r::_w_'-*-:,;.;». 4:51-J23‘-jf_"'.'-.'€?'-‘-:.¥LT 34 - , ,-. «.~~r'~~ '17 1 . lf1fi51-_'i?:;“~y;;va;~§,-._.,, :, , , "~*»-n-i >"‘.~- .'. ‘"3’. ii-*__ I I} ., :1! 5- .. 2",‘-'3"/V-r-“‘ . ,.._,:l., ‘_:l“§‘5,?»s'_,/ ,' J‘: . MEDICARE-MEDICAID by Jennifer O'Sullivan Specialist in Social Legislation :Efi%£fiFFQNQLi§%T%%-E?W,Li@£:g¢ul_ - .~ ;,;'.—'-53$‘ 3 Education and Public Welfare Division ' " “;;'—Lt.;.f.,xi4g.-.MI.»i;. : ' _;.,;f-,;.- -,vA’~, April 7, 1981 RA 413 U.S. B olu 1 niversitflof Missouri O10-103860 M iWFuIuII< 34 - - - . .. - » . ‘ ~- “‘», . _ ._...'_. :_,_ __-__ _ ..;: -_~—_'~....-re, -... ..-Jun:;,,un...'.\*...4:-L:._(._1-».'- .;= ;-.$!a..xAu-=,.~:’; u... ‘ —— ~ - -———- — —- ~ —~ ~ The Congressional Research Service works exclusively for the Congress, conducting research, analyzing legislation, and providing information at the request of committees, Mem- bers, and their staffs. The Service makes such research available, without parti- san bias, in many forms including studies, reports, compila- tions, digests, and background briefings. Upon request, CRS assists committees in analyzing legislative proposals and issues, and in assessing the possible effects of these proposals and their alternatives. The Service’s senior specialists and subject analysts are also available for personal consultations in their respective fields of expertise. ABSTRACT This report contains a brief description of Medicare (the nationwide health insurance program for the aged and certain disabled persons) and Medi- caid (the federally aided, State-designed and administered program of medical assistance for certain categories of low-income persons). It specifies who is covered, how the programs are financed, and what health services are avail- able. Also included are key statistics on program costs and numbers of persons receiving covered services. CRS-v CONTENTS o o o n IOOOOOOCOOOOOOOOOOIOOOOQOOO000000O00000000OOOOOOOOOOOOOOOOOOO Io 090cocoonoooooooooooooooooooooooooooooooooooooooooooooo 1 II. MEDICARE ........................................................... A. Coverage ....................................................... B. Financing ............................... . . . . . .................. C. Benefits ....................................................... 1. Part A Benefits ............................................ 2. Part B Benefits ............................................ D. Reimbursement .................................................. \lO\U'IU'I4-‘U-DU.) III. MEDICAID . . . . . . . . . .................................................. 9 A. Financing ................................ . . . . . . . ............... 9 B. Eligibility .................................................... 9 C: Services ............... . . . . . . . ................. . . . . ............ 11 D. Payment for Services ........................................... 12 E. Cost-Sharing ................................................... 12 APPENDIX A. KEY MEDICARE STATISTICS ........... . . . . ...................... 13 Medicare Outlays ............................. . . . . . . ................ 13 Persons with Medicare Protection ................................... 14 Persons Receiving Reimbursed Services .............................. 14 APPENDIX B. KEY MEDICAID STATISTICS ..................................... 15 Medicaid Recipients ................................................ 15 Federal Medicaid Outlays ........................................... 15 State Medicaid Outlays ........... . . . . .............................. 16 APPENDIX C. FEDERAL MEDICAL ASSISTANCE PERCENTAGES BY STATE ............. 17 APPENDIX D. MEDICAID SERVICES STATE BY STATE . . . . . . . . . ... . . . . . ........... 19 MEDICARE-MEDICAID I. INTRODUCTl9N "Medicare" and "Medicaid" are the popular names of two programs enacted by Congress in 1965 which are intended to help certain persons pay for the costs of needed health care. Both programs are part of the same law--the Social Security Act--and both pay for many of the same kinds of services. Each program, however, is quite different from the other. Medicare is a nationwide health insurance program for people aged 65 and older, for certain disabled persons, and for certain workers and their dependents who need kidney transplantation or dialysis. Health insurance protection under Medicare is available to insured persons without regard to their incomes or assets. Monies from payroll taxes and premiums from beneficiaries are deposited in special trust funds for use in meeting the expenses of those insured by Medi- care. Medicaid, on the other hand, is a medical assistance program for certain categories of low-income persons. The Federal Government and the States share‘ in the cost of health care for program eligibles. Medicare is a Federal program with a uniform eligibility and benefit struc- ture throughout the United States. Medicaid is a federally aided, State-designed