........................... Gibson County, Indiana.. 21780 0.8726 0.9071 3.95
15260........................... Grant County, Indiana... 99915 0.8682 0.8538 -1.66
15270........................... Greene County, Indiana.. 14020 0.8593 0.8533 -0.70
15280........................... Hamilton County, Indiana 26900 0.9893 0.9895 0.02
15290........................... Hancock County, Indiana. 26900 0.9893 0.9895 0.02
15300........................... Harrison County, Indiana 31140 0.9272 0.9118 -1.66
15310........................... Hendricks County, 26900 0.9893 0.9895 0.02
Indiana.
15320........................... Henry County, Indiana... 99915 0.8682 0.8538 -1.66
15330........................... Howard County, Indiana.. 29020 0.9508 0.9669 1.69
15340........................... Huntington County, 99915 0.9165 0.8538 -6.84
Indiana.
15350........................... Jackson County, Indiana. 99915 0.8682 0.8538 -1.66
15360........................... Jasper County, Indiana.. 23844 0.9067 0.9334 2.94
15370........................... Jay County, Indiana..... 99915 0.8682 0.8538 -1.66
15380........................... Jefferson County, 99915 0.8682 0.8538 -1.66
Indiana.
15390........................... Jennings County, Indiana 99915 0.8682 0.8538 -1.66
15400........................... Johnson County, Indiana. 26900 0.9893 0.9895 0.02
15410........................... Knox County, Indiana.... 99915 0.8682 0.8538 -1.66
15420........................... Kosciusko County, 99915 0.8682 0.8538 -1.66
Indiana.
15430........................... Lagrange County, Indiana 99915 0.8682 0.8538 -1.66
15440........................... Lake County, Indiana.... 23844 0.9395 0.9334 -0.65
15450........................... La Porte County, Indiana 33140 0.9069 0.9118 0.54
15460........................... Lawrence County, Indiana 99915 0.8682 0.8538 -1.66
15470........................... Madison County, Indiana. 11300 0.9226 0.8681 -5.91
15480........................... Marion County, Indiana.. 26900 0.9893 0.9895 0.02
15490........................... Marshall County, Indiana 99915 0.8682 0.8538 -1.66
15500........................... Martin County, Indiana.. 99915 0.8682 0.8538 -1.66
15510........................... Miami County, Indiana... 99915 0.8682 0.8538 -1.66
15520........................... Monroe County, Indiana.. 14020 0.8447 0.8533 1.02
15530........................... Montgomery County, 99915 0.8682 0.8538 -1.66
Indiana.
15540........................... Morgan County, Indiana.. 26900 0.9893 0.9895 0.02
15550........................... Newton County, Indiana.. 23844 0.9067 0.9334 2.94
15560........................... Noble County, Indiana... 99915 0.8682 0.8538 -1.66
[[Page 65970]]
15570........................... Ohio County, Indiana.... 17140 0.9675 0.9601 -0.76
15580........................... Orange County, Indiana.. 99915 0.8682 0.8538 -1.66
15590........................... Owen County, Indiana.... 14020 0.8593 0.8533 -0.70
15600........................... Parke County, Indiana... 99915 0.8682 0.8538 -1.66
15610........................... Perry County, Indiana... 99915 0.8682 0.8538 -1.66
15620........................... Pike County, Indiana.... 99915 0.8682 0.8538 -1.66
15630........................... Porter County, Indiana.. 23844 0.9395 0.9334 -0.65
15640........................... Posey County, Indiana... 21780 0.8713 0.9071 4.11
15650........................... Pulaski County, Indiana. 99915 0.8682 0.8538 -1.66
15660........................... Putnam County, Indiana.. 26900 0.9330 0.9895 6.06
15670........................... Randolph County, Indiana 99915 0.8682 0.8538 -1.66
15680........................... Ripley County, Indiana.. 99915 0.8682 0.8538 -1.66
15690........................... Rush County, Indiana.... 99915 0.8682 0.8538 -1.66
15700........................... St Joseph County, 43780 0.9788 0.9842 0.55
Indiana.
15710........................... Scott County, Indiana... 99915 0.8959 0.8538 -4.70
15720........................... Shelby County, Indiana.. 26900 0.9893 0.9895 0.02
15730........................... Spencer County, Indiana. 99915 0.8682 0.8538 -1.66
15740........................... Starke County, Indiana.. 99915 0.8682 0.8538 -1.66
15750........................... Steuben County, Indiana. 99915 0.8682 0.8538 -1.66
15760........................... Sullivan County, Indiana 45460 0.8522 0.8765 2.85
15770........................... Switzerland County, 99915 0.8682 0.8538 -1.66
Indiana.
15780........................... Tippecanoe County, 29140 0.8736 0.8931 2.23
Indiana.
15790........................... Tipton County, Indiana.. 29020 0.9508 0.9669 1.69
15800........................... Union County, Indiana... 99915 0.8682 0.8538 -1.66
15810........................... Vanderburgh County, 21780 0.8713 0.9071 4.11
Indiana.
15820........................... Vermillion County, 45460 0.8321 0.8765 5.34
Indiana.
15830........................... Vigo County, Indiana.... 45460 0.8321 0.8765 5.34
15840........................... Wabash County, Indiana.. 99915 0.8682 0.8538 -1.66
15850........................... Warren County, Indiana.. 99915 0.8682 0.8538 -1.66
15860........................... Warrick County, Indiana. 21780 0.8713 0.9071 4.11
15870........................... Washington County, 31140 0.8995 0.9118 1.37
Indiana.
15880........................... Wayne County, Indiana... 99915 0.8682 0.8538 -1.66
15890........................... Wells County, Indiana... 23060 0.9750 0.9517 -2.39
15900........................... White County, Indiana... 99915 0.8682 0.8538 -1.66
15910........................... Whitley County, Indiana. 23060 0.9750 0.9517 -2.39
16000........................... Adair County, Iowa...... 99916 0.8552 0.8681 1.51
16010........................... Adams County, Iowa...... 99916 0.8552 0.8681 1.51
16020........................... Allamakee County, Iowa.. 99916 0.8552 0.8681 1.51
16030........................... Appanoose County, Iowa.. 99916 0.8552 0.8681 1.51
16040........................... Audubon County, Iowa.... 99916 0.8552 0.8681 1.51
16050........................... Benton County, Iowa..... 16300 0.8710 0.8888 2.04
16060........................... Black Hawk County, Iowa. 47940 0.8557 0.8408 -1.74
16070........................... Boone County, Iowa...... 99916 0.8552 0.8681 1.51
16080........................... Bremer County, Iowa..... 47940 0.8576 0.8408 -1.96
16090........................... Buchanan County, Iowa... 99916 0.8552 0.8681 1.51
16100........................... Buena Vista County, Iowa 99916 0.8552 0.8681 1.51
16110........................... Butler County, Iowa..... 99916 0.8552 0.8681 1.51
16120........................... Calhoun County, Iowa.... 99916 0.8552 0.8681 1.51
16130........................... Carroll County, Iowa.... 99916 0.8552 0.8681 1.51
16140........................... Cass County, Iowa....... 99916 0.8552 0.8681 1.51
16150........................... Cedar County, Iowa...... 99916 0.8552 0.8681 1.51
16160........................... Cerro Gordo County, Iowa 99916 0.8552 0.8681 1.51
16170........................... Cherokee County, Iowa... 99916 0.8552 0.8681 1.51
16180........................... Chickasaw County, Iowa.. 99916 0.8552 0.8681 1.51
16190........................... Clarke County, Iowa..... 99916 0.8552 0.8681 1.51
16200........................... Clay County, Iowa....... 99916 0.8552 0.8681 1.51
16210........................... Clayton County, Iowa.... 99916 0.8552 0.8681 1.51
16220........................... Clinton County, Iowa.... 99916 0.8552 0.8681 1.51
16230........................... Crawford County, Iowa... 99916 0.8552 0.8681 1.51
16240........................... Dallas County, Iowa..... 19780 0.9669 0.9214 -4.71
16250........................... Davis County, Iowa...... 99916 0.8552 0.8681 1.51
16260........................... Decatur County, Iowa.... 99916 0.8552 0.8681 1.51
16270........................... Delaware County, Iowa... 99916 0.8552 0.8681 1.51
16280........................... Des Moines County, Iowa. 99916 0.8552 0.8681 1.51
16290........................... Dickinson County, Iowa.. 99916 0.8552 0.8681 1.51
16300........................... Dubuque County, Iowa.... 20220 0.9024 0.9133 1.21
16310........................... Emmet County, Iowa...... 99916 0.8552 0.8681 1.51
16320........................... Fayette County, Iowa.... 99916 0.8552 0.8681 1.51
[[Page 65971]]
16330........................... Floyd County, Iowa...... 99916 0.8552 0.8681 1.51
16340........................... Franklin County, Iowa... 99916 0.8552 0.8681 1.51
16350........................... Fremont County, Iowa.... 99916 0.8552 0.8681 1.51
16360........................... Greene County, Iowa..... 99916 0.8552 0.8681 1.51
16370........................... Grundy County, Iowa..... 47940 0.8576 0.8408 -1.96
16380........................... Guthrie County, Iowa.... 19780 0.9132 0.9214 0.90
16390........................... Hamilton County, Iowa... 99916 0.8552 0.8681 1.51
16400........................... Hancock County, Iowa.... 99916 0.8552 0.8681 1.51
16410........................... Hardin County, Iowa..... 99916 0.8552 0.8681 1.51
16420........................... Harrison County, Iowa... 36540 0.9077 0.9450 4.11
16430........................... Henry County, Iowa...... 99916 0.8552 0.8681 1.51
16440........................... Howard County, Iowa..... 99916 0.8552 0.8681 1.51
16450........................... Humboldt County, Iowa... 99916 0.8552 0.8681 1.51
16460........................... Ida County, Iowa........ 99916 0.8552 0.8681 1.51
16470........................... Iowa County, Iowa....... 99916 0.8552 0.8681 1.51
16480........................... Jackson County, Iowa.... 99916 0.8552 0.8681 1.51
16490........................... Jasper County, Iowa..... 99916 0.8552 0.8681 1.51
16500........................... Jefferson County, Iowa.. 99916 0.8552 0.8681 1.51
16510........................... Johnson County, Iowa.... 26980 0.9747 0.9714 -0.34
16520........................... Jones County, Iowa...... 16300 0.8710 0.8888 2.04
16530........................... Keokuk County, Iowa..... 99916 0.8552 0.8681 1.51
16540........................... Kossuth County, Iowa.... 99916 0.8552 0.8681 1.51
16550........................... Lee County, Iowa........ 99916 0.8552 0.8681 1.51
16560........................... Linn County, Iowa....... 16300 0.8825 0.8888 0.71
16570........................... Louisa County, Iowa..... 99916 0.8552 0.8681 1.51
16580........................... Lucas County, Iowa...... 99916 0.8552 0.8681 1.51
16590........................... Lyon County, Iowa....... 99916 0.8552 0.8681 1.51
16600........................... Madison County, Iowa.... 19780 0.9132 0.9214 0.90
16610........................... Mahaska County, Iowa.... 99916 0.8552 0.8681 1.51
16620........................... Marion County, Iowa..... 99916 0.8552 0.8681 1.51
16630........................... Marshall County, Iowa... 99916 0.8552 0.8681 1.51
16640........................... Mills County, Iowa...... 36540 0.9077 0.9450 4.11
16650........................... Mitchell County, Iowa... 99916 0.8552 0.8681 1.51
16660........................... Monona County, Iowa..... 99916 0.8552 0.8681 1.51
16670........................... Monroe County, Iowa..... 99916 0.8552 0.8681 1.51
16680........................... Montgomery County, Iowa. 99916 0.8552 0.8681 1.51
16690........................... Muscatine County, Iowa.. 99916 0.8552 0.8681 1.51
16700........................... O Brien County, Iowa.... 99916 0.8552 0.8681 1.51
16710........................... Osceola County, Iowa.... 99916 0.8552 0.8681 1.51
16720........................... Page County, Iowa....... 99916 0.8552 0.8681 1.51
16730........................... Palo Alto County, Iowa.. 99916 0.8552 0.8681 1.51
16740........................... Plymouth County, Iowa... 99916 0.8552 0.8681 1.51
16750........................... Pocahontas County, Iowa. 99916 0.8552 0.8681 1.51
16760........................... Polk County, Iowa....... 19780 0.9669 0.9214 -4.71
16770........................... Pottawattamie County, 36540 0.9560 0.9450 -1.15
Iowa.
16780........................... Poweshiek County, Iowa.. 99916 0.8552 0.8681 1.51
16790........................... Ringgold County, Iowa... 99916 0.8552 0.8681 1.51
16800........................... Sac County, Iowa........ 99916 0.8552 0.8681 1.51
16810........................... Scott County, Iowa...... 19340 0.8724 0.8846 1.40
16820........................... Shelby County, Iowa..... 99916 0.8552 0.8681 1.51
16830........................... Sioux County, Iowa...... 99916 0.8552 0.8681 1.51
16840........................... Story County, Iowa...... 11180 0.9065 0.9760 7.67
16850........................... Tama County, Iowa....... 99916 0.8552 0.8681 1.51
16860........................... Taylor County, Iowa..... 99916 0.8552 0.8681 1.51
16870........................... Union County, Iowa...... 99916 0.8552 0.8681 1.51
16880........................... Van Buren County, Iowa.. 99916 0.8552 0.8681 1.51
16890........................... Wapello County, Iowa.... 99916 0.8552 0.8681 1.51
16900........................... Warren County, Iowa..... 19780 0.9669 0.9214 -4.71
16910........................... Washington County, Iowa. 26980 0.9171 0.9714 5.92
16920........................... Wayne County, Iowa...... 99916 0.8552 0.8681 1.51
16930........................... Webster County, Iowa.... 99916 0.8552 0.8681 1.51
16940........................... Winnebago County, Iowa.. 99916 0.8552 0.8681 1.51
16950........................... Winneshiek County, Iowa. 99916 0.8552 0.8681 1.51
16960........................... Woodbury County, Iowa... 43580 0.9399 0.9200 -2.12
16970........................... Worth County, Iowa...... 99916 0.8552 0.8681 1.51
16980........................... Wright County, Iowa..... 99916 0.8552 0.8681 1.51
17000........................... Allen County, Kansas.... 99917 0.8038 0.7998 -0.50
17010........................... Anderson County, Kansas. 99917 0.8038 0.7998 -0.50
[[Page 65972]]
17020........................... Atchison County, Kansas. 99917 0.8038 0.7998 -0.50
17030........................... Barber County, Kansas... 99917 0.8038 0.7998 -0.50
17040........................... Barton County, Kansas... 99917 0.8038 0.7998 -0.50
17050........................... Bourbon County, Kansas.. 99917 0.8038 0.7998 -0.50
17060........................... Brown County, Kansas.... 99917 0.8038 0.7998 -0.50
17070........................... Butler County, Kansas... 48620 0.9164 0.9063 -1.10
17080........................... Chase County, Kansas.... 99917 0.8038 0.7998 -0.50
17090........................... Chautauqua County, 99917 0.8038 0.7998 -0.50
Kansas.
17100........................... Cherokee County, Kansas. 99917 0.8038 0.7998 -0.50
17110........................... Cheyenne County, Kansas. 99917 0.8038 0.7998 -0.50
17120........................... Clark County, Kansas.... 99917 0.8038 0.7998 -0.50
17130........................... Clay County, Kansas..... 99917 0.8038 0.7998 -0.50
17140........................... Cloud County, Kansas.... 99917 0.8038 0.7998 -0.50
17150........................... Coffey County, Kansas... 99917 0.8038 0.7998 -0.50
17160........................... Comanche County, Kansas. 99917 0.8038 0.7998 -0.50
17170........................... Cowley County, Kansas... 99917 0.8038 0.7998 -0.50
17180........................... Crawford County, Kansas. 99917 0.8038 0.7998 -0.50
17190........................... Decatur County, Kansas.. 99917 0.8038 0.7998 -0.50
17200........................... Dickinson County, Kansas 99917 0.8038 0.7998 -0.50
17210........................... Doniphan County, Kansas. 41140 0.8780 1.0118 15.24
17220........................... Douglas County, Kansas.. 29940 0.8537 0.8365 -2.01
17230........................... Edwards County, Kansas.. 99917 0.8038 0.7998 -0.50
17240........................... Elk County, Kansas...... 99917 0.8038 0.7998 -0.50
17250........................... Ellis County, Kansas.... 99917 0.8038 0.7998 -0.50
17260........................... Ellsworth County, Kansas 99917 0.8038 0.7998 -0.50
17270........................... Finney County, Kansas... 99917 0.8038 0.7998 -0.50
17280........................... Ford County, Kansas..... 99917 0.8038 0.7998 -0.50
17290........................... Franklin County, Kansas. 28140 0.8758 0.9495 8.42
17300........................... Geary County, Kansas.... 99917 0.8038 0.7998 -0.50
17310........................... Gove County, Kansas..... 99917 0.8038 0.7998 -0.50
17320........................... Graham County, Kansas... 99917 0.8038 0.7998 -0.50
17330........................... Grant County, Kansas.... 99917 0.8038 0.7998 -0.50
17340........................... Gray County, Kansas..... 99917 0.8038 0.7998 -0.50
17350........................... Greeley County, Kansas.. 99917 0.8038 0.7998 -0.50
17360........................... Greenwood County, Kansas 99917 0.8038 0.7998 -0.50
17370........................... Hamilton County, Kansas. 99917 0.8038 0.7998 -0.50
17380........................... Harper County, Kansas... 99917 0.8038 0.7998 -0.50
17390........................... Harvey County, Kansas... 48620 0.9164 0.9063 -1.10
17391........................... Haskell County, Kansas.. 99917 0.8038 0.7998 -0.50
17410........................... Hodgeman County, Kansas. 99917 0.8038 0.7998 -0.50
17420........................... Jackson County, Kansas.. 45820 0.8480 0.8730 2.95
17430........................... Jefferson County, Kansas 45820 0.8480 0.8730 2.95
17440........................... Jewell County, Kansas... 99917 0.8038 0.7998 -0.50
17450........................... Johnson County, Kansas.. 28140 0.9483 0.9495 0.13
17451........................... Kearny County, Kansas... 99917 0.8038 0.7998 -0.50
17470........................... Kingman County, Kansas.. 99917 0.8038 0.7998 -0.50
17480........................... Kiowa County, Kansas.... 99917 0.8038 0.7998 -0.50
17490........................... Labette County, Kansas.. 99917 0.8038 0.7998 -0.50
17500........................... Lane County, Kansas..... 99917 0.8038 0.7998 -0.50
17510........................... Leavenworth County, 28140 0.9483 0.9495 0.13
Kansas.
17520........................... Lincoln County, Kansas.. 99917 0.8038 0.7998 -0.50
17530........................... Linn County, Kansas..... 28140 0.8758 0.9495 8.42
17540........................... Logan County, Kansas.... 99917 0.8038 0.7998 -0.50
17550........................... Lyon County, Kansas..... 99917 0.8038 0.7998 -0.50
17560........................... Mc Pherson County, 99917 0.8038 0.7998 -0.50
Kansas.
17570........................... Marion County, Kansas... 99917 0.8038 0.7998 -0.50
17580........................... Marshall County, Kansas. 99917 0.8038 0.7998 -0.50
17590........................... Meade County, Kansas.... 99917 0.8038 0.7998 -0.50
17600........................... Miami County, Kansas.... 28140 0.9483 0.9495 0.13
17610........................... Mitchell County, Kansas. 99917 0.8038 0.7998 -0.50
17620........................... Montgomery County, 99917 0.8038 0.7998 -0.50
Kansas.
17630........................... Morris County, Kansas... 99917 0.8038 0.7998 -0.50
17640........................... Morton County, Kansas... 99917 0.8038 0.7998 -0.50
17650........................... Nemaha County, Kansas... 99917 0.8038 0.7998 -0.50
17660........................... Neosho County, Kansas... 99917 0.8038 0.7998 -0.50
17670........................... Ness County, Kansas..... 99917 0.8038 0.7998 -0.50
17680........................... Norton County, Kansas... 99917 0.8038 0.7998 -0.50
17690........................... Osage County, Kansas.... 45820 0.8480 0.8730 2.95
[[Page 65973]]
17700........................... Osborne County, Kansas.. 99917 0.8038 0.7998 -0.50
17710........................... Ottawa County, Kansas... 99917 0.8038 0.7998 -0.50
17720........................... Pawnee County, Kansas... 99917 0.8038 0.7998 -0.50
17730........................... Phillips County, Kansas. 99917 0.8038 0.7998 -0.50
17740........................... Pottawatomie County, 99917 0.8038 0.7998 -0.50
Kansas.
17750........................... Pratt County, Kansas.... 99917 0.8038 0.7998 -0.50
17760........................... Rawlins County, Kansas.. 99917 0.8038 0.7998 -0.50
17770........................... Reno County, Kansas..... 99917 0.8038 0.7998 -0.50
17780........................... Republic County, Kansas. 99917 0.8038 0.7998 -0.50
17790........................... Rice County, Kansas..... 99917 0.8038 0.7998 -0.50
17800........................... Riley County, Kansas.... 99917 0.8038 0.7998 -0.50
17810........................... Rooks County, Kansas.... 99917 0.8038 0.7998 -0.50
17820........................... Rush County, Kansas..... 99917 0.8038 0.7998 -0.50
17830........................... Russell County, Kansas.. 99917 0.8038 0.7998 -0.50
17840........................... Saline County, Kansas... 99917 0.8038 0.7998 -0.50
17841........................... Scott County, Kansas.... 99917 0.8038 0.7998 -0.50
17860........................... Sedgwick County, Kansas. 48620 0.9164 0.9063 -1.10
17870........................... Seward County, Kansas... 99917 0.8038 0.7998 -0.50
17880........................... Shawnee County, Kansas.. 45820 0.8920 0.8730 -2.13
17890........................... Sheridan County, Kansas. 99917 0.8038 0.7998 -0.50
17900........................... Sherman County, Kansas.. 99917 0.8038 0.7998 -0.50
17910........................... Smith County, Kansas.... 99917 0.8038 0.7998 -0.50
17920........................... Stafford County, Kansas. 99917 0.8038 0.7998 -0.50
17921........................... Stanton County, Kansas.. 99917 0.8038 0.7998 -0.50
17940........................... Stevens County, Kansas.. 99917 0.8038 0.7998 -0.50
17950........................... Sumner County, Kansas... 48620 0.8597 0.9063 5.42
17960........................... Thomas County, Kansas... 99917 0.8038 0.7998 -0.50
17970........................... Trego County, Kansas.... 99917 0.8038 0.7998 -0.50
17980........................... Wabaunsee County, Kansas 45820 0.8480 0.8730 2.95
17981........................... Wallace County, Kansas.. 99917 0.8038 0.7998 -0.50
17982........................... Washington County, 99917 0.8038 0.7998 -0.50
Kansas.
17983........................... Wichita County, Kansas.. 99917 0.8038 0.7998 -0.50
17984........................... Wilson County, Kansas... 99917 0.8038 0.7998 -0.50
17985........................... Woodson County, Kansas.. 99917 0.8038 0.7998 -0.50
17986........................... Wyandotte County, Kansas 28140 0.9483 0.9495 0.13
18000........................... Adair County, Kentucky.. 99918 0.7812 0.7768 -0.56
18010........................... Allen County, Kentucky.. 99918 0.7812 0.7768 -0.56
18020........................... Anderson County, 99918 0.7812 0.7768 -0.56
Kentucky.
18030........................... Ballard County, Kentucky 99918 0.7812 0.7768 -0.56
18040........................... Barren County, Kentucky. 99918 0.7812 0.7768 -0.56
18050........................... Bath County, Kentucky... 99918 0.7812 0.7768 -0.56
18060........................... Bell County, Kentucky... 99918 0.7812 0.7768 -0.56
18070........................... Boone County, Kentucky.. 17140 0.9675 0.9601 -0.76
18080........................... Bourbon County, Kentucky 30460 0.9032 0.9181 1.65
18090........................... Boyd County, Kentucky... 26580 0.9477 0.8997 -5.06
18100........................... Boyle County, Kentucky.. 99918 0.7812 0.7768 -0.56
18110........................... Bracken County, Kentucky 17140 0.8737 0.9601 9.89
18120........................... Breathitt County, 99918 0.7812 0.7768 -0.56
Kentucky.
18130........................... Breckinridge County, 99918 0.7812 0.7768 -0.56
Kentucky.
18140........................... Bullitt County, Kentucky 31140 0.9272 0.9118 -1.66
18150........................... Butler County, Kentucky. 99918 0.7812 0.7768 -0.56
18160........................... Caldwell County, 99918 0.7812 0.7768 -0.56
Kentucky.
18170........................... Calloway County, 99918 0.7812 0.7768 -0.56
Kentucky.
18180........................... Campbell County, 17140 0.9675 0.9601 -0.76
Kentucky.
18190........................... Carlisle County, 99918 0.7812 0.7768 -0.56
Kentucky.
18191........................... Carroll County, Kentucky 99918 0.7812 0.7768 -0.56
18210........................... Carter County, Kentucky. 99918 0.8622 0.7768 -9.90
18220........................... Casey County, Kentucky.. 99918 0.7812 0.7768 -0.56
18230........................... Christian County, 17300 0.8284 0.8436 1.83
Kentucky.
18240........................... Clark County, Kentucky.. 30460 0.9032 0.9181 1.65
18250........................... Clay County, Kentucky... 99918 0.7812 0.7768 -0.56
18260........................... Clinton County, Kentucky 99918 0.7812 0.7768 -0.56
18270........................... Crittenden County, 99918 0.7812 0.7768 -0.56
Kentucky.
18271........................... Cumberland County, 99918 0.7812 0.7768 -0.56
Kentucky.
18290........................... Daviess County, Kentucky 36980 0.8780 0.8748 -0.36
18291........................... Edmonson County, 14540 0.8035 0.8148 1.41
Kentucky.
18310........................... Elliott County, Kentucky 99918 0.7812 0.7768 -0.56
18320........................... Estill County, Kentucky. 99918 0.7812 0.7768 -0.56
[[Page 65974]]
18330........................... Fayette County, Kentucky 30460 0.9032 0.9181 1.65
18340........................... Fleming County, Kentucky 99918 0.7812 0.7768 -0.56
18350........................... Floyd County, Kentucky.. 99918 0.7812 0.7768 -0.56
18360........................... Franklin County, 99918 0.7812 0.7768 -0.56
Kentucky.
18361........................... Fulton County, Kentucky. 99918 0.7812 0.7768 -0.56
18362........................... Gallatin County, 17140 0.9675 0.9601 -0.76
Kentucky.
18390........................... Garrard County, Kentucky 99918 0.7812 0.7768 -0.56
18400........................... Grant County, Kentucky.. 17140 0.9675 0.9601 -0.76
18410........................... Graves County, Kentucky. 99918 0.7812 0.7768 -0.56
18420........................... Grayson County, Kentucky 99918 0.7812 0.7768 -0.56
18421........................... Green County, Kentucky.. 99918 0.7812 0.7768 -0.56
18440........................... Greenup County, Kentucky 26580 0.9477 0.8997 -5.06
18450........................... Hancock County, Kentucky 36980 0.8319 0.8748 5.16
18460........................... Hardin County, Kentucky. 21060 0.8330 0.8697 4.41
18470........................... Harlan County, Kentucky. 99918 0.7812 0.7768 -0.56
18480........................... Harrison County, 99918 0.7812 0.7768 -0.56
Kentucky.
