Section

[Code of Federal Regulations]
[Title 42, Volume 1]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR5.4]

[Page 35-52]

TITLE 42--PUBLIC HEALTH

CHAPTER I--PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN
SERVICES

PART 5--DESIGNATION OF HEALTH PROFESSIONAL(S) SHORTAGE AREAS--Table of Contents

Sec. 5.4 Notification and publication of designations and withdrawals.

(a) The Secretary will give written notice of the designation (or
withdrawal of designation) of a health professional(s) shortage area,
not later

[[Page 36]]

than 60 days from the date of the designation (or withdrawal of
designation), to:
(1) The Governor of each State in which the area, population group,
medical facility, or other public facility so designated is in whole or
in part located;
(2) Each HSA for a health service area which includes all or any
part of the area, population group, medical facility, or other public
facility so designated;
(3) The SHPDA for each State in which the area, population group,
medical facility, or other public facility so designated is in whole or
in part located; and
(4) Appropriate public or nonprofit private entities which are
located in or which have a demonstrated interest in the area so
designated.
(b) The Secretary will periodically publish updated lists of
designated health professional(s) shortage areas in the Federal
Register, by type of professional(s) shortage. An updated list of areas
for each type of professional(s) shortage will be published at least
once annually.
(c) The effective date of the designation of an area shall be the
date of the notification letter to the individual or agency which
requested the designation, or the date of publication in the Federal
Register, whichever comes first.
(d) Once an area is listed in the Federal Register as a designated
health professional(s) shortage area, the effective date of any later
withdrawal of the area's designation shall be the date when notification
of the withdrawal, or an updated list of designated areas which does not
include it, is published in the Federal Register.

Appendix A to Part 5--Criteria for Designation of Areas Having Shortages
of Primary Medical Care Professional(s)

Part I--Geographic Areas

A. Federal and State Correctional Institutions.
1. Criteria.
Medium to maximum security Federal and State correctional
institutions and youth detention facilities will be designated as having
a shortage of primary medical care professional(s) if both the following
criteria are met:
(a) The institution has at least 250 inmates.
(b) The ratio of the number of internees per year to the number of
FTE primary care physicians serving the institution is at least 1,000:1.
Here the number of internees is defined as follows:
(i) If the number of new inmates per year and the average length-of-
stay are not specified, or if the information provided does not indicate
that intake medical examinations are routinely performed upon entry,
then--Number of internees=average number of inmates.
(ii) If the average length-of-stay is specified as one year or more,
and intake medical examinations are routinely performed upon entry,
then--Number of internees=average number of inmates+(0.3)xnumber of new
inmates per year.
(iii) If the average length-of-stay is specified as less than one
year, and intake examinations are routinely performed upon entry, then--
Number of internees=average number of inmates+(0.2)x(1+ALOS/2)xnumber of
new inmates per year where ALOS=average length-of-stay (in fraction of
year). (The number of FTE primary care physicians is computed as in part
I, section B, paragraph 3 above.)
2. Determination of Degree of Shortage.
Designated correctional institutions will be assigned to degree-of-
shortage groups based on the number of inmates and/or the ratio (R) of
internees to primary care physicians, as follows:
Group 1--Institutions with 500 or more inmates and no physicians.
Group 2--Other institutions with no physicians and institutions with
R greater than (or equal to) 2,000:1.
Group 3--Institutions with R greater than (or equal to) 1,000:1 but
less than 2,000:1.
B. Methodology.
In determining whether an area meets the criteria established by
paragraph A of this part, the following methodology will be used:
1. Rational Areas for the Delivery of Primary Medical Care Services.
(a) The following areas will be considered rational areas for the
delivery of primary medical care services:
(i) A county, or a group of contiguous counties whose population
centers are within 30 minutes travel time of each other.
(ii) A portion of a county, or an area made up of portions of more
than one county, whose population, because of topography, market or
transportation patterns, distinctive population characteristics or other
factors, has limited access to contiguous area resources, as measured
generally by a travel time greater than 30 minutes to such resources.