and administered program which varies from State to State. Under Medicaid, the States determine--subject to broad Federal guidelines--eligibility and the scope of benefits to be provided. CRS-3 II. MEDICARE The official name for the Medicare program is Health Insurance for the Aged and Disabled. The program is authorized under the provisions of Title XVIII of the Social Security Act, as amended. Medicare has two parts, the Hospital Insur ance or Part A program and the Supplementary Medical Insurance or Part B program A. Coverage The vast majority of persons reaching age 65 are automatically entitled to protection without cost under the hospital insurance program. Persons aged 65 and older not entitled to coverage may voluntarily obtain hospital insurance protection, providing they pay the full cost of such coverage. Also included are disabled workers at any age, disabled widows and disabled dependent widowers ~between the ages of 50 and 65, beneficiaries aged 18 or older who receive bene- fits because of disability prior to reaching age 22, and disabled railroad annu- itants (all after a certain period of disability). Fully or currently insured workers under Social Security and their dependents with chronic renal disease are, under certain circumstances, considered to be disabled for purposes of hospital insurance coverage. The supplementary medical insurance portion of Medicare is a voluntary pro- gram. All persons aged 65 or older (whether or not they are entitled to hospi- tal insurance) and all other persons entitled to hospital insurance (i.e., the disabled) may elect to enroll in the supplementary medical insurance program. Persons aged 65 or older who elect to "buy into" the hospital insurance program are required to buy supplementary protection as well. CRS-4 B. Financing For the most part, the Part A Hospital Insurance program is financed by means of a special hospital insurance payroll tax levied on employees, employers, and the self-employed. During calendar year 1981, each will pay a tax equal to 1.30 percent of the first $29,700 of covered yearly earnings (compared to 1.05 percent of the first $25,900 in 1980). Thereafter, the amount of taxable earn- ings and the rate of tax will increase according to the following schedule: Hospital Insurance Tax Rates for Employees, Employers, and the Self-Employed Earnings subject Calendar year Tax rate to tax 1981 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 1.30% $29,700 1982-84 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.30% automatically adjusted 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.35% 9 automatically adjusted 1986 and after . . . . . . . . . . ... . . . . . . . . . ...... 1.45% automatically adjusted The Part B Supplementary Medical Insurance program is financed on a current basis from monthly premiums paid by persons insured under the program and from the general revenues of the Treasury. Persons protected by the supplementary program pay only about one-quarter of the costs of benefits and program adminis- tration; the balance is paid for by the Federal Government. Premium amounts are revised annually beginning on July 1st to reflect increases in program costs. The monthly premium charge for enrollees under the Part B program is $9.60 for the period July 1980-June 1981; it will rise to $11.00 for the period July 1981- June 1982. CRS-5 0- 1ie..n..<:£_i_t.§ l. Part A Benefits During each benefit period, lf hospital insurance pays the "reasonable costs” for the following services: ~«o Inpatient hospital care--90 days. For the first 60 days, the reasonable cost of all covered services, except for an initial inpatient hospital deductible ($204 in 1981). For the 61st day through the 90th day, the costs of all covered services, except for a daily coinsurance ($51 in 1981). An additional "lifetime reserve” of 60 hospital days may be drawn upon when more than 90 days per benefit period is needed. Each reserve day pays for all covered services, except for a coinsurance of $102 per reserve day in 1981. Special limitations apply in the case of treatment in mental hospitals. 0 Skilled nursing facility care—-100 days in a skilled nursing facility for persons in need of skilled nursing care and/or skilled rehabilitation services on a daily basis. All covered services are paid for the first 20 days, after which patients must pay a daily coinsurance amount ($25.50 in 1981). Patients must be in a hospital for 3 consecutive days and must, except for special circumstances, be admitted to the skilled nursing facility within 14 days following hospital discharge. 0 Home health care--Up to 100 medically necessary home health visits by nurses, therapists, and other health workers. Hospital insurance pays for these services in the 12-month period following a 3-day hospital stay or discharge from a skilled nursing facility. Effective July 1, 1981, the prior hospitalization requirement and the number of visits limita- tion are deleted; further, occupational therapy is added as a qualifying criteria. 