18490........................... Hart County, Kentucky... 99918 0.7812 0.7768 -0.56
18500........................... Henderson County, 21780 0.8713 0.9071 4.11
Kentucky.
18510........................... Henry County, Kentucky.. 31140 0.8555 0.9118 6.58
18511........................... Hickman County, Kentucky 99918 0.7812 0.7768 -0.56
18530........................... Hopkins County, Kentucky 99918 0.7812 0.7768 -0.56
18540........................... Jackson County, Kentucky 99918 0.7812 0.7768 -0.56
18550........................... Jefferson County, 31140 0.9272 0.9118 -1.66
Kentucky.
18560........................... Jessamine County, 30460 0.9032 0.9181 1.65
Kentucky.
18570........................... Johnson County, Kentucky 99918 0.7812 0.7768 -0.56
18580........................... Kenton County, Kentucky. 17140 0.9675 0.9601 -0.76
18590........................... Knott County, Kentucky.. 99918 0.7812 0.7768 -0.56
18600........................... Knox County, Kentucky... 99918 0.7812 0.7768 -0.56
18610........................... Larue County, Kentucky.. 21060 0.8330 0.8697 4.41
18620........................... Laurel County, Kentucky. 99918 0.7812 0.7768 -0.56
18630........................... Lawrence County, 99918 0.7812 0.7768 -0.56
Kentucky.
18640........................... Lee County, Kentucky.... 99918 0.7812 0.7768 -0.56
18650........................... Leslie County, Kentucky. 99918 0.7812 0.7768 -0.56
18660........................... Letcher County, Kentucky 99918 0.7812 0.7768 -0.56
18670........................... Lewis County, Kentucky.. 99918 0.7812 0.7768 -0.56
18680........................... Lincoln County, Kentucky 99918 0.7812 0.7768 -0.56
18690........................... Livingston County, 99918 0.7812 0.7768 -0.56
Kentucky.
18700........................... Logan County, Kentucky.. 99918 0.7812 0.7768 -0.56
18710........................... Lyon County, Kentucky... 99918 0.7812 0.7768 -0.56
18720........................... Mc Cracken County, 99918 0.7812 0.7768 -0.56
Kentucky.
18730........................... Mc Creary County, 99918 0.7812 0.7768 -0.56
Kentucky.
18740........................... Mc Lean County, Kentucky 36980 0.8319 0.8748 5.16
18750........................... Madison County, Kentucky 99918 0.8377 0.7768 -7.27
18760........................... Magoffin County, 99918 0.7812 0.7768 -0.56
Kentucky.
18770........................... Marion County, Kentucky. 99918 0.7812 0.7768 -0.56
18780........................... Marshall County, 99918 0.7812 0.7768 -0.56
Kentucky.
18790........................... Martin County, Kentucky. 99918 0.7812 0.7768 -0.56
18800........................... Mason County, Kentucky.. 99918 0.7812 0.7768 -0.56
18801........................... Meade County, Kentucky.. 31140 0.8555 0.9118 6.58
18802........................... Menifee County, Kentucky 99918 0.7812 0.7768 -0.56
18830........................... Mercer County, Kentucky. 99918 0.7812 0.7768 -0.56
18831........................... Metcalfe County, 99918 0.7812 0.7768 -0.56
Kentucky.
18850........................... Monroe County, Kentucky. 99918 0.7812 0.7768 -0.56
18860........................... Montgomery County, 99918 0.7812 0.7768 -0.56
Kentucky.
18861........................... Morgan County, Kentucky. 99918 0.7812 0.7768 -0.56
18880........................... Muhlenberg County, 99918 0.7812 0.7768 -0.56
Kentucky.
18890........................... Nelson County, Kentucky. 31140 0.8555 0.9118 6.58
18900........................... Nicholas County, 99918 0.7812 0.7768 -0.56
Kentucky.
18910........................... Ohio County, Kentucky... 99918 0.7812 0.7768 -0.56
18920........................... Oldham County, Kentucky. 31140 0.9272 0.9118 -1.66
18930........................... Owen County, Kentucky... 99918 0.7812 0.7768 -0.56
18931........................... Owsley County, Kentucky. 99918 0.7812 0.7768 -0.56
18932........................... Pendleton County, 17140 0.9675 0.9601 -0.76
Kentucky.
18960........................... Perry County, Kentucky.. 99918 0.7812 0.7768 -0.56
18970........................... Pike County, Kentucky... 99918 0.7812 0.7768 -0.56
18971........................... Powell County, Kentucky. 99918 0.7812 0.7768 -0.56
18972........................... Pulaski County, Kentucky 99918 0.7812 0.7768 -0.56
18973........................... Robertson County, 99918 0.7812 0.7768 -0.56
Kentucky.
[[Page 65975]]
18974........................... Rockcastle County, 99918 0.7812 0.7768 -0.56
Kentucky.
18975........................... Rowan County, Kentucky.. 99918 0.7812 0.7768 -0.56
18976........................... Russell County, Kentucky 99918 0.7812 0.7768 -0.56
18977........................... Scott County, Kentucky.. 30460 0.9032 0.9181 1.65
18978........................... Shelby County, Kentucky. 31140 0.8555 0.9118 6.58
18979........................... Simpson County, Kentucky 99918 0.7812 0.7768 -0.56
18980........................... Spencer County, Kentucky 31140 0.8555 0.9118 6.58
18981........................... Taylor County, Kentucky. 99918 0.7812 0.7768 -0.56
18982........................... Todd County, Kentucky... 99918 0.7812 0.7768 -0.56
18983........................... Trigg County, Kentucky.. 17300 0.8071 0.8436 4.52
18984........................... Trimble County, Kentucky 31140 0.8555 0.9118 6.58
18985........................... Union County, Kentucky.. 99918 0.7812 0.7768 -0.56
18986........................... Warren County, Kentucky. 14540 0.8035 0.8148 1.41
18987........................... Washington County, 99918 0.7812 0.7768 -0.56
Kentucky.
18988........................... Wayne County, Kentucky.. 99918 0.7812 0.7768 -0.56
18989........................... Webster County, Kentucky 21780 0.8286 0.9071 9.47
18990........................... Whitley County, Kentucky 99918 0.7812 0.7768 -0.56
18991........................... Wolfe County, Kentucky.. 99918 0.7812 0.7768 -0.56
18992........................... Woodford County, 30460 0.9032 0.9181 1.65
Kentucky.
19000........................... Acadia County, Louisiana 99919 0.7831 0.7438 -5.02
19010........................... Allen County, Louisiana. 99919 0.7376 0.7438 0.84
19020........................... Ascension County, 12940 0.8618 0.8084 -6.20
Louisiana.
19030........................... Assumption County, 99919 0.7376 0.7438 0.84
Louisiana.
19040........................... Avoyelles County, 99919 0.7376 0.7438 0.84
Louisiana.
19050........................... Beauregard County, 99919 0.7376 0.7438 0.84
Louisiana.
19060........................... Bienville County, 99919 0.7376 0.7438 0.84
Louisiana.
19070........................... Bossier County, 43340 0.8749 0.8865 1.33
Louisiana.
19080........................... Caddo County, Louisiana. 43340 0.8749 0.8865 1.33
19090........................... Calcasieu County, 29340 0.7846 0.7914 0.87
Louisiana.
19100........................... Caldwell County, 99919 0.7376 0.7438 0.84
Louisiana.
19110........................... Cameron County, 29340 0.7587 0.7914 4.31
Louisiana.
19120........................... Catahoula County, 99919 0.7376 0.7438 0.84
Louisiana.
19130........................... Claiborne County, 99919 0.7376 0.7438 0.84
Louisiana.
19140........................... Concordia County, 99919 0.7376 0.7438 0.84
Louisiana.
19150........................... De Soto County, 43340 0.8050 0.8865 10.12
Louisiana.
19160........................... East Baton Rouge County, 12940 0.8618 0.8084 -6.20
Louisiana.
19170........................... East Carroll County, 99919 0.7376 0.7438 0.84
Louisiana.
19180........................... East Feliciana County, 12940 0.7967 0.8084 1.47
Louisiana.
19190........................... Evangeline County, 99919 0.7376 0.7438 0.84
Louisiana.
19200........................... Franklin County, 99919 0.7376 0.7438 0.84
Louisiana.
19210........................... Grant County, Louisiana. 10780 0.7687 0.8006 4.15
19220........................... Iberia County, Louisiana 99919 0.7376 0.7438 0.84
19230........................... Iberville County, 12940 0.7967 0.8084 1.47
Louisiana.
19240........................... Jackson County, 99919 0.7376 0.7438 0.84
Louisiana.
19250........................... Jefferson County, 35380 0.8995 0.8831 -1.82
Louisiana.
19260........................... Jefferson Davis County, 99919 0.7376 0.7438 0.84
Louisiana.
19270........................... Lafayette County, 29180 0.8340 0.8289 -0.61
Louisiana.
19280........................... Lafourche County, 26380 0.7894 0.8082 2.38
Louisiana.
19290........................... La Salle County, 99919 0.7376 0.7438 0.84
Louisiana.
19300........................... Lincoln County, 99919 0.7376 0.7438 0.84
Louisiana.
19310........................... Livingston County, 12940 0.8618 0.8084 -6.20
Louisiana.
19320........................... Madison County, 99919 0.7376 0.7438 0.84
Louisiana.
19330........................... Morehouse County, 99919 0.7376 0.7438 0.84
Louisiana.
19340........................... Natchitoches County, 99919 0.7376 0.7438 0.84
Louisiana.
19350........................... Orleans County, 35380 0.8995 0.8831 -1.82
Louisiana.
19360........................... Ouachita County, 33740 0.8038 0.7997 -0.51
Louisiana.
19370........................... Plaquemines County, 35380 0.8995 0.8831 -1.82
Louisiana.
19380........................... Pointe Coupee County, 12940 0.7967 0.8084 1.47
Louisiana.
19390........................... Rapides County, 10780 0.8033 0.8006 -0.34
Louisiana.
19400........................... Red River County, 99919 0.7376 0.7438 0.84
Louisiana.
19410........................... Richland County, 99919 0.7376 0.7438 0.84
Louisiana.
19420........................... Sabine County, Louisiana 99919 0.7376 0.7438 0.84
19430........................... St Bernard County, 35380 0.8995 0.8831 -1.82
Louisiana.
19440........................... St Charles County, 35380 0.8995 0.8831 -1.82
Louisiana.
19450........................... St Helena County, 12940 0.7967 0.8084 1.47
Louisiana.
19460........................... St James County, 99919 0.8203 0.7438 -9.33
Louisiana.
19470........................... St John Baptist County, 35380 0.8995 0.8831 -1.82
Louisiana.
19480........................... St Landry County, 99919 0.7831 0.7438 -5.02
Louisiana.
[[Page 65976]]
19490........................... St Martin County, 29180 0.8340 0.8289 -0.61
Louisiana.
19500........................... St Mary County, 99919 0.7376 0.7438 0.84
Louisiana.
19510........................... St Tammany County, 35380 0.8995 0.8831 -1.82
Louisiana.
19520........................... Tangipahoa County, 99919 0.7376 0.7438 0.84
Louisiana.
19530........................... Tensas County, Louisiana 99919 0.7376 0.7438 0.84
19540........................... Terrebonne County, 26380 0.7894 0.8082 2.38
Louisiana.
19550........................... Union County, Louisiana. 33740 0.7686 0.7997 4.05
19560........................... Vermilion County, 99919 0.7376 0.7438 0.84
Louisiana.
19570........................... Vernon County, Louisiana 99919 0.7376 0.7438 0.84
19580........................... Washington County, 99919 0.7376 0.7438 0.84
Louisiana.
19590........................... Webster County, 99919 0.8074 0.7438 -7.88
Louisiana.
19600........................... West Baton Rouge County, 12940 0.8618 0.8084 -6.20
Louisiana.
19610........................... West Carroll County, 99919 0.7376 0.7438 0.84
Louisiana.
19620........................... West Feliciana County, 12940 0.7967 0.8084 1.47
Louisiana.
19630........................... Winn County, Louisiana.. 99919 0.7376 0.7438 0.84
20000........................... Androscoggin County, 30340 0.9331 0.9126 -2.20
Maine.
20010........................... Aroostook County, Maine. 99920 0.8843 0.8443 -4.52
20020........................... Cumberland County, Maine 38860 1.0382 0.9908 -4.57
20030........................... Franklin County, Maine.. 99920 0.8843 0.8443 -4.52
20040........................... Hancock County, Maine... 99920 0.8843 0.8443 -4.52
20050........................... Kennebec County, Maine.. 99920 0.8843 0.8443 -4.52
20060........................... Knox County, Maine...... 99920 0.8843 0.8443 -4.52
20070........................... Lincoln County, Maine... 99920 0.8843 0.8443 -4.52
20080........................... Oxford County, Maine.... 99920 0.8843 0.8443 -4.52
20090........................... Penobscot County, Maine. 12620 0.9993 0.9711 -2.82
20100........................... Piscataquis County, 99920 0.8843 0.8443 -4.52
Maine.
20110........................... Sagadahoc County, Maine. 38860 1.0382 0.9908 -4.57
20120........................... Somerset County, Maine.. 99920 0.8843 0.8443 -4.52
20130........................... Waldo County, Maine..... 99920 0.8843 0.8443 -4.52
20140........................... Washington County, Maine 99920 0.8843 0.8443 -4.52
20150........................... York County, Maine...... 38860 1.0382 0.9908 -4.57
21000........................... Allegany County, 19060 0.9317 0.8446 -9.35
Maryland.
21010........................... Anne Arundel County, 12580 0.9897 1.0088 1.93
Maryland.
21020........................... Baltimore County, 12580 0.9897 1.0088 1.93
Maryland.
21030........................... Baltimore City County, 12580 0.9897 1.0088 1.93
Maryland.
21040........................... Calvert County, Maryland 47894 1.0951 1.1054 0.94
21050........................... Caroline County, 99921 0.9292 0.8926 -3.94
Maryland.
21060........................... Carroll County, Maryland 12580 0.9897 1.0088 1.93
21070........................... Cecil County, Maryland.. 48864 1.0499 1.0684 1.76
21080........................... Charles County, Maryland 47894 1.0951 1.1054 0.94
21090........................... Dorchester County, 99921 0.9292 0.8926 -3.94
Maryland.
21100........................... Frederick County, 13644 1.1230 1.0903 -2.91
Maryland.
21110........................... Garrett County, Maryland 99921 0.9292 0.8926 -3.94
21120........................... Harford County, Maryland 12580 0.9897 1.0088 1.93
21130........................... Howard County, Maryland. 12580 0.9897 1.0088 1.93
21140........................... Kent County, Maryland... 99921 0.9292 0.8926 -3.94
21150........................... Montgomery County, 13644 1.1230 1.0903 -2.91
Maryland.
21160........................... Prince Georges County, 47894 1.0951 1.1054 0.94
Maryland.
21170........................... Queen Annes County, 12580 0.9897 1.0088 1.93
Maryland.
21180........................... St Marys County, 99921 0.9292 0.8926 -3.94
Maryland.
21190........................... Somerset County, 41540 0.9147 0.8953 -2.12
Maryland.
21200........................... Talbot County, Maryland. 99921 0.9292 0.8926 -3.94
21210........................... Washington County, 25180 0.9679 0.9038 -6.62
Maryland.
21220........................... Wicomico County, 41540 0.9147 0.8953 -2.12
Maryland.
21230........................... Worcester County, 99921 0.9292 0.8926 -3.94
Maryland.
22000........................... Barnstable County, 12700 1.2600 1.2539 -0.48
Massachusetts.
22010........................... Berkshire County, 38340 1.0181 1.0266 0.83
Massachusetts.
22020........................... Bristol County, 39300 1.1072 1.0783 -2.61
Massachusetts.
22030........................... Dukes County, 99922 1.0216 1.1661 14.14
Massachusetts.
22040........................... Essex County, 21604 1.0858 1.0418 -4.05
Massachusetts.
22060........................... Franklin County, 44140 1.0232 1.0079 -0.64
Massachusetts.
22070........................... Hampden County, 44140 1.0256 1.0079 -1.73
Massachusetts.
22080........................... Hampshire County, 44140 1.0256 1.0079 -1.73
Massachusetts.
22090........................... Middlesex County, 15764 1.1175 1.0970 -1.83
Massachusetts.
22120........................... Nantucket County, 99922 1.0216 1.1661 14.14
Massachusetts.
22130........................... Norfolk County, 14484 1.1368 1.1679 2.74
Massachusetts.
22150........................... Plymouth County, 14484 1.1368 1.1679 2.74
Massachusetts.
22160........................... Suffolk County, 14484 1.1368 1.1679 2.74
Massachusetts.
[[Page 65977]]
22170........................... Worcester County, 49340 1.1103 1.0722 -3.43
Massachusetts.
23000........................... Alcona County, Michigan. 99923 0.8860 0.9062 2.28
23010........................... Alger County, Michigan.. 99923 0.8860 0.9062 2.28
23020........................... Allegan County, Michigan 99923 0.9170 0.9062 -1.18
23030........................... Alpena County, Michigan. 99923 0.8860 0.9062 2.28
23040........................... Antrim County, Michigan. 99923 0.8860 0.9062 2.28
23050........................... Arenac County, Michigan. 99923 0.8860 0.9062 2.28
23060........................... Baraga County, Michigan. 99923 0.8860 0.9062 2.28
23070........................... Barry County, Michigan.. 24340 0.9107 0.9455 3.82
23080........................... Bay County, Michigan.... 13020 0.9292 0.9251 -0.44
23090........................... Benzie County, Michigan. 99923 0.8860 0.9062 2.28
23100........................... Berrien County, Michigan 35660 0.8879 0.8915 0.41
23110........................... Branch County, Michigan. 99923 0.8860 0.9062 2.28
23120........................... Calhoun County, Michigan 12980 0.9826 0.9762 -0.65
23130........................... Cass County, Michigan... 43780 0.9306 0.9842 5.76
23140........................... Charlevoix County, 99923 0.8860 0.9062 2.28
Michigan.
23150........................... Cheboygan County, 99923 0.8860 0.9062 2.28
Michigan.
23160........................... Chippewa County, 99923 0.8860 0.9062 2.28
Michigan.
23170........................... Clare County, Michigan.. 99923 0.8860 0.9062 2.28
23180........................... Clinton County, Michigan 29620 0.9794 1.0088 3.00
23190........................... Crawford County, 99923 0.8860 0.9062 2.28
Michigan.
23200........................... Delta County, Michigan.. 99923 0.8860 0.9062 2.28
23210........................... Dickinson County, 99923 0.8860 0.9062 2.28
Michigan.
23220........................... Eaton County, Michigan.. 29620 0.9794 1.0088 3.00
23230........................... Emmet County, Michigan.. 99923 0.8860 0.9062 2.28
23240........................... Genesee County, Michigan 22420 1.0655 1.0969 2.95
23250........................... Gladwin County, Michigan 99923 0.8860 0.9062 2.28
23260........................... Gogebic County, Michigan 99923 0.8860 0.9062 2.28
23270........................... Grand Traverse County, 99923 0.8860 0.9062 2.28
Michigan.
23280........................... Gratiot County, Michigan 99923 0.8860 0.9062 2.28
23290........................... Hillsdale County, 99923 0.8860 0.9062 2.28
Michigan.
23300........................... Houghton County, 99923 0.8860 0.9062 2.28
Michigan.
23310........................... Huron County, Michigan.. 99923 0.8860 0.9062 2.28
23320........................... Ingham County, Michigan. 29620 0.9794 1.0088 3.00
23330........................... Ionia County, Michigan.. 24340 0.9107 0.9455 3.82
23340........................... Iosco County, Michigan.. 99923 0.8860 0.9062 2.28
23350........................... Iron County, Michigan... 99923 0.8860 0.9062 2.28
23360........................... Isabella County, 99923 0.8860 0.9062 2.28
Michigan.
23370........................... Jackson County, Michigan 27100 0.9304 0.9560 2.75
23380........................... Kalamazoo County, 28020 1.0262 1.0704 4.31
Michigan.
23390........................... Kalkaska County, 99923 0.8860 0.9062 2.28
Michigan.
23400........................... Kent County, Michigan... 24340 0.9418 0.9455 0.39
23410........................... Keweenaw County, 99923 0.8860 0.9062 2.28
Michigan.
23420........................... Lake County, Michigan... 99923 0.8860 0.9062 2.28
23430........................... Lapeer County, Michigan. 47644 1.0009 1.0054 0.45
23440........................... Leelanau County, 99923 0.8860 0.9062 2.28
Michigan.
23450........................... Lenawee County, Michigan 99923 0.9801 0.9062 -7.54
23460........................... Livingston County, 47644 1.0289 1.0054 -2.28
Michigan.
23470........................... Luce County, Michigan... 99923 0.8860 0.9062 2.28
23480........................... Mackinac County, 99923 0.8860 0.9062 2.28
Michigan.
23490........................... Macomb County, Michigan. 47644 1.0009 1.0054 0.45
23500........................... Manistee County, 99923 0.8860 0.9062 2.28
Michigan.
23510........................... Marquette County, 99923 0.8860 0.9062 2.28
Michigan.
23520........................... Mason County, Michigan.. 99923 0.8860 0.9062 2.28
23530........................... Mecosta County, Michigan 99923 0.8860 0.9062 2.28
23540........................... Menominee County, 99923 0.8860 0.9062 2.28
Michigan.
23550........................... Midland County, Michigan 99923 0.9068 0.9062 -0.07
23560........................... Missaukee County, 99923 0.8860 0.9062 2.28
Michigan.
23570........................... Monroe County, Michigan. 33780 0.9808 0.9707 -1.03
23580........................... Montcalm County, 99923 0.8860 0.9062 2.28
Michigan.
23590........................... Montmorency County, 99923 0.8860 0.9062 2.28
Michigan.
23600........................... Muskegon County, 34740 0.9555 0.9941 4.04
Michigan.
23610........................... Newaygo County, Michigan 24340 0.9107 0.9455 3.82
23620........................... Oakland County, Michigan 47644 1.0009 1.0054 0.45
23630........................... Oceana County, Michigan. 99923 0.8860 0.9062 2.28
23640........................... Ogemaw County, Michigan. 99923 0.8860 0.9062 2.28
23650........................... Ontonagon County, 99923 0.8860 0.9062 2.28
Michigan.
23660........................... Osceola County, Michigan 99923 0.8860 0.9062 2.28
[[Page 65978]]
23670........................... Oscoda County, Michigan. 99923 0.8860 0.9062 2.28
23680........................... Otsego County, Michigan. 99923 0.8860 0.9062 2.28
23690........................... Ottawa County, Michigan. 26100 0.9250 0.9163 -0.94
23700........................... Presque Isle County, 99923 0.8860 0.9062 2.28
Michigan.
23710........................... Roscommon County, 99923 0.8860 0.9062 2.28
Michigan.
23720........................... Saginaw County, Michigan 40980 0.9165 0.8874 -3.18
23730........................... St Clair County, 47644 1.0009 1.0054 0.45
Michigan.
23740........................... St Joseph County, 99923 0.8860 0.9062 2.28
Michigan.
23750........................... Sanilac County, Michigan 99923 0.8860 0.9062 2.28
23760........................... Schoolcraft County, 99923 0.8860 0.9062 2.28
Michigan.
23770........................... Shiawassee County, 99923 0.8860 0.9062 2.28
Michigan.
23780........................... Tuscola County, Michigan 99923 0.8860 0.9062 2.28
23790........................... Van Buren County, 28020 1.0262 1.0704 4.31
Michigan.
23800........................... Washtenaw County, 11460 1.0783 1.0826 0.40
Michigan.
23810........................... Wayne County, Michigan.. 19804 1.0286 1.0281 -0.05
23830........................... Wexford County, Michigan 99923 0.8860 0.9062 2.28
24000........................... Aitkin County, Minnesota 99924 0.9132 0.9153 0.23
24010........................... Anoka County, Minnesota. 33460 1.1075 1.0946 -1.16
24020........................... Becker County, Minnesota 99924 0.9132 0.9153 0.23
24030........................... Beltrami County, 99924 0.9132 0.9153 0.23
Minnesota.
24040........................... Benton County, Minnesota 41060 0.9965 1.0362 3.98
24050........................... Big Stone County, 99924 0.9132 0.9153 0.23
Minnesota.
24060........................... Blue Earth County, 99924 0.9132 0.9153 0.23
Minnesota.
24070........................... Brown County, Minnesota. 99924 0.9132 0.9153 0.23
24080........................... Carlton County, 20260 0.9673 1.0042 3.81
Minnesota.
24090........................... Carver County, Minnesota 33460 1.1075 1.0946 -1.16
24100........................... Cass County, Minnesota.. 99924 0.9132 0.9153 0.23
24110........................... Chippewa County, 99924 0.9132 0.9153 0.23
Minnesota.
24120........................... Chisago County, 33460 1.1075 1.0946 -1.16
Minnesota.
24130........................... Clay County, Minnesota.. 22020 0.8486 0.8250 -2.78
24140........................... Clearwater County, 99924 0.9132 0.9153 0.23
Minnesota.
24150........................... Cook County, Minnesota.. 99924 0.9132 0.9153 0.23
24160........................... Cottonwood County, 99924 0.9132 0.9153 0.23
Minnesota.
24170........................... Crow Wing County, 99924 0.9132 0.9153 0.23
Minnesota.
24180........................... Dakota County, Minnesota 33460 1.1075 1.0946 -1.16
24190........................... Dodge County, Minnesota. 40340 1.0132 1.1408 12.59
24200........................... Douglas County, 99924 0.9132 0.9153 0.23
Minnesota.
24210........................... Faribault County, 99924 0.9132 0.9153 0.23
Minnesota.
24220........................... Fillmore County, 99924 0.9132 0.9153 0.23
Minnesota.
24230........................... Freeborn County, 99924 0.9132 0.9153 0.23
Minnesota.
24240........................... Goodhue County, 99924 0.9132 0.9153 0.23
Minnesota.
24250........................... Grant County, Minnesota. 99924 0.9132 0.9153 0.23
24260........................... Hennepin County, 33460 1.1075 1.0946 -1.16
Minnesota.
24270........................... Houston County, 29100 0.9564 0.9426 -1.44
Minnesota.
24280........................... Hubbard County, 99924 0.9132 0.9153 0.23
Minnesota.
24290........................... Isanti County, Minnesota 33460 1.1075 1.0946 -1.16
24300........................... Itasca County, Minnesota 99924 0.9132 0.9153 0.23
24310........................... Jackson County, 99924 0.9132 0.9153 0.23
Minnesota.
24320........................... Kanabec County, 99924 0.9132 0.9153 0.23
Minnesota.
24330........................... Kandiyohi County, 99924 0.9132 0.9153 0.23
Minnesota.
24340........................... Kittson County, 99924 0.9132 0.9153 0.23
Minnesota.
24350........................... Koochiching County, 99924 0.9132 0.9153 0.23
Minnesota.