[[Page 37]]

(iii) Established neighborhoods and communities within metropolitan
areas which display a strong self-identity (as indicated by a
homogeneous socioeconomic or demographic structure and/or a tradition of
interaction or interdependency), have limited interaction with
contiguous areas, and which, in general, have a minimum population of
20,000.
(b) The following distances will be used as guidelines in
determining distances corresponding to 30 minutes travel time:
(i) Under normal conditions with primary roads available: 20 miles.
(ii) In mountainous terrain or in areas with only secondary roads
available: 15 miles.
(iii) In flat terrain or in areas connected by interstate highways:
25 miles.
Within inner portions of metropolitan areas, information on the
public transportation system will be used to determine the distance
corresponding to 30 minutes travel time.
2. Population Count.
The population count used will be the total permanent resident
civilian population of the area, excluding inmates of institutions, with
the following adjustments, where appropriate:
(a) Adjustments to the population for the differing health service
requirements of various age-sex population groups will be computed using
the table below of visit rates for 12 age-sex population cohorts. The
total expected visit rate will first be obtained by multiplying each of
the 12 visit rates in the table by the size of the area population
within that particular age-sex cohort and adding the resultant 12 visit
figures together. This total expected visit rate will then be divided by
the U.S. average per capita visit rate of 5.1, to obtain the adjusted
population for the area.

----------------------------------------------------------------------------------------------------------------
Age groups
-----------------------------------------------------------------------
Sex 65 and
Under 5 5-14 15-24 25-44 45-64 over
----------------------------------------------------------------------------------------------------------------
Male.................................... 7.3 3.6 3.3 3.6 4.7 6.4
Female.................................. 6.4 3.2 5.5 6.4 6.5 6.8
----------------------------------------------------------------------------------------------------------------

(b) The effect of transient populations on the need of an area for
primary care professional(s) will be taken into account as follows:
(i) Seasonal residents, i.e., those who maintain a residence in the
area but inhabit it for only 2 to 8 months per year, may be included but
must be weighted in proportion to the fraction of the year they are
present in the area.
(ii) Other tourists (non-resident) may be included in an area's
population but only with a weight of 0.25, using the following formula:
Effective tourist contribution to population=0.25x(fraction of year
tourists are present in area)x(average daily number of tourists during
portion of year that tourists are present).
(iii) Migratory workers and their families may be included in an
area's population, using the following formula: Effective migrant
contribution to population=(fraction of year migrants are present in
area)x(average daily number of migrants during portion of year that
migrants are present).
3. Counting of Primary Care Practitioners.
(a) All non-Federal doctors of medicine (M.D.) and doctors of
osteopathy (D.O.) providing direct patient care who practice principally
in one of the four primary care specialities--general or family
practice, general internal medicine, pediatrics, and obstetrics and
gynecology--will be counted. Those physicians engaged solely in
administration, research, and teaching will be excluded. Adjustments for
the following factors will be made in computing the number of full-time-
equivalent (FTE) primary care physicians:
(i) Interns and residents will be counted as 0.1 full-time
equivalent (FTE) physicians.
(ii) Graduates of foreign medical schools who are not citizens or
lawful permanent residents of the United States will be excluded from
physician counts.
(iii) Those graduates of foreign medical schools who are citizens or
lawful permanent residents of the United States, but do not have
unrestricted licenses to practice medicine, will be counted as 0.5 FTE
physicians.
(b) Practitioners who are semi-retired, who operate a reduced
practice due to infirmity or other limiting conditions, or who provide
patient care services to the residents of the area only on a part-time
basis will be discounted through the use of full-time equivalency
figures. A 40-hour work week will be used as the standard for
determining full-time equivalents in these cases. For practitioners
working less than a 40-hour week, every four (4) hours (or \1/2\ day)
spent providing patient care, in either ambulatory or inpatient
settings, will be counted as 0.1 FTE (with numbers obtained for FTE's
rounded to the nearest 0.1 FTE), and each physician providing patient
care 40 or more hours a week will be counted as 1.0 FTE physician. (For
cases where data are available only for the