0 Alcohol detoxification facility services--Effective April, 1, 1981, coverage is available when such services are provided on an inpatient basis. Covered services include room and meals (including special diets) in semi-priv accommodations, regular nursing services, drugs provided on an inpatient basis l/ A “benefit period” begins the first time an insured person enters a hospital after his hospital insurance begins. It ends after he has not been a inpatient in a hospital or skilled nursing facility for 60 days in a row. The is no limit to the number of benefit periods an insured person may have. and supplies and equipment furnished by the facility. CRS-6 Excluded are physicians’ services, private duty nurses, costs of 3 pints of blood, and convenience items or services.~ Part B Benefits During any calendar year, supplementary medical insurance (with certain exceptions) pays 80 percent of the “reasonable charges” for covered services, after the insured pays the first $60 toward the costs of such services. Covered expenses incurred toward the end of one calendar year may be used to satisfy this deductible for the following year. Covered services include: Services of independent practitioners--Includes the services of medical doctors, osteopaths, chiropractors, and certain other practitioners regardless of where their services are provided (hospital, office, home, etc.). Special limitations apply in the case of psychiatric care outside of hospitals and for certain therapy services provided by an independent therapist practitioner. 1 Eome health care--100 home health visits in addition to the visits provided for under the hospital insurance program. The 20 percent coinsurance does not apply for such benefits. Effective July 1, 1981, the number of visits limitation is removed and the services will be exempt from the deductible;i payment for services will generally be made under Part A ex- cept where the individual is not eligible under that program. Medical and other services--Certain diagnostic services; X-ray or other radiation treatments; surgical dressings, casts, braces, artificial limbs and eyes; certain other equipment; certain medical supplies, ambulance services; rural health clinic services; kidney dialysis services and supplies; comprehensive outpatient rehabilitation facility services (effective July 1, 1981); and pneumococcal vaccine (flu shot) and its administration without regard to the coinsurance and deductible (effective July 1, 1981). Outpatient and laboratory services--Certain physical therapy and speech pathology services; clinical lab, X-ray and other services of pathologists and radiologists. Effective July 1, 1981, the coinsurance exemption for inpatient radiology and pathologist services will only apply where the physician accepts Medicare payments as payments in full for all program eligibles. CRS-7 Part B coverage excludes routine checkups; prescription or patent drugs; routine foot care (except treatment for plantar warts which is covered beginning July 1, 1981); eyeglasses or examinations; hearing aids; immunizations; most dental care and dentures; first 3 pints of blood received when not a hospital inpatient; and personal comfort or convenience items. D. Reimbursement Payments under Medicare are made on the basis of so-called "reasonable costs" to institutional providers (such as hospitals and skilled nursing facil- ities) and "reasonable charges" to physicians and other practitioners. Spe- cific criteria are established in Medicare law and regulations for making these determinations. Institutional providers of services submit bills on behalf of the beneficiary and agree to accept the program's reasonable cost reimbursement as payment in full for covered services. Beneficiaries are liable only for the applicable deductible and coinsurance amounts in connection with such services. Physicians and other suppliers may choose on a bill-by-bill basis whether or not they will be bound by the program's reasonable charge reimbursement pol- icies. The physician or supplier must agree that he will accept the program's reasonable charge as payment in full if he wishes to submit his bill directly to the program for payment. In this case, the patient assigns his benefit rights to the physician or other supplier and need pay no more than any unpaid deductible amount and the coinsurance (i.e., 20 percent of the reasonable charge in excess of the deductible). Alternatively, the physician may elect not to accept assignment. In this case, the patient submits the claim and the pro- gram's payment to the patient is based on what is determined to be the reasonabl« charge. In addition to the applicable deductible and coinsurance amounts, the CRS-8% patient is responsible for any difference between the reasonable charge as deter- mined by Medicare and the