24360........................... Lac Qui Parle County, 99924 0.9132 0.9153 0.23
Minnesota.
24370........................... Lake County, Minnesota.. 99924 0.9132 0.9153 0.23
24380........................... Lake Of Woods County, 99924 0.9132 0.9153 0.23
Minnesota.
24390........................... Le Sueur County, 99924 0.9132 0.9153 0.23
Minnesota.
24400........................... Lincoln County, 99924 0.9132 0.9153 0.23
Minnesota.
24410........................... Lyon County, Minnesota.. 99924 0.9132 0.9153 0.23
24420........................... Mc Leod County, 99924 0.9132 0.9153 0.23
Minnesota.
24430........................... Mahnomen County, 99924 0.9132 0.9153 0.23
Minnesota.
24440........................... Marshall County, 99924 0.9132 0.9153 0.23
Minnesota.
24450........................... Martin County, Minnesota 99924 0.9132 0.9153 0.23
24460........................... Meeker County, Minnesota 99924 0.9132 0.9153 0.23
24470........................... Mille Lacs County, 99924 0.9132 0.9153 0.23
Minnesota.
24480........................... Morrison County, 99924 0.9132 0.9153 0.23
Minnesota.
24490........................... Mower County, Minnesota. 99924 0.9132 0.9153 0.23
24500........................... Murray County, Minnesota 99924 0.9132 0.9153 0.23
24510........................... Nicollet County, 99924 0.9132 0.9153 0.23
Minnesota.
[[Page 65979]]
24520........................... Nobles County, Minnesota 99924 0.9132 0.9153 0.23
24530........................... Norman County, Minnesota 99924 0.9132 0.9153 0.23
24540........................... Olmsted County, 40340 1.1131 1.1408 2.49
Minnesota.
24550........................... Otter Tail County, 99924 0.9132 0.9153 0.23
Minnesota.
24560........................... Pennington County, 99924 0.9132 0.9153 0.23
Minnesota.
24570........................... Pine County, Minnesota.. 99924 0.9132 0.9153 0.23
24580........................... Pipestone County, 99924 0.9132 0.9153 0.23
Minnesota.
24590........................... Polk County, Minnesota.. 24220 0.7901 0.7949 0.61
24600........................... Pope County, Minnesota.. 99924 0.9132 0.9153 0.23
24610........................... Ramsey County, Minnesota 33460 1.1075 1.0946 -1.16
24620........................... Red Lake County, 99924 0.9132 0.9153 0.23
Minnesota.
24630........................... Redwood County, 99924 0.9132 0.9153 0.23
Minnesota.
24640........................... Renville County, 99924 0.9132 0.9153 0.23
Minnesota.
24650........................... Rice County, Minnesota.. 99924 0.9132 0.9153 0.23
24660........................... Rock County, Minnesota.. 99924 0.9132 0.9153 0.23
24670........................... Roseau County, Minnesota 99924 0.9132 0.9153 0.23
24680........................... St Louis County, 20260 1.0213 1.0042 -1.67
Minnesota.
24690........................... Scott County, Minnesota. 33460 1.1075 1.0946 -1.16
24700........................... Sherburne County, 33460 1.1075 1.0946 -1.16
Minnesota.
24710........................... Sibley County, Minnesota 99924 0.9132 0.9153 0.23
24720........................... Stearns County, 41060 0.9965 1.0362 3.98
Minnesota.
24730........................... Steele County, Minnesota 99924 0.9132 0.9153 0.23
24740........................... Stevens County, 99924 0.9132 0.9153 0.23
Minnesota.
24750........................... Swift County, Minnesota. 99924 0.9132 0.9153 0.23
24760........................... Todd County, Minnesota.. 99924 0.9132 0.9153 0.23
24770........................... Traverse County, 99924 0.9132 0.9153 0.23
Minnesota.
24780........................... Wabasha County, 40340 1.0132 1.1408 12.59
Minnesota.
24790........................... Wadena County, Minnesota 99924 0.9132 0.9153 0.23
24800........................... Waseca County, Minnesota 99924 0.9132 0.9153 0.23
24810........................... Washington County, 33460 1.1075 1.0946 -1.16
Minnesota.
24820........................... Watonwan County, 99924 0.9132 0.9153 0.23
Minnesota.
24830........................... Wilkin County, Minnesota 99924 0.9132 0.9153 0.23
24840........................... Winona County, Minnesota 99924 0.9132 0.9153 0.23
24850........................... Wright County, Minnesota 33460 1.1075 1.0946 -1.16
24860........................... Yellow Medicine County, 99924 0.9132 0.9153 0.23
Minnesota.
25000........................... Adams County, 99925 0.7654 0.7738 1.10
Mississippi.
25010........................... Alcorn County, 99925 0.7654 0.7738 1.10
Mississippi.
25020........................... Amite County, 99925 0.7654 0.7738 1.10
Mississippi.
25030........................... Attala County, 99925 0.7654 0.7738 1.10
Mississippi.
25040........................... Benton County, 99925 0.7654 0.7738 1.10
Mississippi.
25050........................... Bolivar County, 99925 0.7654 0.7738 1.10
Mississippi.
25060........................... Calhoun County, 99925 0.7654 0.7738 1.10
Mississippi.
25070........................... Carroll County, 99925 0.7654 0.7738 1.10
Mississippi.
25080........................... Chickasaw County, 99925 0.7654 0.7738 1.10
Mississippi.
25090........................... Choctaw County, 99925 0.7654 0.7738 1.10
Mississippi.
25100........................... Claiborne County, 99925 0.7654 0.7738 1.10
Mississippi.
25110........................... Clarke County, 99925 0.7654 0.7738 1.10
Mississippi.
25120........................... Clay County, Mississippi 99925 0.7654 0.7738 1.10
25130........................... Coahoma County, 99925 0.7654 0.7738 1.10
Mississippi.
25140........................... Copiah County, 27140 0.7973 0.8271 3.74
Mississippi.
25150........................... Covington County, 99925 0.7654 0.7738 1.10
Mississippi.
25160........................... Desoto County, 32820 0.9407 0.9373 -0.36
Mississippi.
25170........................... Forrest County, 25620 0.7601 0.7430 -2.25
Mississippi.
25180........................... Franklin County, 99925 0.7654 0.7738 1.10
Mississippi.
25190........................... George County, 37700 0.7895 0.8215 4.05
Mississippi.
25200........................... Greene County, 99925 0.7654 0.7738 1.10
Mississippi.
25210........................... Grenada County, 99925 0.7654 0.7738 1.10
Mississippi.
25220........................... Hancock County, 25060 0.8818 0.8915 1.10
Mississippi.
25230........................... Harrison County, 25060 0.8818 0.8915 1.10
Mississippi.
25240........................... Hinds County, 27140 0.8347 0.8271 -0.91
Mississippi.
25250........................... Holmes County, 99925 0.7654 0.7738 1.10
Mississippi.
25260........................... Humphreys County, 99925 0.7654 0.7738 1.10
Mississippi.
25270........................... Issaquena County, 99925 0.7654 0.7738 1.10
Mississippi.
25280........................... Itawamba County, 99925 0.7654 0.7738 1.10
Mississippi.
25290........................... Jackson County, 37700 0.8431 0.8215 -2.56
Mississippi.
25300........................... Jasper County, 99925 0.7654 0.7738 1.10
Mississippi.
25310........................... Jefferson County, 99925 0.7654 0.7738 1.10
Mississippi.
25320........................... Jefferson Davis County, 99925 0.7654 0.7738 1.10
Mississippi.
[[Page 65980]]
25330........................... Jones County, 99925 0.7654 0.7738 1.10
Mississippi.
25340........................... Kemper County, 99925 0.7654 0.7738 1.10
Mississippi.
25350........................... Lafayette County, 99925 0.7654 0.7738 1.10
Mississippi.
25360........................... Lamar County, 25620 0.7601 0.7430 -2.25
Mississippi.
25370........................... Lauderdale County, 99925 0.7654 0.7738 1.10
Mississippi.
25380........................... Lawrence County, 99925 0.7654 0.7738 1.10
Mississippi.
25390........................... Leake County, 99925 0.7654 0.7738 1.10
Mississippi.
25400........................... Lee County, Mississippi. 99925 0.7654 0.7738 1.10
25410........................... Leflore County, 99925 0.7654 0.7738 1.10
Mississippi.
25420........................... Lincoln County, 99925 0.7654 0.7738 1.10
Mississippi.
25430........................... Lowndes County, 99925 0.7654 0.7738 1.10
Mississippi.
25440........................... Madison County, 27140 0.8347 0.8271 -0.91
Mississippi.
25450........................... Marion County, 99925 0.7654 0.7738 1.10
Mississippi.
25460........................... Marshall County, 32820 0.8516 0.9373 10.06
Mississippi.
25470........................... Monroe County, 99925 0.7654 0.7738 1.10
Mississippi.
25480........................... Montgomery County, 99925 0.7654 0.7738 1.10
Mississippi.
25490........................... Neshoba County, 99925 0.7654 0.7738 1.10
Mississippi.
25500........................... Newton County, 99925 0.7654 0.7738 1.10
Mississippi.
25510........................... Noxubee County, 99925 0.7654 0.7738 1.10
Mississippi.
25520........................... Oktibbeha County, 99925 0.7654 0.7738 1.10
Mississippi.
25530........................... Panola County, 99925 0.7654 0.7738 1.10
Mississippi.
25540........................... Pearl River County, 99925 0.7654 0.7738 1.10
Mississippi.
25550........................... Perry County, 25620 0.7618 0.7430 -2.47
Mississippi.
25560........................... Pike County, Mississippi 99925 0.7654 0.7738 1.10
25570........................... Pontotoc County, 99925 0.7654 0.7738 1.10
Mississippi.
25580........................... Prentiss County, 99925 0.7654 0.7738 1.10
Mississippi.
25590........................... Quitman County, 99925 0.7654 0.7738 1.10
Mississippi.
25600........................... Rankin County, 27140 0.8347 0.8271 -0.91
Mississippi.
25610........................... Scott County, 99925 0.7654 0.7738 1.10
Mississippi.
25620........................... Sharkey County, 99925 0.7654 0.7738 1.10
Mississippi.
25630........................... Simpson County, 27140 0.7973 0.8271 3.74
Mississippi.
25640........................... Smith County, 99925 0.7654 0.7738 1.10
Mississippi.
25650........................... Stone County, 25060 0.8282 0.8915 7.64
Mississippi.
25660........................... Sunflower County, 99925 0.7654 0.7738 1.10
Mississippi.
25670........................... Tallahatchie County, 99925 0.7654 0.7738 1.10
Mississippi.
25680........................... Tate County, Mississippi 32820 0.8516 0.9373 10.06
25690........................... Tippah County, 99925 0.7654 0.7738 1.10
Mississippi.
25700........................... Tishomingo County, 99925 0.7654 0.7738 1.10
Mississippi.
25710........................... Tunica County, 32820 0.8516 0.9373 10.06
Mississippi.
25720........................... Union County, 99925 0.7654 0.7738 1.10
Mississippi.
25730........................... Walthall County, 99925 0.7654 0.7738 1.10
Mississippi.
25740........................... Warren County, 99925 0.7654 0.7738 1.10
Mississippi.
25750........................... Washington County, 99925 0.7654 0.7738 1.10
Mississippi.
25760........................... Wayne County, 99925 0.7654 0.7738 1.10
Mississippi.
25770........................... Webster County, 99925 0.7654 0.7738 1.10
Mississippi.
25780........................... Wilkinson County, 99925 0.7654 0.7738 1.10
Mississippi.
25790........................... Winston County, 99925 0.7654 0.7738 1.10
Mississippi.
25800........................... Yalobusha County, 99925 0.7654 0.7738 1.10
Mississippi.
25810........................... Yazoo County, 99925 0.7654 0.7738 1.10
Mississippi.
26000........................... Adair County, Missouri.. 99926 0.7930 0.7927 -0.04
26010........................... Andrew County, Missouri. 41140 0.9519 1.0118 6.29
26020........................... Atchison County, 99926 0.7930 0.7927 -0.04
Missouri.
26030........................... Audrain County, Missouri 99926 0.7930 0.7927 -0.04
26040........................... Barry County, Missouri.. 99926 0.7930 0.7927 -0.04
26050........................... Barton County, Missouri. 99926 0.7930 0.7927 -0.04
26060........................... Bates County, Missouri.. 28140 0.8718 0.9495 8.91
26070........................... Benton County, Missouri. 99926 0.7930 0.7927 -0.04
26080........................... Bollinger County, 99926 0.7930 0.7927 -0.04
Missouri.
26090........................... Boone County, Missouri.. 17860 0.8345 0.8542 2.36
26100........................... Buchanan County, 41140 0.9519 1.0118 6.29
Missouri.
26110........................... Butler County, Missouri. 99926 0.7930 0.7927 -0.04
26120........................... Caldwell County, 28140 0.8718 0.9495 8.91
Missouri.
26130........................... Callaway County, 27620 0.8173 0.8332 1.95
Missouri.
26140........................... Camden County, Missouri. 99926 0.7930 0.7927 -0.04
26150........................... Cape Girardeau County, 99926 0.7930 0.7927 -0.04
Missouri.
26160........................... Carroll County, Missouri 99926 0.7930 0.7927 -0.04
26170........................... Carter County, Missouri. 99926 0.7930 0.7927 -0.04
26180........................... Cass County, Missouri... 28140 0.9483 0.9495 0.13
[[Page 65981]]
26190........................... Cedar County, Missouri.. 99926 0.7930 0.7927 -0.04
26200........................... Chariton County, 99926 0.7930 0.7927 -0.04
Missouri.
26210........................... Christian County, 44180 0.8244 0.8469 2.73
Missouri.
26220........................... Clark County, Missouri.. 99926 0.7930 0.7927 -0.04
26230........................... Clay County, Missouri... 28140 0.9483 0.9495 0.13
26240........................... Clinton County, Missouri 28140 0.9483 0.9495 0.13
26250........................... Cole County, Missouri... 27620 0.8173 0.8332 1.95
26260........................... Cooper County, Missouri. 99926 0.7930 0.7927 -0.04
26270........................... Crawford County, 41180 0.8457 0.9005 6.48
Missouri.
26280........................... Dade County, Missouri... 99926 0.7930 0.7927 -0.04
26290........................... Dallas County, Missouri. 44180 0.8098 0.8469 4.58
26300........................... Daviess County, Missouri 99926 0.7930 0.7927 -0.04
26310........................... De Kalb County, Missouri 41140 0.8739 1.0118 15.78
26320........................... Dent County, Missouri... 99926 0.7930 0.7927 -0.04
26330........................... Douglas County, Missouri 99926 0.7930 0.7927 -0.04
26340........................... Dunklin County, Missouri 99926 0.7930 0.7927 -0.04
26350........................... Franklin County, 41180 0.8958 0.9005 0.52
Missouri.
26360........................... Gasconade County, 99926 0.7930 0.7927 -0.04
Missouri.
26370........................... Gentry County, Missouri. 99926 0.7930 0.7927 -0.04
26380........................... Greene County, Missouri. 44180 0.8244 0.8469 2.73
26390........................... Grundy County, Missouri. 99926 0.7930 0.7927 -0.04
26400........................... Harrison County, 99926 0.7930 0.7927 -0.04
Missouri.
26410........................... Henry County, Missouri.. 99926 0.7930 0.7927 -0.04
26411........................... Hickory County, Missouri 99926 0.7930 0.7927 -0.04
26412........................... Holt County, Missouri... 99926 0.7930 0.7927 -0.04
26440........................... Howard County, Missouri. 17860 0.8152 0.8542 4.78
26450........................... Howell County, Missouri. 99926 0.7930 0.7927 -0.04
26460........................... Iron County, Missouri... 99926 0.7930 0.7927 -0.04
26470........................... Jackson County, Missouri 28140 0.9483 0.9495 0.13
26480........................... Jasper County, Missouri. 27900 0.8582 0.8605 0.27
26490........................... Jefferson County, 41180 0.8958 0.9005 0.52
Missouri.
26500........................... Johnson County, Missouri 99926 0.7930 0.7927 -0.04
26510........................... Knox County, Missouri... 99926 0.7930 0.7927 -0.04
26520........................... Laclede County, Missouri 99926 0.7930 0.7927 -0.04
26530........................... Lafayette County, 28140 0.9483 0.9495 0.13
Missouri.
26540........................... Lawrence County, 99926 0.7930 0.7927 -0.04
Missouri.
26541........................... Lewis County, Missouri.. 99926 0.7930 0.7927 -0.04
26560........................... Lincoln County, Missouri 41180 0.8958 0.9005 0.52
26570........................... Linn County, Missouri... 99926 0.7930 0.7927 -0.04
26580........................... Livingston County, 99926 0.7930 0.7927 -0.04
Missouri.
26590........................... Mc Donald County, 22220 0.8310 0.8865 6.68
Missouri.
26600........................... Macon County, Missouri.. 99926 0.7930 0.7927 -0.04
26601........................... Madison County, Missouri 99926 0.7930 0.7927 -0.04
26620........................... Maries County, Missouri. 99926 0.7930 0.7927 -0.04
26630........................... Marion County, Missouri. 99926 0.7930 0.7927 -0.04
26631........................... Mercer County, Missouri. 99926 0.7930 0.7927 -0.04
26650........................... Miller County, Missouri. 99926 0.7930 0.7927 -0.04
26660........................... Mississippi County, 99926 0.7930 0.7927 -0.04
Missouri.
26670........................... Moniteau County, 27620 0.8173 0.8332 1.95
Missouri.
26680........................... Monroe County, Missouri. 99926 0.7930 0.7927 -0.04
26690........................... Montgomery County, 99926 0.7930 0.7927 -0.04
Missouri.
26700........................... Morgan County, Missouri. 99926 0.7930 0.7927 -0.04
26710........................... New Madrid County, 99926 0.7930 0.7927 -0.04
Missouri.
26720........................... Newton County, Missouri. 27900 0.8582 0.8605 0.27
26730........................... Nodaway County, Missouri 99926 0.7930 0.7927 -0.04
26740........................... Oregon County, Missouri. 99926 0.7930 0.7927 -0.04
26750........................... Osage County, Missouri.. 27620 0.8173 0.8332 1.95
26751........................... Ozark County, Missouri.. 99926 0.7930 0.7927 -0.04
26770........................... Pemiscot County, 99926 0.7930 0.7927 -0.04
Missouri.
26780........................... Perry County, Missouri.. 99926 0.7930 0.7927 -0.04
26790........................... Pettis County, Missouri. 99926 0.7930 0.7927 -0.04
26800........................... Phelps County, Missouri. 99926 0.7930 0.7927 -0.04
26810........................... Pike County, Missouri... 99926 0.7930 0.7927 -0.04
26820........................... Platte County, Missouri. 28140 0.9483 0.9495 0.13
26821........................... Polk County, Missouri... 44180 0.8098 0.8469 4.58
26840........................... Pulaski County, Missouri 99926 0.7930 0.7927 -0.04
26850........................... Putnam County, Missouri. 99926 0.7930 0.7927 -0.04
26860........................... Ralls County, Missouri.. 99926 0.7930 0.7927 -0.04
[[Page 65982]]
26870........................... Randolph County, 99926 0.7930 0.7927 -0.04
Missouri.
26880........................... Ray County, Missouri.... 28140 0.9483 0.9495 0.13
26881........................... Reynolds County, 99926 0.7930 0.7927 -0.04
Missouri.
26900........................... Ripley County, Missouri. 99926 0.7930 0.7927 -0.04
26910........................... St Charles County, 41180 0.8958 0.9005 0.52
Missouri.
26911........................... St Clair County, 99926 0.7930 0.7927 -0.04
Missouri.
26930........................... St Francois County, 99926 0.7930 0.7927 -0.04
Missouri.
26940........................... St Louis County, 41180 0.8958 0.9005 0.52
Missouri.
26950........................... St Louis City County, 41180 0.8958 0.9005 0.52
Missouri.
26960........................... Ste Genevieve County, 99926 0.7930 0.7927 -0.04
Missouri.
26970........................... Saline County, Missouri. 99926 0.7930 0.7927 -0.04
26980........................... Schuyler County, 99926 0.7930 0.7927 -0.04
Missouri.
26981........................... Scotland County, 99926 0.7930 0.7927 -0.04
Missouri.
26982........................... Scott County, Missouri.. 99926 0.7930 0.7927 -0.04
26983........................... Shannon County, Missouri 99926 0.7930 0.7927 -0.04
26984........................... Shelby County, Missouri. 99926 0.7930 0.7927 -0.04
26985........................... Stoddard County, 99926 0.7930 0.7927 -0.04
Missouri.
26986........................... Stone County, Missouri.. 99926 0.7930 0.7927 -0.04
26987........................... Sullivan County, 99926 0.7930 0.7927 -0.04
Missouri.
26988........................... Taney County, Missouri.. 99926 0.7930 0.7927 -0.04
26989........................... Texas County, Missouri.. 99926 0.7930 0.7927 -0.04
26990........................... Vernon County, Missouri. 99926 0.7930 0.7927 -0.04
26991........................... Warren County, Missouri. 41180 0.8958 0.9005 0.52
26992........................... Washington County, 41180 0.8457 0.9005 6.48
Missouri.
26993........................... Wayne County, Missouri.. 99926 0.7930 0.7927 -0.04
26994........................... Webster County, Missouri 44180 0.8244 0.8469 2.73
26995........................... Worth County, Missouri.. 99926 0.7930 0.7927 -0.04
26996........................... Wright County, Missouri. 99926 0.7930 0.7927 -0.04
27000........................... Beaverhead County, 99927 0.8762 0.8590 -1.96
Montana.
27010........................... Big Horn County, Montana 99927 0.8762 0.8590 -1.96
27020........................... Blaine County, Montana.. 99927 0.8762 0.8590 -1.96
27030........................... Broadwater County, 99927 0.8762 0.8590 -1.96
Montana.
27040........................... Carbon County, Montana.. 13740 0.8798 0.8712 -0.98
27050........................... Carter County, Montana.. 99927 0.8762 0.8590 -1.96
27060........................... Cascade County, Montana. 24500 0.9052 0.8598 -5.02
27070........................... Chouteau County, Montana 99927 0.8762 0.8590 -1.96
27080........................... Custer County, Montana.. 99927 0.8762 0.8590 -1.96
27090........................... Daniels County, Montana. 99927 0.8762 0.8590 -1.96
27100........................... Dawson County, Montana.. 99927 0.8762 0.8590 -1.96
27110........................... Deer Lodge County, 99927 0.8762 0.8590 -1.96
Montana.
27113........................... Yellowstone National 99927 0.8762 0.8590 -1.96
Park, Montana.
27120........................... Fallon County, Montana.. 99927 0.8762 0.8590 -1.96
27130........................... Fergus County, Montana.. 99927 0.8762 0.8590 -1.96
27140........................... Flathead County, Montana 99927 0.8762 0.8590 -1.96
27150........................... Gallatin County, Montana 99927 0.8762 0.8590 -1.96
27160........................... Garfield County, Montana 99927 0.8762 0.8590 -1.96
27170........................... Glacier County, Montana. 99927 0.8762 0.8590 -1.96
27180........................... Golden Valley County, 99927 0.8762 0.8590 -1.96
Montana.
27190........................... Granite County, Montana. 99927 0.8762 0.8590 -1.96
27200........................... Hill County, Montana.... 99927 0.8762 0.8590 -1.96
27210........................... Jefferson County, 99927 0.8762 0.8590 -1.96
Montana.
27220........................... Judith Basin County, 99927 0.8762 0.8590 -1.96
Montana.
27230........................... Lake County, Montana.... 99927 0.8762 0.8590 -1.96
27240........................... Lewis And Clark County, 99927 0.8762 0.8590 -1.96
Montana.
27250........................... Liberty County, Montana. 99927 0.8762 0.8590 -1.96
27260........................... Lincoln County, Montana. 99927 0.8762 0.8590 -1.96
27270........................... Mc Cone County, Montana. 99927 0.8762 0.8590 -1.96
27280........................... Madison County, Montana. 99927 0.8762 0.8590 -1.96
27290........................... Meagher County, Montana. 99927 0.8762 0.8590 -1.96
27300........................... Mineral County, Montana. 99927 0.8762 0.8590 -1.96
27310........................... Missoula County, Montana 33540 0.9473 0.8928 -5.75
27320........................... Musselshell County, 99927 0.8762 0.8590 -1.96
Montana.
27330........................... Park County, Montana.... 99927 0.8762 0.8590 -1.96
27340........................... Petroleum County, 99927 0.8762 0.8590 -1.96
Montana.
27350........................... Phillips County, Montana 99927 0.8762 0.8590 -1.96
27360........................... Pondera County, Montana. 99927 0.8762 0.8590 -1.96
27370........................... Powder River County, 99927 0.8762 0.8590 -1.96
Montana.
27380........................... Powell County, Montana.. 99927 0.8762 0.8590 -1.96
[[Continued on page 65983]]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
]
[[pp. 65983-66006]] Medicare Program; Home Health Prospective Payment System Rate
Update for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes
to Medicare Payment for Oxygen Equipment and Capped Rental Durable
Medical Equipment; Final Rule
[[Continued from page 65982]]
[[Page 65983]]
27390........................... Prairie County, Montana. 99927 0.8762 0.8590 -1.96
27400........................... Ravalli County, Montana. 99927 0.8762 0.8590 -1.96
27410........................... Richland County, Montana 99927 0.8762 0.8590 -1.96
27420........................... Roosevelt County, 99927 0.8762 0.8590 -1.96
Montana.
27430........................... Rosebud County, Montana. 99927 0.8762 0.8590 -1.96
27440........................... Sanders County, Montana. 99927 0.8762 0.8590 -1.96
27450........................... Sheridan County, Montana 99927 0.8762 0.8590 -1.96
27460........................... Silver Bow County, 99927 0.8762 0.8590 -1.96
Montana.
27470........................... Stillwater County, 99927 0.8762 0.8590 -1.96
Montana.
27480........................... Sweet Grass County, 99927 0.8762 0.8590 -1.96
Montana.
27490........................... Teton County, Montana... 99927 0.8762 0.8590 -1.96
27500........................... Toole County, Montana... 99927 0.8762 0.8590 -1.96
27510........................... Treasure County, Montana 99927 0.8762 0.8590 -1.96
27520........................... Valley County, Montana.. 99927 0.8762 0.8590 -1.96
27530........................... Wheatland County, 99927 0.8762 0.8590 -1.96
Montana.
27540........................... Wibaux County, Montana.. 99927 0.8762 0.8590 -1.96
27550........................... Yellowstone County, 13740 0.8834 0.8712 -1.38
Montana.
28000........................... Adams County, Nebraska.. 99928 0.8657 0.8677 0.23
28010........................... Antelope County, 99928 0.8657 0.8677 0.23
Nebraska.
28020........................... Arthur County, Nebraska. 99928 0.8657 0.8677 0.23
28030........................... Banner County, Nebraska. 99928 0.8657 0.8677 0.23
28040........................... Blaine County, Nebraska. 99928 0.8657 0.8677 0.23
28050........................... Boone County, Nebraska.. 99928 0.8657 0.8677 0.23
28060........................... Box Butte County, 99928 0.8657 0.8677 0.23
Nebraska.