[[Page 38]]

number of hours providing patient care in office settings, equivalencies
will be provided in guidelines.)
(c) In some cases, physicians located within an area may not be
accessible to the population of the area under consideration. Allowances
for physicians with restricted practices can be made, on a case-by-case
basis. However, where only a portion of the population of the area
cannot access existing primary care resources in the area, a population
group designation may be more appropriate (see part II of this
appendix).
(d) Hospital staff physicians involved exclusively in inpatient care
will be excluded. The number of full-time equivalent physicians
practicing in organized outpatient departments and primary care clinics
will be included, but those in emergency rooms will be excluded.
(e) Physicians who are suspended under provisions of the Medicare-
Medicaid Anti-Fraud and Abuse Act for a period of eighteen months or
more will be excluded.
4. Determination of Unusually High Needs for Primary Medical Care
Services.
An area will be considered as having unusually high needs for
primary health care services if at least one of the following criteria
is met:
(a) The area has more than 100 births per year per 1,000 women aged
15-44.
(b) The area has more than 20 infant deaths per 1,000 live births.
(c) More than 20% of the population (or of all households) have
incomes below the poverty level.
5. Determination of Insufficient Capacity of Existing Primary Care
Providers.
An area's existing primary care providers will be considered to have
insufficient capacity if at least two of the following criteria are met:
(a) More than 8,000 office or outpatient visits per year per FTE
primary care physician serving the area.
(b) Unusually long waits for appointments for routine medical
services (i.e., more than 7 days for established patients and 14 days
for new patients).
(c) Excessive average waiting time at primary care providers (longer
than one hour where patients have appointments or two hours where
patients are treated on a first-come, first-served basis).
(d) Evidence of excessive use of emergency room facilities for
routine primary care.
(e) A substantial proportion (2/3 or more) of the area's physicians
do not accept new patients.
(f) Abnormally low utilization of health services, as indicated by
an average of 2.0 or less office visits per year on the part of the
area's population.
6. Contiguous Area Considerations.
Primary care professional(s) in areas contiguous to an area being
considered for designation will be considered excessively distant,
overutilized or inaccessible to the population of the area under
consideration if one of the following conditions prevails in each
contiguous area:
(a) Primary care professional(s) in the contiguous area are more
than 30 minutes travel time from the population center(s) of the area
being considered for designation (measured in accordance with paragraph
B.1(b) of this part).
(b) The contiguous area population-to-full-time-equivalent primary
care physician ratio is in excess of 2000:1, indicating that
practitioners in the contiguous area cannot be expected to help
alleviate the shortage situation in the area being considered for
designation.
(c) Primary care professional(s) in the contiguous area are
inaccessible to the population of the area under consideration because
of specified access barriers, such as:
(i) Significant differences between the demographic (or socio-
economic) characteristics of the area under consideration and those of
the contiguous area, indicating that the population of the area under
consideration may be effectively isolated from nearby resources. This
isolation could be indicated, for example, by an unusually high
proportion of non-English-speaking persons.
(ii) A lack of economic access to contiguous area resources, as
indicated particularly where a very high proportion of the population of
the area under consideration is poor (i.e., where more than 20 percent
of the population or the households have incomes below the poverty
level), and Medicaid-covered or public primary care services are not
available in the contiguous area.
C. Determination of Degree of Shortage.
Designated areas will be assigned to degree-of-shortage groups,
based on the ratio (R) of population to number of full-time equivalent
primary care physicians and the presence or absence of unusually high
needs for primary health care services, according to the following
table:

------------------------------------------------------------------------
High needs not High needs
indicated indicated
------------------------------------------------------------------------
Group 1......................... No physicians..... No physicians; or
R[ge]5,000
Group 2......................... R[ge]5,000........ 5,000R[
ge]4,000
Group 3......................... 5,000R[ 4,000R[
ge]4,000. ge]3,500
Group 4......................... 4,000R[ 3,500R[
ge]3,500. ge]3,000
------------------------------------------------------------------------

D. Determination of size of primary care physician shortage. Size of
Shortage (in number of FTE primary care physicians needed) will be
computed using the following formulas:
(1) For areas without unusually high need or insufficient capacity:
Primary care physician shortage=area population/3,500-number of FTE
primary care physicians

[[Page 39]]

(2) For areas with unusually high need or insufficient capacity:
Primary care physician shortage=area population/3,000-number of FTE
primary care physicians