physician's actual bill. CRS-9 III. MEDICAID The official name for the Medicaid program is Grants to States for Medical Assistance Programs. It is authorized under Title XIX of the Social Security Act, as amended. Unlike Medicare, Medicaid is not a health insurance program. Instead, it is a federally aided, State-administered program of medical assistance for cer- tain categories of low-income persons. Each State designs its own Medicaid program within certain Federal guidelines and requirements. Thus, there is sub- stantial variation among States in eligibility requirements, range of services offered, limitations imposed on such services, and reimbursement policies. A. Financing The Federal Government helps States share in the cost of Medicaid services by means of a variable matching formula that is periodically adjusted. The matching rate, which is inversely related to a State's per capita income, ranges from 50 to 83 percent. (See appendix C.) The Federal share of administrative costs is 50 percent except for certain items where the authorized rate is higher. B. Eligibility States having Medicaid programs must cover the "categorically needy." In general, categorically needy individuals are persons receiving cash assistance payments under the Aid to Families with Dependent Children program (AFDC) or aged, blind, or disabled persons receiving benefits under the Supplemental CRS-10 Security Income program (SS1). A State must cover under Medicaid all recipients of AFDC payments. A State is, however, provided certain options (based, in large measure, on its coverage levels in effect prior to implementation of SSI in 1974) in determining the extent of coverage for persons receiving Federal SSI benefits and/or State supplementary SSI payments. States may cover certain additional groups of persons as “categorically needy” under their Medicaid programs. These might include persons who would be eligible for cash assistance, except that they are patients in medical facilities (other than for persons under 65 who are in tuberculosis institutions or persons over 21 and under 65 who are in.mental institutions). States may also include the "medically needy"--those whose incomes and resources are large enough to cover daily living expenses, according to income levels set by the State, within certain limits, but not large enough to pay for medical care, providing that they are aged, blind, disabled, or members of families with children. States may also include all needy and medically needy children under the age of 21, even though they are not eligible for assistance under one of the cash assistance programs. All States (except Arizona) and the District of Columbia, Guam, Puerto Rico, the Virgin Islands, and the Northern Mariana Islands, have Medicaid programs. Twenty jurisdictions cover only the "categorically needy,” while 34 cover both the "categorically needy” and the "medically needy." Coverage Limited to the Categorically Needy Alabama Georgia Missouri_ Oregon Alaska Idaho Nevada A South Carolina Colorado Indiana New Jersey South Dakota Delaware Iowa A New Mexico A Texas Florida Mississippi Ohio Wyoming CRS-ll Coverage Includes Both Categorically Needy and Medically Needy Arkansas California Connecticut District of Columbia Guam Hawaii Illinois Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Montana Nebraska New Hampshire New York North Carolina North Dakota Northern Mariana Islands Oklahoma Pennsylvania Puerto Rico Rhode Island Tennessee Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin C. Services Federal law requires States to include the following basic services in their Medicaid programs: inpatient hospital services; outpatient hospital services; laboratory and X-ray services; skilled nursing facility services for individuals 21 and older; home health care services for individuals eligible for skilled nursing facility services; physicians‘ services; family planning services; rural health clinic services; and early and periodic screening, diagnosis and treatment services for individuals under 21. In addition, States may provide any number of other services if they elect to do so, including drugs, eyeglasses, private duty nursing, intermediate care facility services, inpatient psychiatric care for the aged and persons under 21, physical therapy, dental care, etc. (See appendix D.) For both the mandatory and optional services, States may set limitations on the amount, duration, and scope of coverage (for example, a limitation on the number of days of hospital care or on the number of physician visits). Under current law, Medicaid recipients are permitted to obtain medical assistance from any institution, agency, community pharmacy, or person qualified to perform the service if such individual or entity undertakes to provide it. This is known as the “freedom of choice” provision. CRS-12 D. Payment for Services States, in general, determine the reimbursement rate for