28070........................... Boyd County, Nebraska... 99928 0.8657 0.8677 0.23
28080........................... Brown County, Nebraska.. 99928 0.8657 0.8677 0.23
28090........................... Buffalo County, Nebraska 99928 0.8657 0.8677 0.23
28100........................... Burt County, Nebraska... 99928 0.8657 0.8677 0.23
28110........................... Butler County, Nebraska. 99928 0.8657 0.8677 0.23
28120........................... Cass County, Nebraska... 36540 0.9560 0.9450 -1.15
28130........................... Cedar County, Nebraska.. 99928 0.8657 0.8677 0.23
28140........................... Chase County, Nebraska.. 99928 0.8657 0.8677 0.23
28150........................... Cherry County, Nebraska. 99928 0.8657 0.8677 0.23
28160........................... Cheyenne County, 99928 0.8657 0.8677 0.23
Nebraska.
28170........................... Clay County, Nebraska... 99928 0.8657 0.8677 0.23
28180........................... Colfax County, Nebraska. 99928 0.8657 0.8677 0.23
28190........................... Cuming County, Nebraska. 99928 0.8657 0.8677 0.23
28200........................... Custer County, Nebraska. 99928 0.8657 0.8677 0.23
28210........................... Dakota County, Nebraska. 43580 0.9399 0.9200 -2.12
28220........................... Dawes County, Nebraska.. 99928 0.8657 0.8677 0.23
28230........................... Dawson County, Nebraska. 99928 0.8657 0.8677 0.23
28240........................... Deuel County, Nebraska.. 99928 0.8657 0.8677 0.23
28250........................... Dixon County, Nebraska.. 43580 0.9019 0.9200 2.01
28260........................... Dodge County, Nebraska.. 99928 0.8657 0.8677 0.23
28270........................... Douglas County, Nebraska 36540 0.9560 0.9450 -1.15
28280........................... Dundy County, Nebraska.. 99928 0.8657 0.8677 0.23
28290........................... Fillmore County, 99928 0.8657 0.8677 0.23
Nebraska.
28300........................... Franklin County, 99928 0.8657 0.8677 0.23
Nebraska.
28310........................... Frontier County, 99928 0.8657 0.8677 0.23
Nebraska.
28320........................... Furnas County, Nebraska. 99928 0.8657 0.8677 0.23
28330........................... Gage County, Nebraska... 99928 0.8657 0.8677 0.23
28340........................... Garden County, Nebraska. 99928 0.8657 0.8677 0.23
28350........................... Garfield County, 99928 0.8657 0.8677 0.23
Nebraska.
28360........................... Gosper County, Nebraska. 99928 0.8657 0.8677 0.23
28370........................... Grant County, Nebraska.. 99928 0.8657 0.8677 0.23
28380........................... Greeley County, Nebraska 99928 0.8657 0.8677 0.23
28390........................... Hall County, Nebraska... 99928 0.8657 0.8677 0.23
28400........................... Hamilton County, 99928 0.8657 0.8677 0.23
Nebraska.
28410........................... Harlan County, Nebraska. 99928 0.8657 0.8677 0.23
28420........................... Hayes County, Nebraska.. 99928 0.8657 0.8677 0.23
28430........................... Hitchcock County, 99928 0.8657 0.8677 0.23
Nebraska.
28440........................... Holt County, Nebraska... 99928 0.8657 0.8677 0.23
28450........................... Hooker County, Nebraska. 99928 0.8657 0.8677 0.23
28460........................... Howard County, Nebraska. 99928 0.8657 0.8677 0.23
28470........................... Jefferson County, 99928 0.8657 0.8677 0.23
Nebraska.
28480........................... Johnson County, Nebraska 99928 0.8657 0.8677 0.23
28490........................... Kearney County, Nebraska 99928 0.8657 0.8677 0.23
28500........................... Keith County, Nebraska.. 99928 0.8657 0.8677 0.23
[[Page 65984]]
28510........................... Keya Paha County, 99928 0.8657 0.8677 0.23
Nebraska.
28520........................... Kimball County, Nebraska 99928 0.8657 0.8677 0.23
28530........................... Knox County, Nebraska... 99928 0.8657 0.8677 0.23
28540........................... Lancaster County, 30700 1.0214 1.0092 -1.19
Nebraska.
28550........................... Lincoln County, Nebraska 99928 0.8657 0.8677 0.23
28560........................... Logan County, Nebraska.. 99928 0.8657 0.8677 0.23
28570........................... Loup County, Nebraska... 99928 0.8657 0.8677 0.23
28580........................... Mc Pherson County, 99928 0.8657 0.8677 0.23
Nebraska.
28590........................... Madison County, Nebraska 99928 0.8657 0.8677 0.23
28600........................... Merrick County, Nebraska 99928 0.8657 0.8677 0.23
28610........................... Morrill County, Nebraska 99928 0.8657 0.8677 0.23
28620........................... Nance County, Nebraska.. 99928 0.8657 0.8677 0.23
28630........................... Nemaha County, Nebraska. 99928 0.8657 0.8677 0.23
28640........................... Nuckolls County, 99928 0.8657 0.8677 0.23
Nebraska.
28650........................... Otoe County, Nebraska... 99928 0.8657 0.8677 0.23
28660........................... Pawnee County, Nebraska. 99928 0.8657 0.8677 0.23
28670........................... Perkins County, Nebraska 99928 0.8657 0.8677 0.23
28680........................... Phelps County, Nebraska. 99928 0.8657 0.8677 0.23
28690........................... Pierce County, Nebraska. 99928 0.8657 0.8677 0.23
28700........................... Platte County, Nebraska. 99928 0.8657 0.8677 0.23
28710........................... Polk County, Nebraska... 99928 0.8657 0.8677 0.23
28720........................... Redwillow County, 99928 0.8657 0.8677 0.23
Nebraska.
28730........................... Richardson County, 99928 0.8657 0.8677 0.23
Nebraska.
28740........................... Rock County, Nebraska... 99928 0.8657 0.8677 0.23
28750........................... Saline County, Nebraska. 99928 0.8657 0.8677 0.23
28760........................... Sarpy County, Nebraska.. 36540 0.9560 0.9450 -1.15
28770........................... Saunders County, 36540 0.9109 0.9450 3.74
Nebraska.
28780........................... Scotts Bluff County, 99928 0.8657 0.8677 0.23
Nebraska.
28790........................... Seward County, Nebraska. 30700 0.9436 1.0092 6.95
28800........................... Sheridan County, 99928 0.8657 0.8677 0.23
Nebraska.
28810........................... Sherman County, Nebraska 99928 0.8657 0.8677 0.23
28820........................... Sioux County, Nebraska.. 99928 0.8657 0.8677 0.23
28830........................... Stanton County, Nebraska 99928 0.8657 0.8677 0.23
28840........................... Thayer County, Nebraska. 99928 0.8657 0.8677 0.23
28850........................... Thomas County, Nebraska. 99928 0.8657 0.8677 0.23
28860........................... Thurston County, 99928 0.8657 0.8677 0.23
Nebraska.
28870........................... Valley County, Nebraska. 99928 0.8657 0.8677 0.23
28880........................... Washington County, 36540 0.9560 0.9450 -1.15
Nebraska.
28890........................... Wayne County, Nebraska.. 99928 0.8657 0.8677 0.23
28900........................... Webster County, Nebraska 99928 0.8657 0.8677 0.23
28910........................... Wheeler County, Nebraska 99928 0.8657 0.8677 0.23
28920........................... York County, Nebraska... 99928 0.8657 0.8677 0.23
29000........................... Churchill County, Nevada 99929 0.9376 0.8944 -4.61
29010........................... Clark County, Nevada.... 29820 1.1296 1.1430 1.19
29020........................... Douglas County, Nevada.. 99929 0.9376 0.8944 -4.61
29030........................... Elko County, Nevada..... 99929 0.9376 0.8944 -4.61
29040........................... Esmeralda County, Nevada 99929 0.9376 0.8944 -4.61
29050........................... Eureka County, Nevada... 99929 0.9376 0.8944 -4.61
29060........................... Humboldt County, Nevada. 99929 0.9376 0.8944 -4.61
29070........................... Lander County, Nevada... 99929 0.9376 0.8944 -4.61
29080........................... Lincoln County, Nevada.. 99929 0.9376 0.8944 -4.61
29090........................... Lyon County, Nevada..... 99929 0.9376 0.8944 -4.61
29100........................... Mineral County, Nevada.. 99929 0.9376 0.8944 -4.61
29110........................... Nye County, Nevada...... 99929 1.0110 0.8944 -11.53
29120........................... Carson City County, 16180 0.9961 1.0025 0.64
Nevada.
29130........................... Pershing County, Nevada. 99929 0.9376 0.8944 -4.61
29140........................... Storey County, Nevada... 39900 1.0335 1.1963 15.75
29150........................... Washoe County, Nevada... 39900 1.0982 1.1963 8.93
29160........................... White Pine County, 99929 0.9376 0.8944 -4.61
Nevada.
30000........................... Belknap County, New 99930 1.0817 1.0853 0.33
Hampshire.
30010........................... Carroll County, New 99930 1.0817 1.0853 0.33
Hampshire.
30020........................... Cheshire County, New 99930 1.0817 1.0853 0.33
Hampshire.
30030........................... Coos County, New 99930 1.0817 1.0853 0.33
Hampshire.
30040........................... Grafton County, New 99930 1.0817 1.0853 0.33
Hampshire.
30050........................... Hillsboro County, New 31700 1.0766 1.0243 -4.86
Hampshire.
30060........................... Merrimack County, New 31700 1.0766 1.0243 -4.86
Hampshire.
30070........................... Rockingham County, New 40484 1.0776 1.0159 -5.73
Hampshire.
30080........................... Strafford County, New 40484 1.0776 1.0159 -5.73
Hampshire.
[[Page 65985]]
30090........................... Sullivan County, New 99930 1.0817 1.0853 0.33
Hampshire.
31000........................... Atlantic County, New 12100 1.1556 1.1831 2.38
Jersey.
31100........................... Bergen County, New 35644 1.2420 1.3177 6.10
Jersey.
31150........................... Burlington County, New 15804 1.0720 1.0392 -3.06
Jersey.
31160........................... Camden County, New 15804 1.0720 1.0392 -3.06
Jersey.
31180........................... Cape May County, New 36140 1.1254 1.0472 -6.95
Jersey.
31190........................... Cumberland County, New 47220 0.9827 0.9832 0.05
Jersey.
31200........................... Essex County, New Jersey 35084 1.1859 1.1892 0.28
31220........................... Gloucester County, New 15804 1.0720 1.0392 -3.06
Jersey.
31230........................... Hudson County, New 35644 1.2263 1.3177 7.45
Jersey.
31250........................... Hunterdon County, New 35084 1.1525 1.1892 3.18
Jersey.
31260........................... Mercer County, New 45940 1.0834 1.0835 0.01
Jersey.
31270........................... Middlesex County, New 20764 1.1208 1.1190 -0.16
Jersey.
31290........................... Monmouth County, New 20764 1.1255 1.1190 -0.58
Jersey.
31300........................... Morris County, New 35084 1.1859 1.1892 0.28
Jersey.
31310........................... Ocean County, New Jersey 20764 1.1255 1.1190 -0.58
31320........................... Passaic County, New 35644 1.2420 1.3177 6.10
Jersey.
31340........................... Salem County, New Jersey 48864 1.0697 1.0684 -0.12
31350........................... Somerset County, New 20764 1.1208 1.1190 -0.16
Jersey.
31360........................... Sussex County, New 35084 1.1859 1.1892 0.28
Jersey.
31370........................... Union County, New Jersey 35084 1.1859 1.1892 0.28
31390........................... Warren County, New 10900 1.0826 0.9947 -8.12
Jersey.
32000........................... Bernalillo County, New 10740 0.9684 0.9458 -2.33
Mexico.
32010........................... Catron County, New 99932 0.8599 0.8332 -3.11
Mexico.
32020........................... Chaves County, New 99932 0.8599 0.8332 -3.11
Mexico.
32025........................... Cibola County, New 99932 0.8599 0.8332 -3.11
Mexico.
32030........................... Colfax County, New 99932 0.8599 0.8332 -3.11
Mexico.
32040........................... Curry County, New Mexico 99932 0.8599 0.8332 -3.11
32050........................... De Baca County, New 99932 0.8599 0.8332 -3.11
Mexico.
32060........................... Dona Ana County, New 29740 0.8467 0.9273 9.52
Mexico.
32070........................... Eddy County, New Mexico. 99932 0.8599 0.8332 -3.11
32080........................... Grant County, New Mexico 99932 0.8599 0.8332 -3.11
32090........................... Guadalupe County, New 99932 0.8599 0.8332 -3.11
Mexico.
32100........................... Harding County, New 99932 0.8599 0.8332 -3.11
Mexico.
32110........................... Hidalgo County, New 99932 0.8599 0.8332 -3.11
Mexico.
32120........................... Lea County, New Mexico.. 99932 0.8599 0.8332 -3.11
32130........................... Lincoln County, New 99932 0.8599 0.8332 -3.11
Mexico.
32131........................... Los Alamos County, New 99932 0.9692 0.8332 -14.03
Mexico.
32140........................... Luna County, New Mexico. 99932 0.8599 0.8332 -3.11
32150........................... Mc Kinley County, New 99932 0.8599 0.8332 -3.11
Mexico.
32160........................... Mora County, New Mexico. 99932 0.8599 0.8332 -3.11
32170........................... Otero County, New Mexico 99932 0.8599 0.8332 -3.11
32180........................... Quay County, New Mexico. 99932 0.8599 0.8332 -3.11
32190........................... Rio Arriba County, New 99932 0.8599 0.8332 -3.11
Mexico.
32200........................... Roosevelt County, New 99932 0.8599 0.8332 -3.11
Mexico.
32210........................... Sandoval County, New 10740 0.9684 0.9458 -2.33
Mexico.
32220........................... San Juan County, New 22140 0.8536 0.8589 0.62
Mexico.
32230........................... San Miguel County, New 99932 0.8599 0.8332 -3.11
Mexico.
32240........................... Santa Fe County, New 42140 1.0834 1.0824 -0.09
Mexico.
32250........................... Sierra County, New 99932 0.8599 0.8332 -3.11
Mexico.
32260........................... Socorro County, New 99932 0.8599 0.8332 -3.11
Mexico.
32270........................... Taos County, New Mexico. 99932 0.8599 0.8332 -3.11
32280........................... Torrance County, New 10740 0.9124 0.9458 3.66
Mexico.
32290........................... Union County, New Mexico 99932 0.8599 0.8332 -3.11
32300........................... Valencia County, New 10740 0.9684 0.9458 -2.33
Mexico.
33000........................... Albany County, New York. 10580 0.8574 0.8720 1.70
33010........................... Allegany County, New 99933 0.8275 0.8232 -0.52
York.
33020........................... Bronx County, New York.. 35644 1.3326 1.3177 -1.12
33030........................... Broome County, New York. 13780 0.8562 0.8786 2.62
33040........................... Cattaraugus County, New 99933 0.8275 0.8232 -0.52
York.
33050........................... Cayuga County, New York. 99933 0.8823 0.8232 -6.70
33060........................... Chautauqua County, New 99933 0.7849 0.8232 4.88
York.
33070........................... Chemung County, New York 21300 0.8250 0.8240 -0.12
33080........................... Chenango County, New 99933 0.8275 0.8232 -0.52
York.
33090........................... Clinton County, New York 99933 0.8275 0.8232 -0.52
33200........................... Columbia County, New 99933 0.8275 0.8232 -0.52
York.
33210........................... Cortland County, New 99933 0.8275 0.8232 -0.52
York.
33220........................... Delaware County, New 99933 0.8275 0.8232 -0.52
York.
[[Page 65986]]
33230........................... Dutchess County, New 39100 1.0683 1.0911 2.13
York.
33240........................... Erie County, New York... 15380 0.9511 0.9424 -0.91
33260........................... Essex County, New York.. 99933 0.8275 0.8232 -0.52
33270........................... Franklin County, New 99933 0.8275 0.8232 -0.52
York.
33280........................... Fulton County, New York. 99933 0.8275 0.8232 -0.52
33290........................... Genesee County, New York 99933 0.8602 0.8232 -4.30
33300........................... Greene County, New York. 99933 0.8275 0.8232 -0.52
33310........................... Hamilton County, New 99933 0.8275 0.8232 -0.52
York.
33320........................... Herkimer County, New 46540 0.8358 0.8396 0.45
York.
33330........................... Jefferson County, New 99933 0.8275 0.8232 -0.52
York.
33331........................... Kings County, New York.. 35644 1.3326 1.3177 -1.12
33340........................... Lewis County, New York.. 99933 0.8275 0.8232 -0.52
33350........................... Livingston County, New 40380 0.9085 0.8994 -1.00
York.
33360........................... Madison County, New York 45060 0.9533 0.9691 1.66
33370........................... Monroe County, New York. 40380 0.9085 0.8994 -1.00
33380........................... Montgomery County, New 99933 0.8357 0.8232 -1.50
York.
33400........................... Nassau County, New York. 35004 1.2719 1.2662 -0.45
33420........................... New York County, New 35644 1.3326 1.3177 -1.12
York.
33500........................... Niagara County, New York 15380 0.9511 0.9424 -0.91
33510........................... Oneida County, New York. 46540 0.8358 0.8396 0.45
33520........................... Onondaga County, New 45060 0.9533 0.9691 1.66
York.
33530........................... Ontario County, New York 40380 0.9085 0.8994 -1.00
33540........................... Orange County, New York. 39100 1.1049 1.0911 -1.25
33550........................... Orleans County, New York 40380 0.9085 0.8994 -1.00
33560........................... Oswego County, New York. 45060 0.9533 0.9691 1.66
33570........................... Otsego County, New York. 99933 0.8275 0.8232 -0.52
33580........................... Putnam County, New York. 35644 1.3326 1.3177 -1.12
33590........................... Queens County, New York. 35644 1.3326 1.3177 -1.12
33600........................... Rensselaer County, New 10580 0.8574 0.8720 1.70
York.
33610........................... Richmond County, New 35644 1.3326 1.3177 -1.12
York.
33620........................... Rockland County, New 35644 1.3326 1.3177 -1.12
York.
33630........................... St Lawrence County, New 99933 0.8275 0.8232 -0.52
York.
33640........................... Saratoga County, New 10580 0.8574 0.8720 1.70
York.
33650........................... Schenectady County, New 10580 0.8574 0.8720 1.70
York.
33660........................... Schoharie County, New 10580 0.8574 0.8720 1.70
York.
33670........................... Schuyler County, New 99933 0.8275 0.8232 -0.52
York.
33680........................... Seneca County, New York. 99933 0.8275 0.8232 -0.52
33690........................... Steuben County, New York 99933 0.8275 0.8232 -0.52
33700........................... Suffolk County, New York 35004 1.2719 1.2662 -0.45
33710........................... Sullivan County, New 99933 0.8275 0.8232 -0.52
York.
33720........................... Tioga County, New York.. 13780 0.8562 0.8786 2.62
33730........................... Tompkins County, New 27060 0.9094 0.9928 9.17
York.
33740........................... Ulster County, New York. 28740 0.8825 0.9367 6.14
33750........................... Warren County, New York. 24020 0.8559 0.8324 -2.75
33760........................... Washington County, New 24020 0.8559 0.8324 -2.75
York.
33770........................... Wayne County, New York.. 40380 0.9085 0.8994 -1.00
33800........................... Westchester County, New 35644 1.3326 1.3177 -1.12
York.
33900........................... Wyoming County, New York 99933 0.8275 0.8232 -0.52
33910........................... Yates County, New York.. 99933 0.8275 0.8232 -0.52
34000........................... Alamance County, N 15500 0.8962 0.8674 -3.21
Carolina.
34010........................... Alexander County, N 25860 0.8921 0.9010 1.00
Carolina.
34020........................... Alleghany County, N 99934 0.8501 0.8588 1.02
Carolina.
34030........................... Anson County, N Carolina 16740 0.9106 0.9554 4.92
34040........................... Ashe County, N Carolina. 99934 0.8501 0.8588 1.02
34050........................... Avery County, N Carolina 99934 0.8501 0.8588 1.02
34060........................... Beaufort County, N 99934 0.8501 0.8588 1.02
Carolina.
34070........................... Bertie County, N 99934 0.8501 0.8588 1.02
Carolina.
34080........................... Bladen County, N 99934 0.8501 0.8588 1.02
Carolina.
34090........................... Brunswick County, N 48900 0.9582 0.9835 2.64
Carolina.
34100........................... Buncombe County, N 11700 0.9511 0.9216 -3.10
Carolina.
34110........................... Burke County, N Carolina 25860 0.8921 0.9010 1.00
34120........................... Cabarrus County, N 16740 0.9733 0.9554 -1.84
Carolina.
34130........................... Caldwell County, N 25860 0.8921 0.9010 1.00
Carolina.
34140........................... Camden County, N 99934 0.8501 0.8588 1.02
Carolina.
34150........................... Carteret County, N 99934 0.8501 0.8588 1.02
Carolina.
34160........................... Caswell County, N 99934 0.8501 0.8588 1.02
Carolina.
34170........................... Catawba County, N 25860 0.8921 0.9010 1.00
Carolina.
34180........................... Chatham County, N 20500 1.0139 0.9826 -3.09
Carolina.
[[Page 65987]]
34190........................... Cherokee County, N 99934 0.8501 0.8588 1.02
Carolina.
34200........................... Chowan County, N 99934 0.8501 0.8588 1.02
Carolina.
34210........................... Clay County, N Carolina. 99934 0.8501 0.8588 1.02
34220........................... Cleveland County, N 99934 0.8501 0.8588 1.02
Carolina.
34230........................... Columbus County, N 99934 0.8501 0.8588 1.02
Carolina.
34240........................... Craven County, N 99934 0.8501 0.8588 1.02
Carolina.
34250........................... Cumberland County, N 22180 0.9416 0.8945 -5.00
Carolina.
34251........................... Currituck County, N 47260 0.8799 0.8790 -0.10
Carolina.
34270........................... Dare County, N Carolina. 99934 0.8501 0.8588 1.02
34280........................... Davidson County, N 99934 0.8779 0.8588 -2.18
Carolina.
34290........................... Davie County, N Carolina 49180 0.8981 0.9276 3.28
34300........................... Duplin County, N 99934 0.8501 0.8588 1.02
Carolina.
34310........................... Durham County, N 20500 1.0139 0.9826 -3.09
Carolina.
34320........................... Edgecombe County, N 40580 0.8915 0.8854 -0.68
Carolina.
34330........................... Forsyth County, N 49180 0.8981 0.9276 3.28
Carolina.
34340........................... Franklin County, N 39580 0.9863 0.9864 0.01
Carolina.
34350........................... Gaston County, N 16740 0.9733 0.9554 -1.84
Carolina.
34360........................... Gates County, N Carolina 99934 0.8501 0.8588 1.02
34370........................... Graham County, N 99934 0.8501 0.8588 1.02
Carolina.
34380........................... Granville County, N 99934 0.8501 0.8588 1.02
Carolina.
34390........................... Greene County, N 24780 0.8944 0.9432 5.46
Carolina.
34400........................... Guilford County, N 24660 0.9061 0.8866 -2.15
Carolina.
34410........................... Halifax County, N 99934 0.8501 0.8588 1.02
Carolina.
34420........................... Harnett County, N 99934 0.8501 0.8588 1.02
Carolina.
34430........................... Haywood County, N 11700 0.8874 0.9216 3.85
Carolina.
34440........................... Henderson County, N 11700 0.8874 0.9216 3.85
Carolina.
34450........................... Hertford County, N 99934 0.8501 0.8588 1.02
Carolina.
34460........................... Hoke County, N Carolina. 22180 0.8939 0.8945 0.07
34470........................... Hyde County, N Carolina. 99934 0.8501 0.8588 1.02
34480........................... Iredell County, N 99934 0.8501 0.8588 1.02
Carolina.
34490........................... Jackson County, N 99934 0.8501 0.8588 1.02
Carolina.
34500........................... Johnston County, N 39580 0.9863 0.9864 0.01
Carolina.
34510........................... Jones County, N Carolina 99934 0.8501 0.8588 1.02
34520........................... Lee County, N Carolina.. 99934 0.8501 0.8588 1.02
34530........................... Lenoir County, N 99934 0.8501 0.8588 1.02
Carolina.
34540........................... Lincoln County, N 99934 0.9128 0.8588 -5.92
Carolina.
34550........................... Mc Dowell County, N 99934 0.8501 0.8588 1.02
Carolina.
34560........................... Macon County, N Carolina 99934 0.8501 0.8588 1.02
34570........................... Madison County, N 11700 0.9511 0.9216 -3.10
Carolina.
34580........................... Martin County, N 99934 0.8501 0.8588 1.02
Carolina.
34590........................... Mecklenburg County, N 16740 0.9733 0.9554 -1.84
Carolina.
34600........................... Mitchell County, N 99934 0.8501 0.8588 1.02
Carolina.
34610........................... Montgomery County, N 99934 0.8501 0.8588 1.02
Carolina.
34620........................... Moore County, N Carolina 99934 0.8501 0.8588 1.02
34630........................... Nash County, N Carolina. 40580 0.8915 0.8854 -0.68
34640........................... New Hanover County, N 48900 0.9582 0.9835 2.64
Carolina.
34650........................... Northampton County, N 99934 0.8501 0.8588 1.02
Carolina.
34660........................... Onslow County, N 27340 0.8236 0.8231 -0.06
Carolina.
34670........................... Orange County, N 20500 1.0139 0.9826 -3.09
Carolina.
34680........................... Pamlico County, N 99934 0.8501 0.8588 1.02
Carolina.
34690........................... Pasquotank County, N 99934 0.8501 0.8588 1.02
Carolina.
34700........................... Pender County, N 48900 0.9022 0.9835 9.01
Carolina.
34710........................... Perquimans County, N 99934 0.8501 0.8588 1.02
Carolina.
34720........................... Person County, N 20500 0.9353 0.9826 5.06
Carolina.
34730........................... Pitt County, N Carolina. 24780 0.9425 0.9432 0.07
34740........................... Polk County, N Carolina. 99934 0.8501 0.8588 1.02
34750........................... Randolph County, N 24660 0.9061 0.8866 -2.15
Carolina.
34760........................... Richmond County, N 99934 0.8501 0.8588 1.02
Carolina.
34770........................... Robeson County, N 99934 0.8501 0.8588 1.02
Carolina.
34780........................... Rockingham County, N 24660 0.8783 0.8866 0.95
Carolina.
34790........................... Rowan County, N Carolina 99934 0.9128 0.8588 -5.92
34800........................... Rutherford County, N 99934 0.8501 0.8588 1.02
Carolina.
34810........................... Sampson County, N 99934 0.8501 0.8588 1.02
Carolina.
34820........................... Scotland County, N 99934 0.8501 0.8588 1.02
Carolina.
34830........................... Stanly County, N 99934 0.8501 0.8588 1.02
Carolina.
34840........................... Stokes County, N 49180 0.8981 0.9276 3.28
Carolina.