services, except for inpatient hospital care, where they are required to use Medicare's reason- able cost payment system unless they have approval from the Secretary of Health and Human Services to use an alternative payment methodology. States are required to reimburse skilled nursing facilities and intermediate care facili- ties at rates that are reasonable and adequate to meet the cost which must be incurred by efficiently and economically operated facilities in order to meet applicable laws and quality and safety standards. Generally, for other serv- ices, States may establish their own reimbursement levels, provided the amounts do not exceed what would be allowed under Medicare. In many instances, the rates are considerably less. Payments for covered services are made directly to the provider of services and the provider is required to accept the Medicaid payment as payment in full for covered services. E. Cost-Sharing Federal law permits States to impose nominal copayments and deductible amounts with respect to optional services for the categorically needy and for all services for the medically needy. In addition, nursing homes residents are required to turn over their excess income to help pay for the cost of their care; as a minimum they are allowed to retain $25 for their personal needs. CRS-13 APPENDIX A. KEY MEDICARE STATISTICS The following information on Medicare outlays and beneficiaries is from the Administration's FY82 Budget Revisions (and accompanying documents) sub- mitted March 10, 1981. Medicare Outlays (dollars in millions) FY80 FY81 FY82 (actual) (estimated) (estimated) Current program Part A benefits . . . . . . . . . . . . . . . . . . .. $23,760 $27,663 $33,330 Part B benefits . . . . . . . . . . . . . . . . . . .. 10,150 12,321 14,430 Administrative costs and research .. 1,097 1,156 1,183 Hospital reviews . . . . . . . . . . . . . . . . . .. 97 93_a/ 47 3/ Subtotal . . . . . . . . . . . . . . . . . . . . . . . . .. $35,104 $41,233 $48,990 Regulatory initiatives . . . . . . . . . . . .. -$69 -$500 —$803 Total . . . . . . . . . . . . . . . . . . . . . . . . . . .. $35,035 $40,733 $48,187 Proposed legislation Proposed changes . . . . . . . . . . . ..i . . . . .. - $422 -$1,093 0 Total Medicare . . . . . . . . . . . .. $35,035 $41,155 $47,094 a/ Assumes phasing out of Professional Standards Review Organizations (PSROs) which are responsible for the review of the medical necessity and appro- priateness of care provided to Medicare and Medicaid patients. CRSBI4 Persons with Medicare Protection_a/ (in thousands) FY80 FY81 FY82 (actual) (estimated) (estimated) Part A . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27,448 28,027 28,575 Aged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 24,471 24,941 25,397 Disabled . . . . . . . . . . . . . . . . . . . . . . . . . .. 2,977 3,086 3,178 Part B . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27,113 27,725 28,364 Aged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 24,410 24,936 25,469 Disabled . . . . . . . . . . . . . . . . . . . . . . . . . .. 2,703 2,789 2,895 _a/ Only the totals for Parts A and B are presented in the March 10, 1981, Budget Revisions and accompanying documents. These are the same as those appearing in the Carter Administration FY82 Budget Appendix. The distribution of these figures is from the Carter document. Persons Receiving Reimbursed Services_a/ (in thousands) )FY80 FY81 FY82 (actual) (estimated) (estimated) Part A . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6,660 6,900 7,140 Aged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 5,860 6,050 6,240 Disabled . . . . . . . . . . . . . . . . . . . . . . . . . .. 800 850 900 Part B . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 17,262 18,234 19,192 Aged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15,525 16,383 17,217 Disabled . . . . . . . . . . . . . . . . . . . . . . . . . .. 1,737 1,851 1,975 a/ This breakdown is from the Carter Administration FY82 Budget Appendix; comparable data does not appear in the Administration's FY82 Budget Revisions. CRS-15 APPENDIX B: KEY MEDICAID STATISTICS ‘The following data are from the Administration's FY82 Budget Revisions (anc accompanying documents) submitted through March 10, 1981: Medicaid Recipients (estimate in thousands) FY80 FY81 FY82 Aged 65 and over . . . . . ... . . . . . . . . . . . . . . . .. 3,400 3,482 3,557 Blind and disabled . . . . . . . . . . . . . . . . . . . . . .. 2,852 2,942 3,015 Adults in AFDC families . . . . . . . . . . . . . . . . .. 5,047 5,270" 5,373 Children under 21 . . . . . . . . . . . . . . . . . . . . . . .. 10,436 10,819- 11,045 Tota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 21,735 22,513 22,990 Federal Medicaid Outlays (in millions) FY80 FY81 FY82 (actual) (estimated) (estimated) Current program Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $13,232 $15,616 $17,345 State and local administration . . . . . . . .. 