34850........................... Surry County, N Carolina 99934 0.8501 0.8588 1.02
34860........................... Swain County, N Carolina 99934 0.8501 0.8588 1.02
[[Page 65988]]
34870........................... Transylvania County, N 99934 0.8501 0.8588 1.02
Carolina.
34880........................... Tyrrell County, N 99934 0.8501 0.8588 1.02
Carolina.
34890........................... Union County, N Carolina 16740 0.9733 0.9554 -1.84
34900........................... Vance County, N Carolina 99934 0.8501 0.8588 1.02
34910........................... Wake County, N Carolina. 39580 0.9863 0.9864 0.01
34920........................... Warren County, N 99934 0.8501 0.8588 1.02
Carolina.
34930........................... Washington County, N 99934 0.8501 0.8588 1.02
Carolina.
34940........................... Watauga County, N 99934 0.8501 0.8588 1.02
Carolina.
34950........................... Wayne County, N Carolina 24140 0.8775 0.9171 4.51
34960........................... Wilkes County, N 99934 0.8501 0.8588 1.02
Carolina.
34970........................... Wilson County, N 99934 0.8501 0.8588 1.02
Carolina.
34980........................... Yadkin County, N 49180 0.8981 0.9276 3.28
Carolina.
34981........................... Yancey County, N 99934 0.8501 0.8588 1.02
Carolina.
35000........................... Adams County, N Dakota.. 99935 0.7261 0.7215 -0.63
35010........................... Barnes County, N Dakota. 99935 0.7261 0.7215 -0.63
35020........................... Benson County, N Dakota. 99935 0.7261 0.7215 -0.63
35030........................... Billings County, N 99935 0.7261 0.7215 -0.63
Dakota.
35040........................... Bottineau County, N 99935 0.7261 0.7215 -0.63
Dakota.
35050........................... Bowman County, N Dakota. 99935 0.7261 0.7215 -0.63
35060........................... Burke County, N Dakota.. 99935 0.7261 0.7215 -0.63
35070........................... Burleigh County, N 13900 0.7574 0.7240 -4.41
Dakota.
35080........................... Cass County, N Dakota... 22020 0.8486 0.8250 -2.78
35090........................... Cavalier County, N 99935 0.7261 0.7215 -0.63
Dakota.
35100........................... Dickey County, N Dakota. 99935 0.7261 0.7215 -0.63
35110........................... Divide County, N Dakota. 99935 0.7261 0.7215 -0.63
35120........................... Dunn County, N Dakota... 99935 0.7261 0.7215 -0.63
35130........................... Eddy County, N Dakota... 99935 0.7261 0.7215 -0.63
35140........................... Emmons County, N Dakota. 99935 0.7261 0.7215 -0.63
35150........................... Foster County, N Dakota. 99935 0.7261 0.7215 -0.63
35160........................... Golden Valley County, N 99935 0.7261 0.7215 -0.63
Dakota.
35170........................... Grand Forks County, N 24220 0.7901 0.7949 0.61
Dakota.
35180........................... Grant County, N Dakota.. 99935 0.7261 0.7215 -0.63
35190........................... Griggs County, N Dakota. 99935 0.7261 0.7215 -0.63
35200........................... Hettinger County, N 99935 0.7261 0.7215 -0.63
Dakota.
35210........................... Kidder County, N Dakota. 99935 0.7261 0.7215 -0.63
35220........................... La Moure County, N 99935 0.7261 0.7215 -0.63
Dakota.
35230........................... Logan County, N Dakota.. 99935 0.7261 0.7215 -0.63
35240........................... Mc Henry County, N 99935 0.7261 0.7215 -0.63
Dakota.
35250........................... Mc Intosh County, N 99935 0.7261 0.7215 -0.63
Dakota.
35260........................... Mc Kenzie County, N 99935 0.7261 0.7215 -0.63
Dakota.
35270........................... Mc Lean County, N Dakota 99935 0.7261 0.7215 -0.63
35280........................... Mercer County, N Dakota. 99935 0.7261 0.7215 -0.63
35290........................... Morton County, N Dakota. 13900 0.7574 0.7240 -4.41
35300........................... Mountrail County, N 99935 0.7261 0.7215 -0.63
Dakota.
35310........................... Nelson County, N Dakota. 99935 0.7261 0.7215 -0.63
35320........................... Oliver County, N Dakota. 99935 0.7261 0.7215 -0.63
35330........................... Pembina County, N Dakota 99935 0.7261 0.7215 -0.63
35340........................... Pierce County, N Dakota. 99935 0.7261 0.7215 -0.63
35350........................... Ramsey County, N Dakota. 99935 0.7261 0.7215 -0.63
35360........................... Ransom County, N Dakota. 99935 0.7261 0.7215 -0.63
35370........................... Renville County, N 99935 0.7261 0.7215 -0.63
Dakota.
35380........................... Richland County, N 99935 0.7261 0.7215 -0.63
Dakota.
35390........................... Rolette County, N Dakota 99935 0.7261 0.7215 -0.63
35400........................... Sargent County, N Dakota 99935 0.7261 0.7215 -0.63
35410........................... Sheridan County, N 99935 0.7261 0.7215 -0.63
Dakota.
35420........................... Sioux County, N Dakota.. 99935 0.7261 0.7215 -0.63
35430........................... Slope County, N Dakota.. 99935 0.7261 0.7215 -0.63
35440........................... Stark County, N Dakota.. 99935 0.7261 0.7215 -0.63
35450........................... Steele County, N Dakota. 99935 0.7261 0.7215 -0.63
35460........................... Stutsman County, N 99935 0.7261 0.7215 -0.63
Dakota.
35470........................... Towner County, N Dakota. 99935 0.7261 0.7215 -0.63
35480........................... Traill County, N Dakota. 99935 0.7261 0.7215 -0.63
35490........................... Walsh County, N Dakota.. 99935 0.7261 0.7215 -0.63
35500........................... Ward County, N Dakota... 99935 0.7261 0.7215 -0.63
35510........................... Wells County, N Dakota.. 99935 0.7261 0.7215 -0.63
35520........................... Williams County, N 99935 0.7261 0.7215 -0.63
Dakota.
36000........................... Adams County, Ohio...... 99936 0.8874 0.8658 -2.43
36010........................... Allen County, Ohio...... 30620 0.9172 0.9042 -1.42
[[Page 65989]]
36020........................... Ashland County, Ohio.... 99936 0.8874 0.8658 -2.43
36030........................... Ashtabula County, Ohio.. 99936 0.9005 0.8658 -3.85
36040........................... Athens County, Ohio..... 99936 0.8874 0.8658 -2.43
36050........................... Auglaize County, Ohio... 99936 0.8973 0.8658 -3.51
36060........................... Belmont County, Ohio.... 48540 0.7161 0.7010 -2.11
36070........................... Brown County, Ohio...... 17140 0.9675 0.9601 -0.76
36080........................... Butler County, Ohio..... 17140 0.9283 0.9601 3.43
36090........................... Carroll County, Ohio.... 15940 0.8935 0.9031 1.07
36100........................... Champaign County, Ohio.. 99936 0.8874 0.8658 -2.43
36110........................... Clark County, Ohio...... 44220 0.8688 0.8593 -1.09
36120........................... Clermont County, Ohio... 17140 0.9675 0.9601 -0.76
36130........................... Clinton County, Ohio.... 99936 0.8874 0.8658 -2.43
36140........................... Columbiana County, Ohio. 99936 0.8837 0.8658 -2.03
36150........................... Coshocton County, Ohio.. 99936 0.8874 0.8658 -2.43
36160........................... Crawford County, Ohio... 99936 0.9359 0.8658 -7.49
36170........................... Cuyahoga County, Ohio... 17460 0.9198 0.9400 2.20
36190........................... Darke County, Ohio...... 99936 0.8874 0.8658 -2.43
36200........................... Defiance County, Ohio... 99936 0.8874 0.8658 -2.43
36210........................... Delaware County, Ohio... 18140 0.9867 1.0107 2.43
36220........................... Erie County, Ohio....... 41780 0.8970 0.9302 3.70
36230........................... Fairfield County, Ohio.. 18140 0.9867 1.0107 2.43
36240........................... Fayette County, Ohio.... 99936 0.8874 0.8658 -2.43
36250........................... Franklin County, Ohio... 18140 0.9867 1.0107 2.43
36260........................... Fulton County, Ohio..... 45780 0.9574 0.9586 0.13
36270........................... Gallia County, Ohio..... 99936 0.8874 0.8658 -2.43
36280........................... Geauga County, Ohio..... 17460 0.9198 0.9400 2.20
36290........................... Greene County, Ohio..... 19380 0.9022 0.9037 0.17
36300........................... Guernsey County, Ohio... 99936 0.8874 0.8658 -2.43
36310........................... Hamilton County, Ohio... 17140 0.9675 0.9601 -0.76
36330........................... Hancock County, Ohio.... 99936 0.8874 0.8658 -2.43
36340........................... Hardin County, Ohio..... 99936 0.8874 0.8658 -2.43
36350........................... Harrison County, Ohio... 99936 0.8874 0.8658 -2.43
36360........................... Henry County, Ohio...... 99936 0.8874 0.8658 -2.43
36370........................... Highland County, Ohio... 99936 0.8874 0.8658 -2.43
36380........................... Hocking County, Ohio.... 99936 0.8874 0.8658 -2.43
36390........................... Holmes County, Ohio..... 99936 0.8874 0.8658 -2.43
36400........................... Huron County, Ohio...... 99936 0.8874 0.8658 -2.43
36410........................... Jackson County, Ohio.... 99936 0.8874 0.8658 -2.43
36420........................... Jefferson County, Ohio.. 48260 0.7819 0.8063 3.12
36430........................... Knox County, Ohio....... 99936 0.8874 0.8658 -2.43
36440........................... Lake County, Ohio....... 17460 0.9198 0.9400 2.20
36450........................... Lawrence County, Ohio... 26580 0.9477 0.8997 -5.06
36460........................... Licking County, Ohio.... 18140 0.9867 1.0107 2.43
36470........................... Logan County, Ohio...... 99936 0.8874 0.8658 -2.43
36480........................... Lorain County, Ohio..... 17460 0.9198 0.9400 2.20
36490........................... Lucas County, Ohio...... 45780 0.9574 0.9586 0.13
36500........................... Madison County, Ohio.... 18140 0.9867 1.0107 2.43
36510........................... Mahoning County, Ohio... 49660 0.8726 0.8802 0.87
36520........................... Marion County, Ohio..... 99936 0.8874 0.8658 -2.43
36530........................... Medina County, Ohio..... 17460 0.9198 0.9400 2.20
36540........................... Meigs County, Ohio...... 99936 0.8874 0.8658 -2.43
36550........................... Mercer County, Ohio..... 99936 0.8874 0.8658 -2.43
36560........................... Miami County, Ohio...... 19380 0.9022 0.9037 0.17
36570........................... Monroe County, Ohio..... 99936 0.8874 0.8658 -2.43
36580........................... Montgomery County, Ohio. 19380 0.9022 0.9037 0.17
36590........................... Morgan County, Ohio..... 99936 0.8874 0.8658 -2.43
36600........................... Morrow County, Ohio..... 18140 0.9391 1.0107 7.62
36610........................... Muskingum County, Ohio.. 99936 0.8874 0.8658 -2.43
36620........................... Noble County, Ohio...... 99936 0.8874 0.8658 -2.43
36630........................... Ottawa County, Ohio..... 45780 0.9248 0.9586 3.65
36640........................... Paulding County, Ohio... 99936 0.8874 0.8658 -2.43
36650........................... Perry County, Ohio...... 99936 0.8874 0.8658 -2.43
36660........................... Pickaway County, Ohio... 18140 0.9867 1.0107 2.43
36670........................... Pike County, Ohio....... 99936 0.8874 0.8658 -2.43
36680........................... Portage County, Ohio.... 10420 0.8982 0.8654 -3.65
36690........................... Preble County, Ohio..... 19380 0.8993 0.9037 0.49
36700........................... Putnam County, Ohio..... 99936 0.8874 0.8658 -2.43
36710........................... Richland County, Ohio... 31900 0.9891 0.9271 -6.27
[[Page 65990]]
36720........................... Ross County, Ohio....... 99936 0.8874 0.8658 -2.43
36730........................... Sandusky County, Ohio... 99936 0.8874 0.8658 -2.43
36740........................... Scioto County, Ohio..... 99936 0.8874 0.8658 -2.43
36750........................... Seneca County, Ohio..... 99936 0.8874 0.8658 -2.43
36760........................... Shelby County, Ohio..... 99936 0.8874 0.8658 -2.43
36770........................... Stark County, Ohio...... 15940 0.8935 0.9031 1.07
36780........................... Summit County, Ohio..... 10420 0.8982 0.8654 -3.65
36790........................... Trumbull County, Ohio... 49660 0.8726 0.8802 0.87
36800........................... Tuscarawas County, Ohio. 99936 0.8874 0.8658 -2.43
36810........................... Union County, Ohio...... 18140 0.9391 1.0107 7.62
36820........................... Van Wert County, Ohio... 99936 0.8874 0.8658 -2.43
36830........................... Vinton County, Ohio..... 99936 0.8874 0.8658 -2.43
36840........................... Warren County, Ohio..... 17140 0.9675 0.9601 -0.76
36850........................... Washington County, Ohio. 37620 0.8270 0.7977 -3.54
36860........................... Wayne County, Ohio...... 99936 0.8874 0.8658 -2.43
36870........................... Williams County, Ohio... 99936 0.8874 0.8658 -2.43
36880........................... Wood County, Ohio....... 45780 0.9574 0.9586 0.13
36890........................... Wyandot County, Ohio.... 99936 0.8874 0.8658 -2.43
37000........................... Adair County, Oklahoma.. 99937 0.7512 0.7629 1.56
37010........................... Alfalfa County, Oklahoma 99937 0.7512 0.7629 1.56
37020........................... Atoka County, Oklahoma.. 99937 0.7512 0.7629 1.56
37030........................... Beaver County, Oklahoma. 99937 0.7512 0.7629 1.56
37040........................... Beckham County, Oklahoma 99937 0.7512 0.7629 1.56
37050........................... Blaine County, Oklahoma. 99937 0.7512 0.7629 1.56
37060........................... Bryan County, Oklahoma.. 99937 0.7512 0.7629 1.56
37070........................... Caddo County, Oklahoma.. 99937 0.7512 0.7629 1.56
37080........................... Canadian County, 36420 0.9028 0.8843 -2.05
Oklahoma.
37090........................... Carter County, Oklahoma. 99937 0.7512 0.7629 1.56
37100........................... Cherokee County, 99937 0.7512 0.7629 1.56
Oklahoma.
37110........................... Choctaw County, Oklahoma 99937 0.7512 0.7629 1.56
37120........................... Cimarron County, 99937 0.7512 0.7629 1.56
Oklahoma.
37130........................... Cleveland County, 36420 0.9028 0.8843 -2.05
Oklahoma.
37140........................... Coal County, Oklahoma... 99937 0.7512 0.7629 1.56
37150........................... Comanche County, 30020 0.7872 0.8065 2.45
Oklahoma.
37160........................... Cotton County, Oklahoma. 99937 0.7512 0.7629 1.56
37170........................... Craig County, Oklahoma.. 99937 0.7512 0.7629 1.56
37180........................... Creek County, Oklahoma.. 46140 0.8565 0.8103 -5.39
37190........................... Custer County, Oklahoma. 99937 0.7512 0.7629 1.56
37200........................... Delaware County, 99937 0.7512 0.7629 1.56
Oklahoma.
37210........................... Dewey County, Oklahoma.. 99937 0.7512 0.7629 1.56
37220........................... Ellis County, Oklahoma.. 99937 0.7512 0.7629 1.56
37230........................... Garfield County, 99937 0.8124 0.7629 -6.09
Oklahoma.
37240........................... Garvin County, Oklahoma. 99937 0.7512 0.7629 1.56
37250........................... Grady County, Oklahoma.. 36420 0.8237 0.8843 7.36
37260........................... Grant County, Oklahoma.. 99937 0.7512 0.7629 1.56
37270........................... Greer County, Oklahoma.. 99937 0.7512 0.7629 1.56
37280........................... Harmon County, Oklahoma. 99937 0.7512 0.7629 1.56
37290........................... Harper County, Oklahoma. 99937 0.7512 0.7629 1.56
37300........................... Haskell County, Oklahoma 99937 0.7512 0.7629 1.56
37310........................... Hughes County, Oklahoma. 99937 0.7512 0.7629 1.56
37320........................... Jackson County, Oklahoma 99937 0.7512 0.7629 1.56
37330........................... Jefferson County, 99937 0.7512 0.7629 1.56
Oklahoma.
37340........................... Johnston County, 99937 0.7512 0.7629 1.56
Oklahoma.
37350........................... Kay County, Oklahoma.... 99937 0.7512 0.7629 1.56
37360........................... Kingfisher County, 99937 0.7512 0.7629 1.56
Oklahoma.
37370........................... Kiowa County, Oklahoma.. 99937 0.7512 0.7629 1.56
37380........................... Latimer County, Oklahoma 99937 0.7512 0.7629 1.56
37390........................... Le Flore County, 22900 0.7836 0.7731 -1.34
Oklahoma.
37400........................... Lincoln County, Oklahoma 36420 0.8237 0.8843 7.36
37410........................... Logan County, Oklahoma.. 36420 0.9028 0.8843 -2.05
37420........................... Love County, Oklahoma... 99937 0.7512 0.7629 1.56
37430........................... Mc Clain County, 36420 0.9028 0.8843 -2.05
Oklahoma.
37440........................... Mc Curtain County, 99937 0.7512 0.7629 1.56
Oklahoma.
37450........................... Mc Intosh County, 99937 0.7512 0.7629 1.56
Oklahoma.
37460........................... Major County, Oklahoma.. 99937 0.7512 0.7629 1.56
37470........................... Marshall County, 99937 0.7512 0.7629 1.56
Oklahoma.
37480........................... Mayes County, Oklahoma.. 99937 0.7512 0.7629 1.56
37490........................... Murray County, Oklahoma. 99937 0.7512 0.7629 1.56
[[Page 65991]]
37500........................... Muskogee County, 99937 0.7512 0.7629 1.56
Oklahoma.
37510........................... Noble County, Oklahoma.. 99937 0.7512 0.7629 1.56
37520........................... Nowata County, Oklahoma. 99937 0.7512 0.7629 1.56
37530........................... Okfuskee County, 99937 0.7512 0.7629 1.56
Oklahoma.
37540........................... Oklahoma County, 36420 0.9028 0.8843 -2.05
Oklahoma.
37550........................... Okmulgee County, 46140 0.7993 0.8103 1.38
Oklahoma.
37560........................... Osage County, Oklahoma.. 46140 0.8565 0.8103 -5.39
37570........................... Ottawa County, Oklahoma. 99937 0.7512 0.7629 1.56
37580........................... Pawnee County, Oklahoma. 46140 0.7993 0.8103 1.38
37590........................... Payne County, Oklahoma.. 99937 0.7512 0.7629 1.56
37600........................... Pittsburg County, 99937 0.7512 0.7629 1.56
Oklahoma.
37610........................... Pontotoc County, 99937 0.7512 0.7629 1.56
Oklahoma.
37620........................... Pottawatomie County, 99937 0.8303 0.7629 -8.12
Oklahoma.
37630........................... Pushmataha County, 99937 0.7512 0.7629 1.56
Oklahoma.
37640........................... Roger Mills County, 99937 0.7512 0.7629 1.56
Oklahoma.
37650........................... Rogers County, Oklahoma. 46140 0.8565 0.8103 -5.39
37660........................... Seminole County, 99937 0.7512 0.7629 1.56
Oklahoma.
37670........................... Sequoyah County, 22900 0.8238 0.7731 -6.15
Oklahoma.
37680........................... Stephens County, 99937 0.7512 0.7629 1.56
Oklahoma.
37690........................... Texas County, Oklahoma.. 99937 0.7512 0.7629 1.56
37700........................... Tillman County, Oklahoma 99937 0.7512 0.7629 1.56
37710........................... Tulsa County, Oklahoma.. 46140 0.8565 0.8103 -5.39
37720........................... Wagoner County, Oklahoma 46140 0.8565 0.8103 -5.39
37730........................... Washington County, 99937 0.7512 0.7629 1.56
Oklahoma.
37740........................... Washita County, Oklahoma 99937 0.7512 0.7629 1.56
37750........................... Woods County, Oklahoma.. 99937 0.7512 0.7629 1.56
37760........................... Woodward County, 99937 0.7512 0.7629 1.56
Oklahoma.
38000........................... Baker County, Oregon.... 99938 0.9939 0.9753 -1.87
38010........................... Benton County, Oregon... 18700 1.0729 1.1546 7.61
38020........................... Clackamas County, Oregon 38900 1.1266 1.1416 1.33
38030........................... Clatsop County, Oregon.. 99938 0.9939 0.9753 -1.87
38040........................... Columbia County, Oregon. 38900 1.1266 1.1416 1.33
38050........................... Coos County, Oregon..... 99938 0.9939 0.9753 -1.87
38060........................... Crook County, Oregon.... 99938 0.9939 0.9753 -1.87
38070........................... Curry County, Oregon.... 99938 0.9939 0.9753 -1.87
38080........................... Deschutes County, Oregon 13460 1.0419 1.0743 3.11
38090........................... Douglas County, Oregon.. 99938 0.9939 0.9753 -1.87
38100........................... Gilliam County, Oregon.. 99938 0.9939 0.9753 -1.87
38110........................... Grant County, Oregon.... 99938 0.9939 0.9753 -1.87
38120........................... Harney County, Oregon... 99938 0.9939 0.9753 -1.87
38130........................... Hood River County, 99938 0.9939 0.9753 -1.87
Oregon.
38140........................... Jackson County, Oregon.. 32780 1.0225 1.0818 5.80
38150........................... Jefferson County, Oregon 99938 0.9939 0.9753 -1.87
38160........................... Josephine County, Oregon 99938 0.9939 0.9753 -1.87
38170........................... Klamath County, Oregon.. 99938 0.9939 0.9753 -1.87
38180........................... Lake County, Oregon..... 99938 0.9939 0.9753 -1.87
38190........................... Lane County, Oregon..... 21660 1.0818 1.0876 0.54
38200........................... Lincoln County, Oregon.. 99938 0.9939 0.9753 -1.87
38210........................... Linn County, Oregon..... 99938 0.9939 0.9753 -1.87
38220........................... Malheur County, Oregon.. 99938 0.9939 0.9753 -1.87
38230........................... Marion County, Oregon... 41420 1.0442 1.0438 -0.04
38240........................... Morrow County, Oregon... 99938 0.9939 0.9753 -1.87
38250........................... Multnomah County, Oregon 38900 1.1266 1.1416 1.33
38260........................... Polk County, Oregon..... 41420 1.0442 1.0438 -0.04
38270........................... Sherman County, Oregon.. 99938 0.9939 0.9753 -1.87
38280........................... Tillamook County, Oregon 99938 0.9939 0.9753 -1.87
38290........................... Umatilla County, Oregon. 99938 0.9939 0.9753 -1.87
38300........................... Union County, Oregon.... 99938 0.9939 0.9753 -1.87
38310........................... Wallowa County, Oregon.. 99938 0.9939 0.9753 -1.87
38320........................... Wasco County, Oregon.... 99938 0.9939 0.9753 -1.87
38330........................... Washington County, 38900 1.1266 1.1416 1.33
Oregon.
38340........................... Wheeler County, Oregon.. 99938 0.9939 0.9753 -1.87
38350........................... Yamhill County, Oregon.. 38900 1.1266 1.1416 1.33
39000........................... Adams County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39010........................... Allegheny County, 38300 0.8853 0.8674 -2.02
Pennsylvania.
39070........................... Armstrong County, 38300 0.8582 0.8674 1.07
Pennsylvania.
39080........................... Beaver County, 38300 0.8853 0.8674 -2.02
Pennsylvania.
39100........................... Bedford County, 99939 0.8305 0.8320 0.18
Pennsylvania.
[[Page 65992]]
39110........................... Berks County, 39740 0.9686 0.9622 -0.66
Pennsylvania.
39120........................... Blair County, 11020 0.8944 0.8812 -1.48
Pennsylvania.
39130........................... Bradford County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39140........................... Bucks County, 37964 1.0980 1.0996 0.15
Pennsylvania.
39150........................... Butler County, 38300 0.8853 0.8674 -2.02
Pennsylvania.
39160........................... Cambria County, 27780 0.8220 0.8620 4.87
Pennsylvania.
39180........................... Cameron County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39190........................... Carbon County, 10900 0.9832 0.9947 1.17
Pennsylvania.
39200........................... Centre County, 44300 0.8356 0.8784 5.12
Pennsylvania.
39210........................... Chester County, 37964 1.0980 1.0996 0.15
Pennsylvania.
39220........................... Clarion County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39230........................... Clearfield County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39240........................... Clinton County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39250........................... Columbia County, 99939 0.8408 0.8320 -1.05
Pennsylvania.
39260........................... Crawford County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39270........................... Cumberland County, 25420 0.9273 0.9402 1.39
Pennsylvania.
39280........................... Dauphin County, 25420 0.9273 0.9402 1.39
Pennsylvania.
39290........................... Delaware County, 37964 1.0980 1.0996 0.15
Pennsylvania.
39310........................... Elk County, Pennsylvania 99939 0.8305 0.8320 0.18
39320........................... Erie County, 21500 0.8737 0.8827 1.03
Pennsylvania.
39330........................... Fayette County, 38300 0.8853 0.8674 -2.02
Pennsylvania.
39340........................... Forest County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39350........................... Franklin County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39360........................... Fulton County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39370........................... Greene County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39380........................... Huntingdon County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39390........................... Indiana County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39400........................... Jefferson County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39410........................... Juniata County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39420........................... Lackawanna County, 42540 0.8532 0.8347 -2.17
Pennsylvania.
39440........................... Lancaster County, 29540 0.9694 0.9589 -1.08
Pennsylvania.
39450........................... Lawrence County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39460........................... Lebanon County, 30140 0.8846 0.8679 -1.89
Pennsylvania.
39470........................... Lehigh County, 10900 0.9832 0.9947 1.17
Pennsylvania.
39480........................... Luzerne County, 42540 0.8532 0.8347 -2.17
Pennsylvania.
39510........................... Lycoming County, 48700 0.8364 0.8139 -2.69
Pennsylvania.
39520........................... Mc Kean County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39530........................... Mercer County, 49660 0.8198 0.8802 7.37
Pennsylvania.
39540........................... Mifflin County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39550........................... Monroe County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39560........................... Montgomery County, 37964 1.0980 1.0996 0.15
Pennsylvania.
39580........................... Montour County, 99939 0.8305 0.8320 0.18
Pennsylvania.
90 Nor.......................... thampton County, 10900 0.9832 0.9947 1.17
Pennsylvania.
39600........................... Northumberland County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39610........................... Perry County, 25420 0.9273 0.9402 1.39
Pennsylvania.
39620........................... Philadelphia County, 37964 1.0980 1.0996 0.15
Pennsylvania.
39630........................... Pike County, 35084 1.1545 1.1892 3.01
Pennsylvania.