688 830 866 State certification . . . . . . . . . . . . . . . . . . .. 37 36 33 Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $13,957 $16,482 $18,244 Proposedelegislation Proposed changes . . . . . . . . . . . . . . . . ....... —- -$370 -$1,039 Total Federal outlays . . . . . . . . . . . . . . . . . . .. $13,957 $16,112 $17,205 CRS-16 State Medicaid Outlays (in millions) 0 The Administration‘s FY82 Budget Revisions did not contain revised estimates for State outlays under Medicaid. The following data are from the Carter Administration's Budget Appendix; some modifications in these estimates may be made at a later date. ~ Carter Administration FY80 9’ Z FY81 A FY82 current program estimates (actual) (estimated) (estimated) Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $10,732 $12,197 $15,535 Administration . . . . . . . . . . . . . . ..1 . . . . . ..., 499 597 620 Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. A‘$11,231 p$l2,795 $14,154 NOTE: Total may not add due to rounding. CRS-17 APPENDIX C. FEDERAL MEDICAL ASSISTANCE PERCENTAGES BY STATE Effective: Effective: State 10/1/79-9/30/81 10/1/81-9/30/83 Alabama . . . . . . . . . . . . . . . . . . . . . . . . .. 71.32 71.13 Alaska . . . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 Arizona . . . . . . . . . . . . . . . . . . . . . . . . . . -- '== Arkansas . . . . . . . . . . . . . . . . . . . . . . . .. 72.87 72.16 California . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 Colorado . . . . . . . . . . . . . . . . . . . . . . . .. 53.16 52.28 Connecticut . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 Delaware . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 District of Columbia . . . . . . . . . . . .. 50.00 50.00 Florida . . . . . . . . . . . . . . . . . . . . . . . . .. 58.94 57.92 Georgia . . . . . . . . . . . . . . . . . . . . . . . . .. 66.76 66.28 Guam . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . .. 65.70 65.43 Illinois . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 Indiana . . . . . . . . . . . . . . . . . . . . . . . . .. 57.28 56.73 Iowa . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 56.57 55.35 Kansas . . . . . . . . . . . . . . . . . . . . . . . . . .. 53.52 52.50 Kentucky . . . . . . . . . . . . . . . . . . . . . . . .. 68.07 67 95 Louisiana . . . . . . . . . . . . . . . . . . . . . . .. 68.82 66.85 Maine . . . . . . . . . . . . . . . . . . . . . . . . . . .. 69.53 70.63 Maryland . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 Massachusetts . . . . . . . . . . . . . . . . . . .. 51.75 53.56 Michigan . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 Minnesota . . . . . . . . . . . . . . . . . . . . . . .. 55.64 54.39 Mississippi . . . . . . . . . . . . . . . . . . . . .. 77.55 77.36 Missouri . . . . . . . . . . . . . . . . . . . . . . . .. 60.36 60.38 Montana . . . . . . . . . . . . . . . . . . . . . . . . .. 64.28 65.34 Nebraska . . . . . . . . . . . . . . . . . . . . . . . .. 57.62’ 58.12 Nevada . . . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 New Hampshire . . . . . . . . . . . . . . . . . . .. 61.11 59.41 New Jersey . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 New Mexico . . . . . . . . . . . . . . . . . . . . . .. 69.03 67.19 New York . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.88 North Carolina . . . . . . . . . . . . . . . . . .. 67.64 67.81 North Dakota . . . . . . . . . . . . . . . . . . . .. 61.44 62.11 Northern Mariana Islands . . . . . . . .. —- 50.00 Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 55.10 55.10 Oklahoma . . . . . . . . . . . . . . . . . . . . . . . .. 63.64 59.91 Oregon . . . . . . . . . . . . . . . . . . . . . . . . . .. 55.66 52.81 Pennsylvania..................... 55.14 56.78 Puerto Rico . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 Rhode Island . . . . . . . . . . . . . . . . . . . .. 57.81 57.77 South Carolina . . . . . . . . . . . . . . . . . .. 70.97 70.77 South Dakota . . . . . . . . . . . . . . . . . . . .. 68.78 68.19 Tennessee . . . . . . . . . . . . . . . . . . . . . . .. 69.43 68.53 Texas . . . . . . .. . . . . . . . . . . . . . . . . . . .. 58.35 55.75 Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 68.07 68.64 Vermont . . . . . . . . . . . . . . . . . . . . . . . . .. 68.40 68.59 Virgin Islands . . . . . . . . . . . . . . . . . .. 50.00 50.00 Virginia . . . . . . . . . . . . . . . . . . . . . . . .. 56.54 56.74 Washington . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 West Virginia . . . . . . . . . . . . . . . . . . .. 67.35 67.95 Wisconsin . . . . . . . . . . . . . . . . . . . . . . .. 57.95 58.02 Wyoming . . . . . . . . . . . . . . . . . . . . . . . . .. 50.00 50.00 :o_~m.zm_c_En< m:_ocmcI Eco _.:_mmI mwu_>.uw cmE:I Q 5.31 we EmEtmamD 30$. v.¢oo.uwuZ >:mu_to.2 .mucmS_.u.mm _m_ucmc: Dwtonasm >__m._ov3 m:_>_mum._ Enema “>302 >:wo_._omo:.Um . fiwuczo. 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