39640........................... Potter County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39650........................... Schuylkill County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39670........................... Snyder County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39680........................... Somerset County, 99939 0.8189 0.8320 1.60
Pennsylvania.
39690........................... Sullivan County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39700........................... Susquehanna County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39710........................... Tioga County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39720........................... Union County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39730........................... Venango County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39740........................... Warren County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39750........................... Washington County, 38300 0.8853 0.8674 -2.02
Pennsylvania.
39760........................... Wayne County, 99939 0.8305 0.8320 0.18
Pennsylvania.
39770........................... Westmoreland County, 38300 0.8853 0.8674 -2.02
Pennsylvania.
39790........................... Wyoming County, 42540 0.8532 0.8347 -2.17
Pennsylvania.
39800........................... York County, 49620 0.9347 0.9397 0.53
Pennsylvania.
40010........................... Adjuntas County, Puerto 99940 0.3826 0.4047 5.78
Rico.
40020........................... Aguada County, Puerto 10380 0.4807 0.3915 -18.56
Rico.
40030........................... Aguadilla County, Puerto 10380 0.4807 0.3915 -18.56
Rico.
40040........................... Aguas Buenas County, 41980 0.4687 0.4452 -5.01
Puerto Rico.
40050........................... Aibonito County, Puerto 41980 0.4113 0.4452 8.24
Rico.
40060........................... Anasco County, Puerto 10380 0.4491 0.3915 -12.83
Rico.
[[Page 65993]]
40070........................... Arecibo County, Puerto 41980 0.4367 0.4452 1.95
Rico.
40080........................... Arroyo County, Puerto 25020 0.3393 0.3235 -4.66
Rico.
40090........................... Barceloneta County, 41980 0.4687 0.4452 -5.01
Puerto Rico.
40100........................... Barranquitas County, 41980 0.4113 0.4452 8.24
Puerto Rico.
40110........................... Bayamon County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40120........................... Cabo Rojo County, Puerto 41900 0.4447 0.4885 9.85
Rico.
40130........................... Caguas County, Puerto 41980 0.4371 0.4452 1.85
Rico.
40140........................... Camuy County, Puerto 41980 0.4367 0.4452 1.95
Rico.
40145........................... Canovanas County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40150........................... Carolina County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40160........................... Catano County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40170........................... Cayey County, Puerto 41980 0.4371 0.4452 1.85
Rico.
40180........................... Ceiba County, Puerto 21940 0.4453 0.4036 -9.36
Rico.
40190........................... Ciales County, Puerto 41980 0.4113 0.4452 8.24
Rico.
40200........................... Cidra County, Puerto 41980 0.4371 0.4452 1.85
Rico.
40210........................... Coamo County, Puerto 99940 0.3826 0.4047 5.78
Rico.
40220........................... Comerio County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40230........................... Corozal County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40240........................... Culebra County, Puerto 99940 0.3826 0.4047 5.78
Rico.
40250........................... Dorado County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40260........................... Fajardo County, Puerto 21940 0.4453 0.4036 -9.36
Rico.
40265........................... Florida County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40270........................... Guanica County, Puerto 49500 0.4006 0.3854 -3.79
Rico.
40280........................... Guayama County, Puerto 25020 0.3393 0.3235 -4.66
Rico.
40290........................... Guayanilla County, 49500 0.4645 0.3854 -17.03
Puerto Rico.
40300........................... Guaynabo County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40310........................... Gurabo County, Puerto 41980 0.4371 0.4452 1.85
Rico.
40320........................... Hatillo County, Puerto 41980 0.4367 0.4452 1.95
Rico.
40330........................... Hormigueros County, 32420 0.4132 0.3848 -6.87
Puerto Rico.
40340........................... Humacao County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40350........................... Isabela County, Puerto 10380 0.4171 0.3915 -6.14
Rico.
40360........................... Jayuya County, Puerto 99940 0.3826 0.4047 5.78
Rico.
40370........................... Juana Diaz County, 38660 0.4910 0.4842 -1.38
Puerto Rico.
40380........................... Juncos County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40390........................... Lajas County, Puerto 41900 0.4127 0.4885 18.37
Rico.
40400........................... Lares County, Puerto 10380 0.4171 0.3915 -6.14
Rico.
40410........................... Las Marias County, 99940 0.3826 0.4047 5.78
Puerto Rico.
40420........................... Las Piedras County, 41980 0.4687 0.4452 -5.01
Puerto Rico.
40430........................... Loiza County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40440........................... Luquillo County, Puerto 21940 0.4453 0.4036 -9.36
Rico.
40450........................... Manati County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40460........................... Maricao County, Puerto 99940 0.3826 0.4047 5.78
Rico.
40470........................... Maunabo County, Puerto 41980 0.4113 0.4452 8.24
Rico.
40480........................... Mayaguez County, Puerto 32420 0.4132 0.3848 -6.87
Rico.
40490........................... Moca County, Puerto Rico 10380 0.4807 0.3915 -18.56
40500........................... Morovis County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40510........................... Naguabo County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40520........................... Naranjito County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40530........................... Orocovis County, Puerto 41980 0.4113 0.4452 8.24
Rico.
40540........................... Patillas County, Puerto 25020 0.3393 0.3235 -4.66
Rico.
40550........................... Penuelas County, Puerto 49500 0.4645 0.3854 -17.03
Rico.
40560........................... Ponce County, Puerto 38660 0.4910 0.4842 -1.38
Rico.
40570........................... Quebradillas County, 41980 0.4113 0.4452 8.24
Puerto Rico.
40580........................... Rincon County, Puerto 10380 0.4171 0.3915 -6.14
Rico.
40590........................... Rio Grande County, 41980 0.4687 0.4452 -5.01
Puerto Rico.
40610........................... Sabana Grande County, 41900 0.4447 0.4885 9.85
Puerto Rico.
40620........................... Salinas County, Puerto 99940 0.3826 0.4047 5.78
Rico.
40630........................... San German County, 41900 0.4447 0.4885 9.85
Puerto Rico.
40640........................... San Juan County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40650........................... San Lorenzo County, 41980 0.4371 0.4452 1.85
Puerto Rico.
40660........................... San Sebastian County, 10380 0.4171 0.3915 -6.14
Puerto Rico.
40670........................... Santa Isabel County, 99940 0.3826 0.4047 5.78
Puerto Rico.
40680........................... Toa Alta County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40690........................... Toa Baja County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40700........................... Trujillo Alto County, 41980 0.4687 0.4452 -5.01
Puerto Rico.
40710........................... Utuado County, Puerto 99940 0.3826 0.4047 5.78
Rico.
40720........................... Vega Alta County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40730........................... Vega Baja County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
[[Page 65994]]
40740........................... Vieques County, Puerto 99940 0.3826 0.4047 5.78
Rico.
40750........................... Villalba County, Puerto 38660 0.4910 0.4842 -1.38
Rico.
40760........................... Yabucoa County, Puerto 41980 0.4687 0.4452 -5.01
Rico.
40770........................... Yauco County, Puerto 49500 0.4645 0.3854 -17.03
Rico.
41000........................... Bristol County, Rhode 39300 1.1012 1.0783 -2.08
Island.
41010........................... Kent County, Rhode 39300 1.1012 1.0783 -2.08
Island.
41020........................... Newport County, Rhode 39300 1.1012 1.0783 -2.08
Island.
41030........................... Providence County, Rhode 39300 1.1012 1.0783 -2.08
Island.
41050........................... Washington County, Rhode 39300 1.1012 1.0783 -2.08
Island.
42000........................... Abbeville County, S 99942 0.8635 0.8566 -0.80
Carolina.
42010........................... Aiken County, S Carolina 12260 0.9778 0.9667 -1.14
42020........................... Allendale County, S 99942 0.8635 0.8566 -0.80
Carolina.
42030........................... Anderson County, S 11340 0.9306 0.9017 -3.11
Carolina.
42040........................... Bamberg County, S 99942 0.8635 0.8566 -0.80
Carolina.
42050........................... Barnwell County, S 99942 0.8635 0.8566 -0.80
Carolina.
42060........................... Beaufort County, S 99942 0.8635 0.8566 -0.80
Carolina.
42070........................... Berkeley County, S 16700 0.9245 0.9145 -1.08
Carolina.
42080........................... Calhoun County, S 17900 0.8844 0.8933 1.01
Carolina.
42090........................... Charleston County, S 16700 0.9245 0.9145 -1.08
Carolina.
42100........................... Cherokee County, S 99942 0.9127 0.8566 -6.15
Carolina.
42110........................... Chester County, S 99942 0.8635 0.8566 -0.80
Carolina.
42120........................... Chesterfield County, S 99942 0.8635 0.8566 -0.80
Carolina.
42130........................... Clarendon County, S 99942 0.8635 0.8566 -0.80
Carolina.
42140........................... Colleton County, S 99942 0.8635 0.8566 -0.80
Carolina.
42150........................... Darlington County, S 22500 0.8789 0.8388 -4.56
Carolina.
42160........................... Dillon County, S 99942 0.8635 0.8566 -0.80
Carolina.
42170........................... Dorchester County, S 16700 0.9245 0.9145 -1.08
Carolina.
42180........................... Edgefield County, S 12260 0.9778 0.9667 -1.14
Carolina.
42190........................... Fairfield County, S 17900 0.8844 0.8933 1.01
Carolina.
42200........................... Florence County, S 22500 0.8995 0.8388 -6.75
Carolina.
42210........................... Georgetown County, S 99942 0.8635 0.8566 -0.80
Carolina.
42220........................... Greenville County, S 24860 0.9821 0.9804 -0.17
Carolina.
42230........................... Greenwood County, S 99942 0.8635 0.8566 -0.80
Carolina.
42240........................... Hampton County, S 99942 0.8635 0.8566 -0.80
Carolina.
42250........................... Horry County, S Carolina 34820 0.8934 0.8810 -1.39
42260........................... Jasper County, S 99942 0.8635 0.8566 -0.80
Carolina.
42270........................... Kershaw County, S 17900 0.8844 0.8933 1.01
Carolina.
42280........................... Lancaster County, S 99942 0.8635 0.8566 -0.80
Carolina.
42290........................... Laurens County, S 24860 0.9329 0.9804 5.09
Carolina.
42300........................... Lee County, S Carolina.. 99942 0.8635 0.8566 -0.80
42310........................... Lexington County, S 17900 0.9070 0.8933 -1.51
Carolina.
42320........................... Mc Cormick County, S 99942 0.8635 0.8566 -0.80
Carolina.
42330........................... Marion County, S 99942 0.8635 0.8566 -0.80
Carolina.
42340........................... Marlboro County, S 99942 0.8635 0.8566 -0.80
Carolina.
42350........................... Newberry County, S 99942 0.8635 0.8566 -0.80
Carolina.
42360........................... Oconee County, S 99942 0.8635 0.8566 -0.80
Carolina.
42370........................... Orangeburg County, S 99942 0.8635 0.8566 -0.80
Carolina.
42380........................... Pickens County, S 24860 0.9821 0.9804 -0.17
Carolina.
42390........................... Richland County, S 17900 0.9070 0.8933 -1.51
Carolina.
42400........................... Saluda County, S 17900 0.8844 0.8933 1.01
Carolina.
42410........................... Spartanburg County, S 43900 0.9394 0.9174 -2.34
Carolina.
42420........................... Sumter County, S 44940 0.8377 0.8083 -3.51
Carolina.
42430........................... Union County, S Carolina 99942 0.8635 0.8566 -0.80
42440........................... Williamsburg County, S 99942 0.8635 0.8566 -0.80
Carolina.
42450........................... York County, S Carolina. 16740 0.9733 0.9554 -1.84
43010........................... Aurora County, S Dakota. 99943 0.8556 0.8480 -0.89
43020........................... Beadle County, S Dakota. 99943 0.8556 0.8480 -0.89
43030........................... Bennett County, S Dakota 99943 0.8556 0.8480 -0.89
43040........................... Bon Homme County, S 99943 0.8556 0.8480 -0.89
Dakota.
43050........................... Brookings County, S 99943 0.8556 0.8480 -0.89
Dakota.
43060........................... Brown County, S Dakota.. 99943 0.8556 0.8480 -0.89
43070........................... Brule County, S Dakota.. 99943 0.8556 0.8480 -0.89
43080........................... Buffalo County, S Dakota 99943 0.8556 0.8480 -0.89
43090........................... Butte County, S Dakota.. 99943 0.8556 0.8480 -0.89
43100........................... Campbell County, S 99943 0.8556 0.8480 -0.89
Dakota.
43110........................... Charles Mix County, S 99943 0.8556 0.8480 -0.89
Dakota.
43120........................... Clark County, S Dakota.. 99943 0.8556 0.8480 -0.89
43130........................... Clay County, S Dakota... 99943 0.8556 0.8480 -0.89
[[Page 65995]]
43140........................... Codington County, S 99943 0.8556 0.8480 -0.89
Dakota.
43150........................... Corson County, S Dakota. 99943 0.8556 0.8480 -0.89
43160........................... Custer County, S Dakota. 99943 0.8556 0.8480 -0.89
43170........................... Davison County, S Dakota 99943 0.8556 0.8480 -0.89
43180........................... Day County, S Dakota.... 99943 0.8556 0.8480 -0.89
43190........................... Deuel County, S Dakota.. 99943 0.8556 0.8480 -0.89
43200........................... Dewey County, S Dakota.. 99943 0.8556 0.8480 -0.89
43210........................... Douglas County, S Dakota 99943 0.8556 0.8480 -0.89
43220........................... Edmunds County, S Dakota 99943 0.8556 0.8480 -0.89
43230........................... Fall River County, S 99943 0.8556 0.8480 -0.89
Dakota.
43240........................... Faulk County, S Dakota.. 99943 0.8556 0.8480 -0.89
43250........................... Grant County, S Dakota.. 99943 0.8556 0.8480 -0.89
43260........................... Gregory County, S Dakota 99943 0.8556 0.8480 -0.89
43270........................... Haakon County, S Dakota. 99943 0.8556 0.8480 -0.89
43280........................... Hamlin County, S Dakota. 99943 0.8556 0.8480 -0.89
43290........................... Hand County, S Dakota... 99943 0.8556 0.8480 -0.89
43300........................... Hanson County, S Dakota. 99943 0.8556 0.8480 -0.89
43310........................... Harding County, S Dakota 99943 0.8556 0.8480 -0.89
43320........................... Hughes County, S Dakota. 99943 0.8556 0.8480 -0.89
43330........................... Hutchinson County, S 99943 0.8556 0.8480 -0.89
Dakota.
43340........................... Hyde County, S Dakota... 99943 0.8556 0.8480 -0.89
43350........................... Jackson County, S Dakota 99943 0.8556 0.8480 -0.89
43360........................... Jerauld County, S Dakota 99943 0.8556 0.8480 -0.89
43370........................... Jones County, S Dakota.. 99943 0.8556 0.8480 -0.89
43380........................... Kingsbury County, S 99943 0.8556 0.8480 -0.89
Dakota.
43390........................... Lake County, S Dakota... 99943 0.8556 0.8480 -0.89
43400........................... Lawrence County, S 99943 0.8556 0.8480 -0.89
Dakota.
43410........................... Lincoln County, S Dakota 43620 0.9635 0.9559 -0.79
43420........................... Lyman County, S Dakota.. 99943 0.8556 0.8480 -0.89
43430........................... Mc Cook County, S Dakota 43620 0.9093 0.9559 5.12
43440........................... Mc Pherson County, S 99943 0.8556 0.8480 -0.89
Dakota.
43450........................... Marshall County, S 99943 0.8556 0.8480 -0.89
Dakota.
43460........................... Meade County, S Dakota.. 39660 0.8769 0.8833 0.73
43470........................... Mellette County, S 99943 0.8556 0.8480 -0.89
Dakota.
43480........................... Miner County, S Dakota.. 99943 0.8556 0.8480 -0.89
43490........................... Minnehaha County, S 43620 0.9635 0.9559 -0.79
Dakota.
43500........................... Moody County, S Dakota.. 99943 0.8556 0.8480 -0.89
43510........................... Pennington County, S 39660 0.8987 0.8833 -1.71
Dakota.
43520........................... Perkins County, S Dakota 99943 0.8556 0.8480 -0.89
43530........................... Potter County, S Dakota. 99943 0.8556 0.8480 -0.89
43540........................... Roberts County, S Dakota 99943 0.8556 0.8480 -0.89
43550........................... Sanborn County, S Dakota 99943 0.8556 0.8480 -0.89
43560........................... Shannon County, S Dakota 99943 0.8556 0.8480 -0.89
43570........................... Spink County, S Dakota.. 99943 0.8556 0.8480 -0.89
43580........................... Stanley County, S Dakota 99943 0.8556 0.8480 -0.89
43590........................... Sully County, S Dakota.. 99943 0.8556 0.8480 -0.89
43600........................... Todd County, S Dakota... 99943 0.8556 0.8480 -0.89
43610........................... Tripp County, S Dakota.. 99943 0.8556 0.8480 -0.89
43620........................... Turner County, S Dakota. 43620 0.9093 0.9559 5.12
43630........................... Union County, S Dakota.. 43580 0.8966 0.9200 2.61
43640........................... Walworth County, S 99943 0.8556 0.8480 -0.89
Dakota.
43650........................... Washabaugh County, S 99943 0.8556 0.8480 -0.89
Dakota.
43670........................... Yankton County, S Dakota 99943 0.8556 0.8480 -0.89
43680........................... Ziebach County, S Dakota 99943 0.8556 0.8480 -0.89
44000........................... Anderson County, 28940 0.8419 0.8249 -2.02
Tennessee.
44010........................... Bedford County, 99944 0.7915 0.7827 -1.11
Tennessee.
44020........................... Benton County, Tennessee 99944 0.7915 0.7827 -1.11
44030........................... Bledsoe County, 99944 0.7915 0.7827 -1.11
Tennessee.
44040........................... Blount County, Tennessee 28940 0.8419 0.8249 -2.02
44050........................... Bradley County, 17420 0.8037 0.8109 0.90
Tennessee.
44060........................... Campbell County, 99944 0.7915 0.7827 -1.11
Tennessee.
44070........................... Cannon County, Tennessee 34980 0.8838 0.9847 11.42
44080........................... Carroll County, 99944 0.7915 0.7827 -1.11
Tennessee.
44090........................... Carter County, Tennessee 27740 0.7972 0.8043 0.89
44100........................... Cheatham County, 34980 0.9751 0.9847 0.98
Tennessee.
44110........................... Chester County, 27180 0.8964 0.8853 -1.24
Tennessee.
44120........................... Claiborne County, 99944 0.7915 0.7827 -1.11
Tennessee.
44130........................... Clay County, Tennessee.. 99944 0.7915 0.7827 -1.11
[[Page 65996]]
44140........................... Cocke County, Tennessee. 99944 0.7915 0.7827 -1.11
44150........................... Coffee County, Tennessee 99944 0.7915 0.7827 -1.11
44160........................... Crockett County, 99944 0.7915 0.7827 -1.11
Tennessee.
44170........................... Cumberland County, 99944 0.7915 0.7827 -1.11
Tennessee.
44180........................... Davidson County, 34980 0.9751 0.9847 0.98
Tennessee.
44190........................... Decatur County, 99944 0.7915 0.7827 -1.11
Tennessee.
44200........................... De Kalb County, 99944 0.7915 0.7827 -1.11
Tennessee.
44210........................... Dickson County, 34980 0.9751 0.9847 0.98
Tennessee.
44220........................... Dyer County, Tennessee.. 99944 0.7915 0.7827 -1.11
44230........................... Fayette County, 32820 0.9407 0.9373 -0.36
Tennessee.
44240........................... Fentress County, 99944 0.7915 0.7827 -1.11
Tennessee.
44250........................... Franklin County, 99944 0.7915 0.7827 -1.11
Tennessee.
44260........................... Gibson County, Tennessee 99944 0.7915 0.7827 -1.11
44270........................... Giles County, Tennessee. 99944 0.7915 0.7827 -1.11
44280........................... Grainger County, 34100 0.7948 0.7933 -0.19
Tennessee.
44290........................... Greene County, Tennessee 99944 0.7915 0.7827 -1.11
44300........................... Grundy County, Tennessee 99944 0.7915 0.7827 -1.11
44310........................... Hamblen County, 34100 0.7948 0.7933 -0.19
Tennessee.
44320........................... Hamilton County, 16860 0.9088 0.8948 -1.54
Tennessee.
44330........................... Hancock County, 99944 0.7915 0.7827 -1.11
Tennessee.
44340........................... Hardeman County, 99944 0.7915 0.7827 -1.11
Tennessee.
44350........................... Hardin County, Tennessee 99944 0.7915 0.7827 -1.11
44360........................... Hawkins County, 28700 0.8031 0.7985 -0.57
Tennessee.
44370........................... Haywood County, 99944 0.7915 0.7827 -1.11
Tennessee.
44380........................... Henderson County, 99944 0.7915 0.7827 -1.11
Tennessee.
44390........................... Henry County, Tennessee. 99944 0.7915 0.7827 -1.11
44400........................... Hickman County, 34980 0.8838 0.9847 11.42
Tennessee.
44410........................... Houston County, 99944 0.7915 0.7827 -1.11
Tennessee.
44420........................... Humphreys County, 99944 0.7915 0.7827 -1.11
Tennessee.
44430........................... Jackson County, 99944 0.7915 0.7827 -1.11
Tennessee.
44440........................... Jefferson County, 34100 0.7948 0.7933 -0.19
Tennessee.
44450........................... Johnson County, 99944 0.7915 0.7827 -1.11
Tennessee.
44460........................... Knox County, Tennessee.. 28940 0.8419 0.8249 -2.02
44470........................... Lake County, Tennessee.. 99944 0.7915 0.7827 -1.11
44480........................... Lauderdale County, 99944 0.7915 0.7827 -1.11
Tennessee.
44490........................... Lawrence County, 99944 0.7915 0.7827 -1.11
Tennessee.
44500........................... Lewis County, Tennessee. 99944 0.7915 0.7827 -1.11
44510........................... Lincoln County, 99944 0.7915 0.7827 -1.11
Tennessee.
44520........................... Loudon County, Tennessee 28940 0.8419 0.8249 -2.02
44530........................... Mc Minn County, 99944 0.7915 0.7827 -1.11
Tennessee.
44540........................... Mc Nairy County, 99944 0.7915 0.7827 -1.11
Tennessee.
44550........................... Macon County, Tennessee. 34980 0.8838 0.9847 11.42
44560........................... Madison County, 27180 0.8964 0.8853 -1.24
Tennessee.
44570........................... Marion County, Tennessee 16860 0.9088 0.8948 -1.54
44580........................... Marshall County, 99944 0.7915 0.7827 -1.11
Tennessee.
44590........................... Maury County, Tennessee. 99944 0.7915 0.7827 -1.11
44600........................... Meigs County, Tennessee. 99944 0.7915 0.7827 -1.11
44610........................... Monroe County, Tennessee 99944 0.7915 0.7827 -1.11
44620........................... Montgomery County, 17300 0.8284 0.8436 1.83
Tennessee.
44630........................... Moore County, Tennessee. 99944 0.7915 0.7827 -1.11
44640........................... Morgan County, Tennessee 99944 0.7915 0.7827 -1.11
44650........................... Obion County, Tennessee. 99944 0.7915 0.7827 -1.11
44660........................... Overton County, 99944 0.7915 0.7827 -1.11
Tennessee.
44670........................... Perry County, Tennessee. 99944 0.7915 0.7827 -1.11
44680........................... Pickett County, 99944 0.7915 0.7827 -1.11
Tennessee.
44690........................... Polk County, Tennessee.. 17420 0.8037 0.8109 0.90
44700........................... Putnam County, Tennessee 99944 0.7915 0.7827 -1.11
44710........................... Rhea County, Tennessee.. 99944 0.7915 0.7827 -1.11
44720........................... Roane County, Tennessee. 99944 0.7915 0.7827 -1.11
44730........................... Robertson County, 34980 0.9751 0.9847 0.98
Tennessee.
44740........................... Rutherford County, 34980 0.9751 0.9847 0.98
Tennessee.
44750........................... Scott County, Tennessee. 99944 0.7915 0.7827 -1.11
44760........................... Sequatchie County, 16860 0.8512 0.8948 5.12
Tennessee.
44770........................... Sevier County, Tennessee 99944 0.8146 0.7827 -3.92
44780........................... Shelby County, Tennessee 32820 0.9407 0.9373 -0.36
44790........................... Smith County, Tennessee. 34980 0.8838 0.9847 11.42
44800........................... Stewart County, 17300 0.8110 0.8436 4.02
Tennessee.
44810........................... Sullivan County, 28700 0.8031 0.7985 -0.57
Tennessee.
[[Page 65997]]
44820........................... Sumner County, Tennessee 34980 0.9751 0.9847 0.98
44830........................... Tipton County, Tennessee 32820 0.9407 0.9373 -0.36
44840........................... Trousdale County, 34980 0.8838 0.9847 11.42
Tennessee.
44850........................... Unicoi County, Tennessee 27740 0.7972 0.8043 0.89
44860........................... Union County, Tennessee. 28940 0.8419 0.8249 -2.02
44870........................... Van Buren County, 99944 0.7915 0.7827 -1.11
Tennessee.
44880........................... Warren County, Tennessee 99944 0.7915 0.7827 -1.11
44890........................... Washington County, 27740 0.7972 0.8043 0.89
Tennessee.
44900........................... Wayne County, Tennessee. 99944 0.7915 0.7827 -1.11
44910........................... Weakley County, 99944 0.7915 0.7827 -1.11
Tennessee.
44920........................... White County, Tennessee. 99944 0.7915 0.7827 -1.11
44930........................... Williamson County, 34980 0.9751 0.9847 0.98
Tennessee.
44940........................... Wilson County, Tennessee 34980 0.9751 0.9847 0.98
45000........................... Anderson County, Texas.. 99945 0.7967 0.7965 -0.03
45010........................... Andrews County, Texas... 99945 0.7967 0.7965 -0.03
45020........................... Angelina County, Texas.. 99945 0.7967 0.7965 -0.03
45030........................... Aransas County, Texas... 18580 0.8241 0.8564 3.92
45040........................... Archer County, Texas.... 48660 0.8325 0.8311 -0.17
45050........................... Armstrong County, Texas. 11100 0.8544 0.9169 7.32
45060........................... Atascosa County, Texas.. 41700 0.8456 0.8844 4.59
45070........................... Austin County, Texas.... 26420 0.8962 1.0008 11.67
45080........................... Bailey County, Texas.... 99945 0.7967 0.7965 -0.03
45090........................... Bandera County, Texas... 41700 0.8456 0.8844 4.59
45100........................... Bastrop County, Texas... 12420 0.9437 0.9344 -0.99
45110........................... Baylor County, Texas.... 99945 0.7967 0.7965 -0.03
45113........................... Bee County, Texas....... 99945 0.7967 0.7965 -0.03
45120........................... Bell County, Texas...... 28660 0.8526 0.8901 4.40
45130........................... Bexar County, Texas..... 41700 0.8982 0.8844 -1.54
45140........................... Blanco County, Texas.... 99945 0.7967 0.7965 -0.03
45150........................... Borden County, Texas.... 99945 0.7967 0.7965 -0.03
45160........................... Bosque County, Texas.... 99945 0.7967 0.7965 -0.03
45170........................... Bowie County, Texas..... 45500 0.8283 0.8104 -2.16
45180........................... Brazoria County, Texas.. 26420 0.9278 1.0008 7.87
45190........................... Brazos County, Texas.... 17780 0.8900 0.9045 1.63
45200........................... Brewster County, Texas.. 99945 0.7967 0.7965 -0.03
45201........................... Briscoe County, Texas... 99945 0.7967 0.7965 -0.03
45210........................... Brooks County, Texas.... 99945 0.7967 0.7965 -0.03
45220........................... Brown County, Texas..... 99945 0.7967 0.7965 -0.03
45221........................... Burleson County, Texas.. 17780 0.8416 0.9045 7.47
45222........................... Burnet County, Texas.... 99945 0.7967 0.7965 -0.03
45223........................... Caldwell County, Texas.. 12420 0.9437 0.9344 -0.99
45224........................... Calhoun County, Texas... 47020 0.8046 0.8560 6.39
45230........................... Callahan County, Texas.. 10180 0.7914 0.8000 1.09
45240........................... Cameron County, Texas... 15180 0.9804 0.9430 -3.81
45250........................... Camp County, Texas...... 99945 0.7967 0.7965 -0.03
45251........................... Carson County, Texas.... 11100 0.8544 0.9169 7.32
45260........................... Cass County, Texas...... 99945 0.7967 0.7965 -0.03
45270........................... Castro County, Texas.... 99945 0.7967 0.7965 -0.03
45280........................... Chambers County, Texas.. 26420 1.0040 1.0008 -0.32
45281........................... Cherokee County, Texas.. 99945 0.7967 0.7965 -0.03
45290........................... Childress County, Texas. 99945 0.7967 0.7965 -0.03
45291........................... Clay County, Texas...... 48660 0.8108 0.8311 2.50
45292........................... Cochran County, Texas... 99945 0.7967 0.7965 -0.03
45300........................... Coke County, Texas...... 99945 0.7967 0.7965 -0.03
45301........................... Coleman County, Texas... 99945 0.7967 0.7965 -0.03
45310........................... Collin County, Texas.... 19124 1.0217 1.0075 -1.39
45311........................... Collingsworth County, 99945 0.7967 0.7965 -0.03
Texas.
45312........................... Colorado County, Texas.. 99945 0.7967 0.7965 -0.03
45320........................... Comal County, Texas..... 41700 0.8982 0.8844 -1.54
45321........................... Comanche County, Texas.. 99945 0.7967 0.7965 -0.03
45330........................... Concho County, Texas.... 99945 0.7967 0.7965 -0.03
45340........................... Cooke County, Texas..... 99945 0.7967 0.7965 -0.03
45341........................... Coryell County, Texas... 28660 0.8526 0.8901 4.40
45350........................... Cottle County, Texas.... 99945 0.7967 0.7965 -0.03
45360........................... Crane County, Texas..... 99945 0.7967 0.7965 -0.03
45361........................... Crockett County, Texas.. 99945 0.7967 0.7965 -0.03
45362........................... Crosby County, Texas.... 31180 0.8357 0.8613 3.06
45370........................... Culberson County, Texas. 99945 0.7967 0.7965 -0.03
[[Page 65998]]
45380........................... Dallam County, Texas.... 99945 0.7967 0.7965 -0.03
45390........................... Dallas County, Texas.... 19124 1.0217 1.0075 -1.39
45391........................... Dawson County, Texas.... 99945 0.7967 0.7965 -0.03
45392........................... Deaf Smith County, Texas 99945 0.7967 0.7965 -0.03
45400........................... Delta County, Texas..... 19124 0.9080 1.0075 10.96
45410........................... Denton County, Texas.... 19124 1.0217 1.0075 -1.39
45420........................... De Witt County, Texas... 99945 0.7967 0.7965 -0.03
45421........................... Dickens County, Texas... 99945 0.7967 0.7965 -0.03
45430........................... Dimmit County, Texas.... 99945 0.7967 0.7965 -0.03
45431........................... Donley County, Texas.... 99945 0.7967 0.7965 -0.03
45440........................... Duval County, Texas..... 99945 0.7967 0.7965 -0.03
45450........................... Eastland County, Texas.. 99945 0.7967 0.7965 -0.03
45451........................... Ector County, Texas..... 36220 0.9813 1.0073 2.65
45460........................... Edwards County, Texas... 99945 0.7967 0.7965 -0.03
45470........................... Ellis County, Texas..... 19124 1.0217 1.0075 -1.39
45480........................... El Paso County, Texas... 21340 0.8977 0.9053 0.85
45490........................... Erath County, Texas..... 99945 0.7967 0.7965 -0.03
45500........................... Falls County, Texas..... 99945 0.7967 0.7965 -0.03
45510........................... Fannin County, Texas.... 99945 0.7967 0.7965 -0.03
45511........................... Fayette County, Texas... 99945 0.7967 0.7965 -0.03
45520........................... Fisher County, Texas.... 99945 0.7967 0.7965 -0.03
45521........................... Floyd County, Texas..... 99945 0.7967 0.7965 -0.03
45522........................... Foard County, Texas..... 99945 0.7967 0.7965 -0.03
45530........................... Fort Bend County, Texas. 26420 1.0040 1.0008 -0.32
45531........................... Franklin County, Texas.. 99945 0.7967 0.7965 -0.03
45540........................... Freestone County, Texas. 99945 0.7967 0.7965 -0.03
45541........................... Frio County, Texas...... 99945 0.7967 0.7965 -0.03
45542........................... Gaines County, Texas.... 99945 0.7967 0.7965 -0.03
45550........................... Galveston County, Texas. 26420 0.9814 1.0008 1.98
45551........................... Garza County, Texas..... 99945 0.7967 0.7965 -0.03
45552........................... Gillespie County, Texas. 99945 0.7967 0.7965 -0.03
45560........................... Glasscock County, Texas. 99945 0.7967 0.7965 -0.03
45561........................... Goliad County, Texas.... 47020 0.8046 0.8560 6.39
45562........................... Gonzales County, Texas.. 99945 0.7967 0.7965 -0.03
45563........................... Gray County, Texas...... 99945 0.7967 0.7965 -0.03
45564........................... Grayson County, Texas... 43300 0.9507 0.8502 -10.57
45570........................... Gregg County, Texas..... 30980 0.8809 0.8788 -0.24
45580........................... Grimes County, Texas.... 99945 0.7967 0.7965 -0.03
45581........................... Guadaloupe County, Texas 41700 0.8982 0.8844 -1.54
45582........................... Hale County, Texas...... 99945 0.7967 0.7965 -0.03
45583........................... Hall County, Texas...... 99945 0.7967 0.7965 -0.03
45590........................... Hamilton County, Texas.. 99945 0.7967 0.7965 -0.03
45591........................... Hansford County, Texas.. 99945 0.7967 0.7965 -0.03
45592........................... Hardeman County, Texas.. 99945 0.7967 0.7965 -0.03
45600........................... Hardin County, Texas.... 13140 0.8412 0.8595 2.18
45610........................... Harris County, Texas.... 26420 1.0040 1.0008 -0.32
45620........................... Harrison County, Texas.. 99945 0.8446 0.7965 -5.70
45621........................... Hartley County, Texas... 99945 0.7967 0.7965 -0.03
45630........................... Haskell County, Texas... 99945 0.7967 0.7965 -0.03
45631........................... Hays County, Texas...... 12420 0.9437 0.9344 -0.99
45632........................... Hemphill County, Texas.. 99945 0.7967 0.7965 -0.03
45640........................... Henderson County, Texas. 99945 0.9104 0.7965 -12.51
45650........................... Hidalgo County, Texas... 32580 0.8934 0.8773 -1.80
45651........................... Hill County, Texas...... 99945 0.7967 0.7965 -0.03
45652........................... Hockley County, Texas... 99945 0.7967 0.7965 -0.03
45653........................... Hood County, Texas...... 99945 0.8763 0.7965 -9.11
45654........................... Hopkins County, Texas... 99945 0.7967 0.7965 -0.03
45660........................... Houston County, Texas... 99945 0.7967 0.7965 -0.03
45661........................... Howard County, Texas.... 99945 0.7967 0.7965 -0.03
45662........................... Hudspeth County, Texas.. 99945 0.7967 0.7965 -0.03
45670........................... Hunt County, Texas...... 19124 1.0217 1.0075 -1.39
45671........................... Hutchinson County, Texas 99945 0.7967 0.7965 -0.03
45672........................... Irion County, Texas..... 41660 0.8101 0.8362 3.22
45680........................... Jack County, Texas...... 99945 0.7967 0.7965 -0.03
45681........................... Jackson County, Texas... 99945 0.7967 0.7965 -0.03
45690........................... Jasper County, Texas.... 99945 0.7967 0.7965 -0.03
45691........................... Jeff Davis County, Texas 99945 0.7967 0.7965 -0.03
45700........................... Jefferson County, Texas. 13140 0.8412 0.8595 2.18
[[Page 65999]]
45710........................... Jim Hogg County, Texas.. 99945 0.7967 0.7965 -0.03
45711........................... Jim Wells County, Texas. 99945 0.7967 0.7965 -0.03
45720........................... Johnson County, Texas... 23104 0.9504 0.9569 0.68
45721........................... Jones County, Texas..... 10180 0.7914 0.8000 1.09
45722........................... Karnes County, Texas.... 99945 0.7967 0.7965 -0.03
45730........................... Kaufman County, Texas... 19124 1.0217 1.0075 -1.39
45731........................... Kendall County, Texas... 41700 0.8456 0.8844 4.59
45732........................... Kenedy County, Texas.... 99945 0.7967 0.7965 -0.03
45733........................... Kent County, Texas...... 99945 0.7967 0.7965 -0.03
45734........................... Kerr County, Texas...... 99945 0.7967 0.7965 -0.03
45740........................... Kimble County, Texas.... 99945 0.7967 0.7965 -0.03
45741........................... King County, Texas...... 99945 0.7967 0.7965 -0.03
45742........................... Kinney County, Texas.... 99945 0.7967 0.7965 -0.03
45743........................... Kleberg County, Texas... 99945 0.7967 0.7965 -0.03
45744........................... Knox County, Texas...... 99945 0.7967 0.7965 -0.03
45750........................... Lamar County, Texas..... 99945 0.7967 0.7965 -0.03
45751........................... Lamb County, Texas...... 99945 0.7967 0.7965 -0.03
45752........................... Lampasas County, Texas.. 28660 0.8229 0.8901 8.17
45753........................... La Salle County, Texas.. 99945 0.7967 0.7965 -0.03
45754........................... Lavaca County, Texas.... 99945 0.7967 0.7965 -0.03
45755........................... Lee County, Texas....... 99945 0.7967 0.7965 -0.03
45756........................... Leon County, Texas...... 99945 0.7967 0.7965 -0.03
45757........................... Liberty County, Texas... 26420 1.0040 1.0008 -0.32
45758........................... Limestone County, Texas. 99945 0.7967 0.7965 -0.03
45759........................... Lipscomb County, Texas.. 99945 0.7967 0.7965 -0.03
45760........................... Live Oak County, Texas.. 99945 0.7967 0.7965 -0.03
45761........................... Llano County, Texas..... 99945 0.7967 0.7965 -0.03
45762........................... Loving County, Texas.... 99945 0.7967 0.7965 -0.03
45770........................... Lubbock County, Texas... 31180 0.8783 0.8613 -1.94
45771........................... Lynn County, Texas...... 99945 0.7967 0.7965 -0.03
45772........................... Mc Culloch County, Texas 99945 0.7967 0.7965 -0.03
45780........................... Mc Lennan County, Texas. 47380 0.8518 0.8633 1.35
45781........................... Mc Mullen County, Texas. 99945 0.7967 0.7965 -0.03
45782........................... Madison County, Texas... 99945 0.7967 0.7965 -0.03
45783........................... Marion County, Texas.... 99945 0.7967 0.7965 -0.03
45784........................... Martin County, Texas.... 99945 0.7967 0.7965 -0.03
45785........................... Mason County, Texas..... 99945 0.7967 0.7965 -0.03
45790........................... Matagorda County, Texas. 99945 0.7967 0.7965 -0.03
45791........................... Maverick County, Texas.. 99945 0.7967 0.7965 -0.03
45792........................... Medina County, Texas.... 41700 0.8456 0.8844 4.59
45793........................... Menard County, Texas.... 99945 0.7967 0.7965 -0.03
45794........................... Midland County, Texas... 33260 0.9628 0.9786 1.64
45795........................... Milam County, Texas..... 99945 0.7967 0.7965 -0.03
45796........................... Mills County, Texas..... 99945 0.7967 0.7965 -0.03
45797........................... Mitchell County, Texas.. 99945 0.7967 0.7965 -0.03
45800........................... Montague County, Texas.. 99945 0.7967 0.7965 -0.03
45801........................... Montgomery County, Texas 26420 1.0040 1.0008 -0.32
45802........................... Moore County, Texas..... 99945 0.7967 0.7965 -0.03
45803........................... Morris County, Texas.... 99945 0.7967 0.7965 -0.03
45804........................... Motley County, Texas.... 99945 0.7967 0.7965 -0.03
45810........................... Nacogdoches County, 99945 0.7967 0.7965 -0.03
Texas.
45820........................... Navarro County, Texas... 99945 0.7967 0.7965 -0.03
45821........................... Newton County, Texas.... 99945 0.7967 0.7965 -0.03
45822........................... Nolan County, Texas..... 99945 0.7967 0.7965 -0.03
45830........................... Nueces County, Texas.... 18580 0.8550 0.8564 0.16
45831........................... Ochiltree County, Texas. 99945 0.7967 0.7965 -0.03
45832........................... Oldham County, Texas.... 99945 0.7967 0.7965 -0.03
45840........................... Orange County, Texas.... 13140 0.8412 0.8595 2.18
45841........................... Palo Pinto County, Texas 99945 0.7967 0.7965 -0.03
45842........................... Panola County, Texas.... 99945 0.7967 0.7965 -0.03
45843........................... Parker County, Texas.... 23104 0.9504 0.9569 0.68
45844........................... Parmer County, Texas.... 99945 0.7967 0.7965 -0.03
45845........................... Pecos County, Texas..... 99945 0.7967 0.7965 -0.03
45850........................... Polk County, Texas...... 99945 0.7967 0.7965 -0.03
45860........................... Potter County, Texas.... 11100 0.9156 0.9169 0.14
45861........................... Presidio County, Texas.. 99945 0.7967 0.7965 -0.03
45870........................... Rains County, Texas..... 99945 0.7967 0.7965 -0.03
45871........................... Randall County, Texas... 11100 0.9156 0.9169 0.14
[[Page 66000]]
45872........................... Reagan County, Texas.... 99945 0.7967 0.7965 -0.03
45873........................... Real County, Texas...... 99945 0.7967 0.7965 -0.03
45874........................... Red River County, Texas. 99945 0.7967 0.7965 -0.03
45875........................... Reeves County, Texas.... 99945 0.7967 0.7965 -0.03
45876........................... Refugio County, Texas... 99945 0.7967 0.7965 -0.03
45877........................... Roberts County, Texas... 99945 0.7967 0.7965 -0.03
45878........................... Robertson County, Texas. 17780 0.8416 0.9045 7.47
45879........................... Rockwall County, Texas.. 19124 1.0217 1.0075 -1.39
45880........................... Runnels County, Texas... 99945 0.7967 0.7965 -0.03
45881........................... Rusk County, Texas...... 30980 0.8331 0.8788 5.49
45882........................... Sabine County, Texas.... 99945 0.7967 0.7965 -0.03
45883........................... San Augustine County, 99945 0.7967 0.7965 -0.03
Texas.
45884........................... San Jacinto County, 26420 0.8962 1.0008 11.67
Texas.
45885........................... San Patricio County, 18580 0.8550 0.8564 0.16
Texas.
45886........................... San Saba County, Texas.. 99945 0.7967 0.7965 -0.03
45887........................... Schleicher County, Texas 99945 0.7967 0.7965 -0.03
45888........................... Scurry County, Texas.... 99945 0.7967 0.7965 -0.03
45889........................... Shackelford County, 99945 0.7967 0.7965 -0.03
Texas.
45890........................... Shelby County, Texas.... 99945 0.7967 0.7965 -0.03
45891........................... Sherman County, Texas... 99945 0.7967 0.7965 -0.03
45892........................... Smith County, Texas..... 46340 0.9168 0.8811 -3.89
45893........................... Somervell County, Texas. 99945 0.7967 0.7965 -0.03
45900........................... Starr County, Texas..... 99945 0.7967 0.7965 -0.03
45901........................... Stephens County, Texas.. 99945 0.7967 0.7965 -0.03
45902........................... Sterling County, Texas.. 99945 0.7967 0.7965 -0.03
45903........................... Stonewall County, Texas. 99945 0.7967 0.7965 -0.03
45904........................... Sutton County, Texas.... 99945 0.7967 0.7965 -0.03
45905........................... Swisher County, Texas... 99945 0.7967 0.7965 -0.03
45910........................... Tarrant County, Texas... 23104 0.9504 0.9569 0.68
45911........................... Taylor County, Texas.... 10180 0.7975 0.8000 0.31
45912........................... Terrell County, Texas... 99945 0.7967 0.7965 -0.03
45913........................... Terry County, Texas..... 99945 0.7967 0.7965 -0.03
45920........................... Throckmorton County, 99945 0.7967 0.7965 -0.03
Texas.
45921........................... Titus County, Texas..... 99945 0.7967 0.7965 -0.03
45930........................... Tom Green County, Texas. 41660 0.8271 0.8362 1.10
45940........................... Travis County, Texas.... 12420 0.9437 0.9344 -0.99
45941........................... Trinity County, Texas... 99945 0.7967 0.7965 -0.03
45942........................... Tyler County, Texas..... 99945 0.7967 0.7965 -0.03
45943........................... Upshur County, Texas.... 30980 0.8809 0.8788 -0.24
45944........................... Upton County, Texas..... 99945 0.7967 0.7965 -0.03
45945........................... Uvalde County, Texas.... 99945 0.7967 0.7965 -0.03
45946........................... Val Verde County, Texas. 99945 0.7967 0.7965 -0.03
45947........................... Van Zandt County, Texas. 99945 0.7967 0.7965 -0.03
45948........................... Victoria County, Texas.. 47020 0.8160 0.8560 4.90
45949........................... Walker County, Texas.... 99945 0.7967 0.7965 -0.03
45950........................... Waller County, Texas.... 26420 1.0040 1.0008 -0.32
45951........................... Ward County, Texas...... 99945 0.7967 0.7965 -0.03
45952........................... Washington County, Texas 99945 0.7967 0.7965 -0.03
45953........................... Webb County, Texas...... 29700 0.8068 0.7811 -3.19
45954........................... Wharton County, Texas... 99945 0.7967 0.7965 -0.03
45955........................... Wheeler County, Texas... 99945 0.7967 0.7965 -0.03
45960........................... Wichita County, Texas... 48660 0.8325 0.8311 -0.17
45961........................... Wilbarger County, Texas. 99945 0.7967 0.7965 -0.03
45962........................... Willacy County, Texas... 99945 0.7967 0.7965 -0.03
45970........................... Williamson County, Texas 12420 0.9437 0.9344 -0.99
45971........................... Wilson County, Texas.... 41700 0.8982 0.8844 -1.54
45972........................... Winkler County, Texas... 99945 0.7967 0.7965 -0.03
45973........................... Wise County, Texas...... 23104 0.8709 0.9569 9.87
45974........................... Wood County, Texas...... 99945 0.7967 0.7965 -0.03
45980........................... Yoakum County, Texas.... 99945 0.7967 0.7965 -0.03
45981........................... Young County, Texas..... 99945 0.7967 0.7965 -0.03
45982........................... Zapata County, Texas.... 99945 0.7967 0.7965 -0.03
45983........................... Zavala County, Texas.... 99945 0.7967 0.7965 -0.03
46000........................... Beaver County, Utah..... 99946 0.8440 0.8140 -3.55
46010........................... Box Elder County, Utah.. 99946 0.8440 0.8140 -3.55
46020........................... Cache County, Utah...... 30860 0.8963 0.9022 0.66
46030........................... Carbon County, Utah..... 99946 0.8440 0.8140 -3.55
46040........................... Daggett County, Utah.... 99946 0.8440 0.8140 -3.55
[[Page 66001]]
46050........................... Davis County, Utah...... 36260 0.9185 0.8995 -2.07
46060........................... Duchesne County, Utah... 99946 0.8440 0.8140 -3.55
46070........................... Emery County, Utah...... 99946 0.8440 0.8140 -3.55
46080........................... Garfield County, Utah... 99946 0.8440 0.8140 -3.55
46090........................... Grand County, Utah...... 99946 0.8440 0.8140 -3.55
46100........................... Iron County, Utah....... 99946 0.8440 0.8140 -3.55
46110........................... Juab County, Utah....... 39340 0.9131 0.9537 4.45
46120........................... Kane County, Utah....... 99946 0.9982 0.8140 -18.45
46130........................... Millard County, Utah.... 99946 0.8440 0.8140 -3.55
46140........................... Morgan County, Utah..... 36260 0.8896 0.8995 1.11
46150........................... Piute County, Utah...... 99946 0.8440 0.8140 -3.55
46160........................... Rich County, Utah....... 99946 0.8440 0.8140 -3.55
46170........................... Salt Lake County, Utah.. 41620 0.9381 0.9402 0.22
46180........................... San Juan County, Utah... 99946 0.8440 0.8140 -3.55
46190........................... Sanpete County, Utah.... 99946 0.8440 0.8140 -3.55
46200........................... Sevier County, Utah..... 99946 0.8440 0.8140 -3.55
46210........................... Summit County, Utah..... 41620 0.9092 0.9402 3.41
46220........................... Tooele County, Utah..... 41620 0.9092 0.9402 3.41
46230........................... Uintah County, Utah..... 99946 0.8440 0.8140 -3.55
46240........................... Utah County, Utah....... 39340 0.9500 0.9537 0.39
46250........................... Wasatch County, Utah.... 99946 0.8440 0.8140 -3.55
46260........................... Washington County, Utah. 41100 0.9077 0.9265 2.07
46270........................... Wayne County, Utah...... 99946 0.8440 0.8140 -3.55
46280........................... Weber County, Utah...... 36260 0.9185 0.8995 -2.07
47000........................... Addison County, Vermont. 99947 0.9830 0.9744 -0.87
47010........................... Bennington County, 99947 0.9830 0.9744 -0.87
Vermont.
47020........................... Caledonia County, 99947 0.9830 0.9744 -0.87
Vermont.
47030........................... Chittenden County, 15540 0.9410 0.9474 0.68
Vermont.
47040........................... Essex County, Vermont... 99947 0.9830 0.9744 -0.87
47050........................... Franklin County, Vermont 15540 0.9410 0.9474 0.68
47060........................... Grand Isle County, 15540 0.9410 0.9474 0.68
Vermont.
47070........................... Lamoille County, Vermont 99947 0.9830 0.9744 -0.87
47080........................... Orange County, Vermont.. 99947 0.9830 0.9744 -0.87
47090........................... Orleans County, Vermont. 99947 0.9830 0.9744 -0.87
47100........................... Rutland County, Vermont. 99947 0.9830 0.9744 -0.87
47110........................... Washington County, 99947 0.9830 0.9744 -0.87
Vermont.
47120........................... Windham County, Vermont. 99947 0.9830 0.9744 -0.87
47130........................... Windsor County, Vermont. 99947 0.9830 0.9744 -0.87
48010........................... St Croix County, Virgin 99948 0.7615 0.8467 11.19
Islands.
48020........................... St Thomas-John County, 99948 0.7615 0.8467 11.19
Virgin Islands.
49000........................... Accomack County, 99949 0.8215 0.7940 -3.35
Virginia.
49010........................... Albemarle County, 16820 1.0187 1.0125 -0.61
Virginia.
49011........................... Alexandria City County, 47894 1.0951 1.1054 0.94
Virginia.
49020........................... Alleghany County, 99949 0.8215 0.7940 -3.35
Virginia.
49030........................... Amelia County, Virginia. 40060 0.8873 0.9177 3.43
49040........................... Amherst County, Virginia 31340 0.8691 0.8694 0.03
49050........................... Appomattox County, 31340 0.8554 0.8694 1.64
Virginia.
49060........................... Arlington County, 47894 1.0951 1.1054 0.94
Virginia.
49070........................... Augusta County, Virginia 99949 0.8215 0.7940 -3.35
49080........................... Bath County, Virginia... 99949 0.8215 0.7940 -3.35
49088........................... Bedford City County, 31340 0.8691 0.8694 0.03
Virginia.
49090........................... Bedford County, Virginia 31340 0.8691 0.8694 0.03
49100........................... Bland County, Virginia.. 99949 0.8215 0.7940 -3.35
49110........................... Botetourt County, 40220 0.8381 0.8647 3.17
Virginia.
49111........................... Bristol City County, 28700 0.8031 0.7985 -0.57
Virginia.
49120........................... Brunswick County, 99949 0.8215 0.7940 -3.35
Virginia.
49130........................... Buchanan County, 99949 0.8215 0.7940 -3.35
Virginia.
49140........................... Buckingham County, 99949 0.8215 0.7940 -3.35
Virginia.
49141........................... Buena Vista City County, 99949 0.8215 0.7940 -3.35
Virginia.
49150........................... Campbell County, 31340 0.8691 0.8694 0.03
Virginia.
49160........................... Caroline County, 40060 0.8873 0.9177 3.43
Virginia.
49170........................... Carroll County, Virginia 99949 0.8215 0.7940 -3.35
49180........................... Charles City County, 40060 0.9328 0.9177 -1.62
Virginia.
49190........................... Charlotte County, 99949 0.8215 0.7940 -3.35
Virginia.
49191........................... Charlottesville City 16820 1.0187 1.0125 -0.61
County, Virginia.
49194........................... Chesapeake County, 47260 0.8799 0.8790 -0.10
Virginia.
49200........................... Chesterfield County, 40060 0.9328 0.9177 -1.62
Virginia.
49210........................... Clarke County, Virginia. 47894 1.0951 1.1054 0.94
[[Page 66002]]
49211........................... Clifton Forge City 99949 0.8215 0.7940 -3.35
County, Virginia.
49212........................... Colonial Heights County, 40060 0.9328 0.9177 -1.62
Virginia.
49213........................... Covington City County, 99949 0.8215 0.7940 -3.35
Virginia.
49220........................... Craig County, Virginia.. 40220 0.8396 0.8647 2.99
49230........................... Culpeper County, 99949 0.9495 0.7940 -16.38
Virginia.
49240........................... Cumberland County, 40060 0.8873 0.9177 3.43
Virginia.
49241........................... Danville City County, 19260 0.8489 0.8451 -0.45
Virginia.
49250........................... Dickenson County, 99949 0.8215 0.7940 -3.35
Virginia.
49260........................... Dinniddie County, 40060 0.9328 0.9177 -1.62
Virginia.
49270........................... Emporia County, Virginia 99949 0.8215 0.7940 -3.35
49280........................... Essex County, Virginia.. 99949 0.8215 0.7940 -3.35
49288........................... Fairfax City County, 47894 1.0951 1.1054 0.94
Virginia.
49290........................... Fairfax County, Virginia 47894 1.0951 1.1054 0.94
49291........................... Falls Church City 47894 1.0951 1.1054 0.94
County, Virginia.
49300........................... Fauquier County, 47894 1.0951 1.1054 0.94
Virginia.
49310........................... Floyd County, Virginia.. 99949 0.8215 0.7940 -3.35
49320........................... Fluvanna County, 16820 1.0187 1.0125 -0.61
Virginia.
49328........................... Franklin City County, 99949 0.8215 0.7940 -3.35
Virginia.
49330........................... Franklin County, 40220 0.8396 0.8647 2.99
Virginia.
49340........................... Frederick County, 49020 0.9316 1.0091 8.32
Virginia.
49342........................... Fredericksburg City 47894 1.0951 1.1054 0.94
County, Virginia.
49343........................... Galax City County, 99949 0.8215 0.7940 -3.35
Virginia.
49350........................... Giles County, Virginia.. 13980 0.8186 0.8213 0.33
49360........................... Gloucester County, 47260 0.8799 0.8790 -0.10
Virginia.
49370........................... Goochland County, 40060 0.9328 0.9177 -1.62
Virginia.
49380........................... Grayson County, Virginia 99949 0.8215 0.7940 -3.35
49390........................... Greene County, Virginia. 16820 1.0187 1.0125 -0.61
49400........................... Greensville County, 99949 0.8215 0.7940 -3.35
Virginia.
49410........................... Halifax County, Virginia 99949 0.8215 0.7940 -3.35
49411........................... Hampton City County, 47260 0.8799 0.8790 -0.10
Virginia.
49420........................... Hanover County, Virginia 40060 0.9328 0.9177 -1.62
49421........................... Harrisonburg City 25500 0.8753 0.9073 3.66
County, Virginia.
49430........................... Henrico County, Virginia 40060 0.9328 0.9177 -1.62
49440........................... Henry County, Virginia.. 99949 0.8215 0.7940 -3.35
49450........................... Highland County, 99949 0.8215 0.7940 -3.35
Virginia.
49451........................... Hopewell City County, 40060 0.9328 0.9177 -1.62
Virginia.
49460........................... Isle Of Wight County, 47260 0.8799 0.8790 -0.10
Virginia.
49470........................... James City Co County, 47260 0.8799 0.8790 -0.10
Virginia.
49480........................... King And Queen County, 40060 0.8873 0.9177 3.43
Virginia.
49490........................... King George County, 99949 0.9495 0.7940 -16.38
Virginia.
49500........................... King William County, 40060 0.8873 0.9177 3.43
Virginia.
49510........................... Lancaster County, 99949 0.8215 0.7940 -3.35
Virginia.
49520........................... Lee County, Virginia.... 99949 0.8215 0.7940 -3.35
49522........................... Lexington County, 99949 0.8215 0.7940 -3.35
Virginia.
49530........................... Loudoun County, Virginia 47894 1.0951 1.1054 0.94
49540........................... Louisa County, Virginia. 40060 0.8873 0.9177 3.43
49550........................... Lunenburg County, 99949 0.8215 0.7940 -3.35
Virginia.
49551........................... Lynchburg City County, 31340 0.8691 0.8694 0.03
Virginia.
49560........................... Madison County, Virginia 99949 0.8215 0.7940 -3.35
49561........................... Martinsville City 99949 0.8215 0.7940 -3.35
County, Virginia.
49563........................... Manassas City County, 47894 1.0951 1.1054 0.94
Virginia.
49565........................... Manassas Park City 47894 1.0951 1.1054 0.94
County, Virginia.
49570........................... Mathews County, Virginia 47260 0.8799 0.8790 -0.10
49580........................... Mecklenburg County, 99949 0.8215 0.7940 -3.35
Virginia.
49590........................... Middlesex County, 99949 0.8215 0.7940 -3.35
Virginia.
49600........................... Montgomery County, 13980 0.8186 0.8213 0.33
Virginia.
49610........................... Nansemond, Virginia..... 99949 0.8215 0.7940 -3.35
49620........................... Nelson County, Virginia. 16820 0.9302 1.0125 8.85
49621........................... New Kent County, 40060 0.9328 0.9177 -1.62
Virginia.
49622........................... Newport News City 47260 0.8799 0.8790 -0.10
County, Virginia.
49641........................... Norfolk City County, 47260 0.8799 0.8790 -0.10
Virginia.
49650........................... Northampton County, 99949 0.8215 0.7940 -3.35
Virginia.
49660........................... Northumberland County, 99949 0.8215 0.7940 -3.35
Virginia.
49661........................... Norton City County, 99949 0.8215 0.7940 -3.35
Virginia.
49670........................... Nottoway County, 99949 0.8215 0.7940 -3.35
Virginia.
49680........................... Orange County, Virginia. 99949 0.8215 0.7940 -3.35
49690........................... Page County, Virginia... 99949 0.8215 0.7940 -3.35
49700........................... Patrick County, Virginia 99949 0.8215 0.7940 -3.35
[[Page 66003]]
49701........................... Petersburg City County, 40060 0.9328 0.9177 -1.62
Virginia.
49710........................... Pittsylvania County, 19260 0.8489 0.8451 -0.45
Virginia.
49711........................... Portsmouth City County, 47260 0.8799 0.8790 -0.10
Virginia.
49712........................... Poquoson City County, 47260 0.8799 0.8790 -0.10
Virginia.
49720........................... Powhatan County, 40060 0.9328 0.9177 -1.62
Virginia.
49730........................... Prince Edward County, 99949 0.8215 0.7940 -3.35
Virginia.
49740........................... Prince George County, 40060 0.9328 0.9177 -1.62
Virginia.
49750........................... Prince William County, 47894 1.0951 1.1054 0.94
Virginia.
49770........................... Pulaski County, Virginia 13980 0.8186 0.8213 0.33
49771........................... Radford City County, 13980 0.8186 0.8213 0.33
Virginia.
49780........................... Rappahannock County, 99949 0.8215 0.7940 -3.35
Virginia.
49790........................... Richmond County, 99949 0.8215 0.7940 -3.35
Virginia.
49791........................... Richmond City County, 40060 0.9328 0.9177 -1.62
Virginia.
49800........................... Roanoke County, Virginia 40220 0.8381 0.8647 3.17
49801........................... Roanoke City County, 40220 0.8381 0.8647 3.17
Virginia.
49810........................... Rockbridge County, 99949 0.8215 0.7940 -3.35
Virginia.
49820........................... Rockingham County, 25500 0.8753 0.9073 3.66
Virginia.
49830........................... Russell County, Virginia 99949 0.8215 0.7940 -3.35
49838........................... Salem County, Virginia.. 40220 0.8381 0.8647 3.17
49840........................... Scott County, Virginia.. 28700 0.8031 0.7985 -0.57
49850........................... Shenandoah County, 99949 0.8215 0.7940 -3.35
Virginia.
49860........................... Smyth County, Virginia.. 99949 0.8215 0.7940 -3.35
49867........................... South Boston City 99949 0.8215 0.7940 -3.35
County, Virginia.
49870........................... Southampton County, 99949 0.8215 0.7940 -3.35
Virginia.
49880........................... Spotsylvania County, 47894 1.0951 1.1054 0.94
Virginia.
49890........................... Stafford County, 47894 1.0951 1.1054 0.94
Virginia.
49891........................... Staunton City County, 99949 0.8215 0.7940 -3.35
Virginia.
49892........................... Suffolk City County, 47260 0.8799 0.8790 -0.10
Virginia.
49900........................... Surry County, Virginia.. 47260 0.8608 0.8790 2.11
49910........................... Sussex County, Virginia. 40060 0.8873 0.9177 3.43
49920........................... Tazewell County, 99949 0.8215 0.7940 -3.35
Virginia.
49921........................... Virginia Beach City 47260 0.8799 0.8790 -0.10
County, Virginia.
49930........................... Warren County, Virginia. 47894 1.0951 1.1054 0.94
49950........................... Washington County, 28700 0.8031 0.7985 -0.57
Virginia.
49951........................... Waynesboro City County, 99949 0.8215 0.7940 -3.35
Virginia.
49960........................... Westmoreland County, 99949 0.8215 0.7940 -3.35
Virginia.
49961........................... Williamsburg City 47260 0.8799 0.8790 -0.10
County, Virginia.
49962........................... Winchester City County, 49020 0.9316 1.0091 8.32
Virginia.
49970........................... Wise County, Virginia... 99949 0.8215 0.7940 -3.35
49980........................... Wythe County, Virginia.. 99949 0.8215 0.7940 -3.35
49981........................... York County, Virginia... 47260 0.8799 0.8790 -0.10
50000........................... Adams County, Washington 99950 1.0364 1.0263 -0.97
50010........................... Asotin County, 30300 1.0052 0.9853 -1.98
Washington.
50020........................... Benton County, 28420 1.0619 1.0343 -2.60
Washington.
50030........................... Chelan County, 48300 1.0144 1.0346 1.99
Washington.
50040........................... Clallam County, 99950 1.0364 1.0263 -0.97
Washington.
50050........................... Clark County, Washington 38900 1.1266 1.1416 1.33
50060........................... Columbia County, 99950 1.0364 1.0263 -0.97
Washington.
50070........................... Cowlitz County, 31020 0.9898 1.0011 1.14
Washington.
50080........................... Douglas County, 48300 1.0144 1.0346 1.99
Washington.
50090........................... Ferry County, Washington 99950 1.0364 1.0263 -0.97
50100........................... Franklin County, 28420 1.0619 1.0343 -2.60
Washington.
50110........................... Garfield County, 99950 1.0364 1.0263 -0.97
Washington.
50120........................... Grant County, Washington 99950 1.0364 1.0263 -0.97
50130........................... Grays Harbor County, 99950 1.0364 1.0263 -0.97
Washington.
50140........................... Island County, 99950 1.1039 1.0263 -7.03
Washington.
50150........................... Jefferson County, 99950 1.0364 1.0263 -0.97
Washington.
50160........................... King County, Washington. 42644 1.1572 1.1434 -1.19
50170........................... Kitsap County, 14740 1.0675 1.0913 2.23
Washington.
50180........................... Kittitas County, 99950 1.0364 1.0263 -0.97
Washington.
50190........................... Klickitat County, 99950 1.0364 1.0263 -0.97
Washington.
50200........................... Lewis County, Washington 99950 1.0364 1.0263 -0.97
50210........................... Lincoln County, 99950 1.0364 1.0263 -0.97
Washington.
50220........................... Mason County, Washington 99950 1.0364 1.0263 -0.97
50230........................... Okanogan County, 99950 1.0364 1.0263 -0.97
Washington.
50240........................... Pacific County, 99950 1.0364 1.0263 -0.97
Washington.
50250........................... Pend Oreille County, 99950 1.0364 1.0263 -0.97
Washington.
50260........................... Pierce County, 45104 1.0742 1.0789 0.44
Washington.
[[Page 66004]]
50270........................... San Juan County, 99950 1.0364 1.0263 -0.97
Washington.
50280........................... Skagit County, 34580 1.0336 1.0517 1.75
Washington.
50290........................... Skamania County, 38900 1.0742 1.1416 6.27
Washington.
50300........................... Snohomish County, 42644 1.1572 1.1434 -1.19
Washington.
50310........................... Spokane County, 44060 1.0905 1.0447 -4.20
Washington.
50320........................... Stevens County, 99950 1.0364 1.0263 -0.97
Washington.
50330........................... Thurston County, 36500 1.0927 1.1081 1.41
Washington.
50340........................... Wahkiakum County, 99950 1.0364 1.0263 -0.97
Washington.
50350........................... Walla Walla County, 99950 1.0364 1.0263 -0.97
Washington.
50360........................... Whatcom County, 13380 1.1731 1.1104 -5.34
Washington.
50370........................... Whitman County, 99950 1.0364 1.0263 -0.97
Washington.
50380........................... Yakima County, 49420 1.0155 0.9847 -3.03
Washington.
51000........................... Barbour County, W 99951 0.7809 0.7607 -2.59
Virginia.
51010........................... Berkeley County, W 25180 1.0233 0.9038 -11.68
Virginia.
51020........................... Boone County, W Virginia 16620 0.8173 0.8542 4.51
51030........................... Braxton County, W 99951 0.7809 0.7607 -2.59
Virginia.
51040........................... Brooke County, W 48260 0.7819 0.8063 3.12
Virginia.
51050........................... Cabell County, W 26580 0.9477 0.8997 -5.06
Virginia.
51060........................... Calhoun County, W 99951 0.7809 0.7607 -2.59
Virginia.
51070........................... Clay County, W Virginia. 16620 0.8173 0.8542 4.51
51080........................... Doddridge County, W 99951 0.7809 0.7607 -2.59
Virginia.
51090........................... Fayette County, W 99951 0.7809 0.7607 -2.59
Virginia.
51100........................... Gilmer County, W 99951 0.7809 0.7607 -2.59
Virginia.
51110........................... Grant County, W Virginia 99951 0.7809 0.7607 -2.59
51120........................... Greenbrier County, W 99951 0.7809 0.7607 -2.59
Virginia.
51130........................... Hampshire County, W 49020 0.9057 1.0091 11.42
Virginia.
51140........................... Hancock County, W 48260 0.7819 0.8063 3.12
Virginia.
51150........................... Hardy County, W Virginia 99951 0.7809 0.7607 -2.59
51160........................... Harrison County, W 99951 0.7809 0.7607 -2.59
Virginia.
51170........................... Jackson County, W 99951 0.7809 0.7607 -2.59
Virginia.
51180........................... Jefferson County, W 47894 1.0951 1.1054 0.94
Virginia.
51190........................... Kanawha County, W 16620 0.8445 0.8542 1.15
Virginia.
51200........................... Lewis County, W Virginia 99951 0.7809 0.7607 -2.59
51210........................... Lincoln County, W 16620 0.8173 0.8542 4.51
Virginia.
51220........................... Logan County, W Virginia 99951 0.7809 0.7607 -2.59
51230........................... Mc Dowell County, W 99951 0.7809 0.7607 -2.59
Virginia.
51240........................... Marion County, W 99951 0.7809 0.7607 -2.59
Virginia.
51250........................... Marshall County, W 48540 0.7161 0.7010 -2.11
Virginia.
51260........................... Mason County, W Virginia 99951 0.7809 0.7607 -2.59
51270........................... Mercer County, W 99951 0.7809 0.7607 -2.59
Virginia.
51280........................... Mineral County, W 19060 0.9317 0.8446 -9.35
Virginia.
51290........................... Mingo County, W Virginia 99951 0.7809 0.7607 -2.59
51300........................... Monongalia County, W 34060 0.8160 0.8423 3.22
Virginia.
51310........................... Monroe County, W 99951 0.7809 0.7607 -2.59
Virginia.
51320........................... Morgan County, W 25180 0.8695 0.9038 3.94
Virginia.
51330........................... Nicholas County, W 99951 0.7809 0.7607 -2.59
Virginia.
51340........................... Ohio County, W Virginia. 48540 0.7161 0.7010 -2.11
51350........................... Pendleton County, W 99951 0.7809 0.7607 -2.59
Virginia.
51360........................... Pleasants County, W 37620 0.8085 0.7977 -1.34
Virginia.
51370........................... Pocahontas County, W 99951 0.7809 0.7607 -2.59
Virginia.
51380........................... Preston County, W 34060 0.8160 0.8423 3.22
Virginia.
51390........................... Putnam County, W 16620 0.8445 0.8542 1.15
Virginia.
51400........................... Raleigh County, W 99951 0.7809 0.7607 -2.59
Virginia.
51410........................... Randolph County, W 99951 0.7809 0.7607 -2.59
Virginia.
51420........................... Ritchie County, W 99951 0.7809 0.7607 -2.59
Virginia.
51430........................... Roane County, W Virginia 99951 0.7809 0.7607 -2.59
51440........................... Summers County, W 99951 0.7809 0.7607 -2.59
Virginia.
51450........................... Taylor County, W 99951 0.7809 0.7607 -2.59
Virginia.
51460........................... Tucker County, W 99951 0.7809 0.7607 -2.59
Virginia.
51470........................... Tyler County, W Virginia 99951 0.7809 0.7607 -2.59
51480........................... Upshur County, W 99951 0.7809 0.7607 -2.59
Virginia.
51490........................... Wayne County, W Virginia 26580 0.9477 0.8997 -5.06
51500........................... Webster County, W 99951 0.7809 0.7607 -2.59
Virginia.
51510........................... Wetzel County, W 99951 0.7809 0.7607 -2.59
Virginia.
51520........................... Wirt County, W Virginia. 37620 0.8085 0.7977 -1.34
51530........................... Wood County, W Virginia. 37620 0.8270 0.7977 -3.54
51540........................... Wyoming County, W 99951 0.7809 0.7607 -2.59
Virginia.
52000........................... Adams County, Wisconsin. 99952 0.9494 0.9553 0.62
[[Page 66005]]
52010........................... Ashland County, 99952 0.9494 0.9553 0.62
Wisconsin.
52020........................... Barron County, Wisconsin 99952 0.9494 0.9553 0.62
52030........................... Bayfield County, 99952 0.9494 0.9553 0.62
Wisconsin.
52040........................... Brown County, Wisconsin. 24580 0.9483 0.9787 3.21
52050........................... Buffalo County, 99952 0.9494 0.9553 0.62
Wisconsin.
52060........................... Burnett County, 99952 0.9494 0.9553 0.62
Wisconsin.
52070........................... Calumet County, 11540 0.9264 0.9455 2.06
Wisconsin.
52080........................... Chippewa County, 20740 0.9201 0.9630 4.66
Wisconsin.
52090........................... Clark County, Wisconsin. 99952 0.9494 0.9553 0.62
52100........................... Columbia County, 31540 1.0069 1.0840 7.66
Wisconsin.
52110........................... Crawford County, 99952 0.9494 0.9553 0.62
Wisconsin.
52120........................... Dane County, Wisconsin.. 31540 1.0707 1.0840 1.24
52130........................... Dodge County, Wisconsin. 99952 0.9494 0.9553 0.62
52140........................... Door County, Wisconsin.. 99952 0.9494 0.9553 0.62
52150........................... Douglas County, 20260 1.0213 1.0042 -1.67
Wisconsin.
52160........................... Dunn County, Wisconsin.. 99952 0.9494 0.9553 0.62
52170........................... Eau Claire County, 20740 0.9201 0.9630 4.66
Wisconsin.
52180........................... Florence County, 99952 0.9494 0.9553 0.62
Wisconsin.
52190........................... Fond Du Lac County, 22540 0.9559 1.0063 5.27
Wisconsin.
52200........................... Forest County, Wisconsin 99952 0.9494 0.9553 0.62
52210........................... Grant County, Wisconsin. 99952 0.9494 0.9553 0.62
52220........................... Green County, Wisconsin. 99952 0.9494 0.9553 0.62
52230........................... Green Lake County, 99952 0.9494 0.9553 0.62
Wisconsin.
52240........................... Iowa County, Wisconsin.. 31540 1.0069 1.0840 7.66
52250........................... Iron County, Wisconsin.. 99952 0.9494 0.9553 0.62
52260........................... Jackson County, 99952 0.9494 0.9553 0.62
Wisconsin.
52270........................... Jefferson County, 99952 0.9494 0.9553 0.62
Wisconsin.
52280........................... Juneau County, Wisconsin 99952 0.9494 0.9553 0.62
52290........................... Kenosha County, 29404 1.0095 1.0570 4.71
Wisconsin.
52300........................... Kewaunee County, 24580 0.9481 0.9787 3.23
Wisconsin.
52310........................... La Crosse County, 29100 0.9564 0.9426 -1.44
Wisconsin.
52320........................... Lafayette County, 99952 0.9494 0.9553 0.62
Wisconsin.
52330........................... Langlade County, 99952 0.9494 0.9553 0.62
Wisconsin.
52340........................... Lincoln County, 99952 0.9494 0.9553 0.62
Wisconsin.
52350........................... Manitowoc County, 99952 0.9494 0.9553 0.62
Wisconsin.
52360........................... Marathon County, 48140 0.9590 0.9722 1.38
Wisconsin.
52370........................... Marinette County, 99952 0.9494 0.9553 0.62
Wisconsin.
52380........................... Marquette County, 99952 0.9494 0.9553 0.62
Wisconsin.
52381........................... Menominee County, 99952 0.9494 0.9553 0.62
Wisconsin.
52390........................... Milwaukee County, 33340 1.0146 1.0218 0.71
Wisconsin.
52400........................... Monroe County, Wisconsin 99952 0.9494 0.9553 0.62
52410........................... Oconto County, Wisconsin 24580 0.9481 0.9787 3.23
52420........................... Oneida County, Wisconsin 99952 0.9494 0.9553 0.62
52430........................... Outagamie County, 11540 0.9264 0.9455 2.06
Wisconsin.
52440........................... Ozaukee County, 33340 1.0146 1.0218 0.71
Wisconsin.
52450........................... Pepin County, Wisconsin. 99952 0.9494 0.9553 0.62
52460........................... Pierce County, Wisconsin 33460 1.1075 1.0946 -1.16
52470........................... Polk County, Wisconsin.. 99952 0.9494 0.9553 0.62
52480........................... Portage County, 99952 0.9494 0.9553 0.62
Wisconsin.
52490........................... Price County, Wisconsin. 99952 0.9494 0.9553 0.62
52500........................... Racine County, Wisconsin 39540 0.8997 0.9356 3.99
52510........................... Richland County, 99952 0.9494 0.9553 0.62
Wisconsin.
52520........................... Rock County, Wisconsin.. 27500 0.9538 0.9655 1.23
52530........................... Rusk County, Wisconsin.. 99952 0.9494 0.9553 0.62
52540........................... St Croix County, 33460 1.1075 1.0946 -1.16
Wisconsin.
52550........................... Sauk County, Wisconsin.. 99952 0.9494 0.9553 0.62
52560........................... Sawyer County, Wisconsin 99952 0.9494 0.9553 0.62
52570........................... Shawano County, 99952 0.9494 0.9553 0.62
Wisconsin.
52580........................... Sheboygan County, 43100 0.8911 0.9026 1.29
Wisconsin.
52590........................... Taylor County, Wisconsin 99952 0.9494 0.9553 0.62
52600........................... Trempealeau County, 99952 0.9494 0.9553 0.62
Wisconsin.
52610........................... Vernon County, Wisconsin 99952 0.9494 0.9553 0.62
52620........................... Vilas County, Wisconsin. 99952 0.9494 0.9553 0.62
52630........................... Walworth County, 99952 0.9494 0.9553 0.62
Wisconsin.
52640........................... Washburn County, 99952 0.9494 0.9553 0.62
Wisconsin.
52650........................... Washington County, 33340 1.0146 1.0218 0.71
Wisconsin.
52660........................... Waukesha County, 33340 1.0146 1.0218 0.71
Wisconsin.
52670........................... Waupaca County, 99952 0.9494 0.9553 0.62
Wisconsin.
[[Page 66006]]
52680........................... Waushara County, 99952 0.9494 0.9553 0.62
Wisconsin.
52690........................... Winnebago County, 36780 0.9211 0.9315 1.13
Wisconsin.
52700........................... Wood County, Wisconsin.. 99952 0.9494 0.9553 0.62
53000........................... Albany County, Wyoming.. 99953 0.9257 0.9295 0.41
53010........................... Big Horn County, Wyoming 99953 0.9257 0.9295 0.41
53020........................... Campbell County, Wyoming 99953 0.9257 0.9295 0.41
53030........................... Carbon County, Wyoming.. 99953 0.9257 0.9295 0.41
53040........................... Converse County, Wyoming 99953 0.9257 0.9295 0.41
53050........................... Crook County, Wyoming... 99953 0.9257 0.9295 0.41
53060........................... Fremont County, Wyoming. 99953 0.9257 0.9295 0.41
53070........................... Goshen County, Wyoming.. 99953 0.9257 0.9295 0.41
53080........................... Hot Springs County, 99953 0.9257 0.9295 0.41
Wyoming.
53090........................... Johnson County, Wyoming. 99953 0.9257 0.9295 0.41
53100........................... Laramie County, Wyoming. 16940 0.8775 0.9060 3.25
53110........................... Lincoln County, Wyoming. 99953 0.9257 0.9295 0.41
53120........................... Natrona County, Wyoming. 16220 0.9026 0.9145 1.32
53130........................... Niobrara County, Wyoming 99953 0.9257 0.9295 0.41
53140........................... Park County, Wyoming.... 99953 0.9257 0.9295 0.41
53150........................... Platte County, Wyoming.. 99953 0.9257 0.9295 0.41
53160........................... Sheridan County, Wyoming 99953 0.9257 0.9295 0.41
53170........................... Sublette County, Wyoming 99953 0.9257 0.9295 0.41
53180........................... Sweetwater County, 99953 0.9257 0.9295 0.41
Wyoming.
53190........................... Teton County, Wyoming... 99953 0.9257 0.9295 0.41
53200........................... Uinta County, Wyoming... 99953 0.9257 0.9295 0.41
53210........................... Washakie County, Wyoming 99953 0.9257 0.9295 0.41
53220........................... Weston County, Wyoming.. 99953 0.9257 0.9295 0.41
65010........................... Agana County, Guam...... 99965 0.9611 0.9611 0.00
65020........................... Agana Heights County, 99965 0.9611 0.9611 0.00
Guam.
65030........................... Agat County, Guam....... 99965 0.9611 0.9611 0.00
65040........................... Asan County, Guam....... 99965 0.9611 0.9611 0.00
65050........................... Barrigada County, Guam.. 99965 0.9611 0.9611 0.00
65060........................... Chalan Pago County, Guam 99965 0.9611 0.9611 0.00
65070........................... Dededo County, Guam..... 99965 0.9611 0.9611 0.00
65080........................... Inarajan County, Guam... 99965 0.9611 0.9611 0.00
65090........................... Maite County, Guam...... 99965 0.9611 0.9611 0.00
65100........................... Mangilao County, Guam... 99965 0.9611 0.9611 0.00
65110........................... Merizo County, Guam..... 99965 0.9611 0.9611 0.00
65120........................... Mongmong County, Guam... 99965 0.9611 0.9611 0.00
65130........................... Ordot County, Guam...... 99965 0.9611 0.9611 0.00
65140........................... Piti County, Guam....... 99965 0.9611 0.9611 0.00
65150........................... Santa Rita County, Guam. 99965 0.9611 0.9611 0.00
65160........................... Sinajana County, Guam... 99965 0.9611 0.9611 0.00
65170........................... Talofofo County, Guam... 99965 0.9611 0.9611 0.00
65180........................... Tamuning County, Guam... 99965 0.9611 0.9611 0.00
65190........................... Toto County, Guam....... 99965 0.9611 0.9611 0.00
65200........................... Umatac County, Guam..... 99965 0.9611 0.9611 0.00
65210........................... Yigo County, Guam....... 99965 0.9611 0.9611 0.00
65220........................... Yona County, Guam....... 99965 0.9611 0.9611 0.00
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[FR Doc. 06-9068 Filed 11-1-06; 4:00 pm]
BILLING CODE 4120-01-P