Part II--Population Groups

A. Criteria.
1. In general, specific population groups within particular
geographic areas will be designated as having a shortage of primary
medical care professional(s) if the following three criteria are met:
(a) The area in which they reside is rational for the delivery of
primary medical care services, as defined in paragraph B.1 of part I of
this appendix.
(b) Access barriers prevent the population group from use of the
area's primary medical care providers. Such barriers may be economic,
linguistic, cultural, or architectural, or could involve refusal of some
providers to accept certain types of patients or to accept Medicaid
reimbursement.
(c) The ratio of the number of persons in the population group to
the number of primary care physicians practicing in the area and serving
the population group is at least 3,000 : 1.
2. Indians and Alaska Natives will be considered for designation as
having shortages of primary care professional(s) as follows:
(a) Groups of members of Indian tribes (as defined in section 4(d)
of Pub. L. 94-437, the Indian Health Care Improvement Act of 1976) are
automatically designated.
(b) Other groups of Indians or Alaska Natives (as defined in section
4(c) of Pub. L. 94-437) will be designated if the general criteria in
paragraph A are met.
B. Determination of Degree of Shortage.
Each designated population group will be assigned to a degree-of-
shortage group, based on the ratio (R) of the group's population to the
number of primary care physicians serving it, as follows:

Group 1--No physicians or R5,000.
Group 2--5,000R[ge]4,000.
Group 3--4,000R[ge]3,500.
Group 4--3,500R[ge]3,000.

Population groups which have received ``automatic'' designation will
be assigned to degree-of-shortage group 4 if no information on the ratio
of the number of persons in the group to the number of FTE primary care
physicians serving them is provided.
C. Determination of size of primary care physician shortage. Size of
shortage (in number of primary care physicians needed) will be computed
as follows:
Primary care physician shortage=number of persons in population
group/3,000-number of FTE primary care physicians

Part III--Facilities

Group 1--Institutions with 500 or more inmates and no physicians.
Group 2--Other institutions with no physicians and institutions with
R[ge]2,000.
Group 3--Institutions with 2,000R[ge]1,000.

B. Public or Non-Profit Medical Facilities.
1. Criteria.
Public or non-profit private medical facilities will be designated
as having a shortage of primary medical care professional(s) if:
(a) the facility is providing primary medical care services to an
area or population group designated as having a primary care
professional(s) shortage; and
(b) the facility has insufficient capacity to meet the primary care
needs of that area or population group.
2. Methodology
In determining whether public or nonprofit private medical
facilities meet the criteria established by paragraph B.1 of this Part,
the following methodology will be used:
(a) Provision of Services to a Designated Area or Population Group.
A facility will be considered to be providing services to a
designated area or population group if either:
(i) A majority of the facility's primary care services are being
provided to residents of designated primary care professional(s)
shortage areas or to population groups designated as having a shortage
of primary care professional(s); or
(ii) The population within a designated primary care shortage area
or population group

[[Page 40]]

has reasonable access to primary care services provided at the facility.
Reasonable access will be assumed if the area within which the
population resides lies within 30 minutes travel time of the facility
and non-physical barriers (relating to demographic and socioeconomic
characteristics of the population) do not prevent the population from
receiving care at the facility.
Migrant health centers (as defined in section 319(a)(1) of the Act)
which are located in areas with designated migrant population groups and
Indian Health Service facilities are assumed to be meeting this
requirement.
(b) Insufficient capacity to meet primary care needs.
A facility will be considered to have insufficient capacity to meet
the primary care needs of the area or population it serves if at least
two of the following conditions exist at the facility:
(i) There are more than 8,000 outpatient visits per year per FTE
primary care physician on the staff of the facility. (Here the number of
FTE primary care physicians is computed as in Part I, Section B,
paragraph 3 above.)
(ii) There is excessive usage of emergency room facilities for
routine primary care.
(iii) Waiting time for appointments is more than 7 days for
established patients or more than 14 days for new patients, for routine
health services.
(iv) Waiting time at the facility is longer than 1 hour where
patients have appointments or 2 hours where patients are treated on a
first-come, first-served basis.
3. Determination of Degree of Shortage.
Each designated medical facility will be assigned to the same
degree-of-shortage group as the designated area or population group
which it serves.

[45 FR 76000, Nov. 17, 1980, as amended at 54 FR 8737, Mar. 2, 1989; 57
FR 2480, Jan. 22, 1992]

Appendix B to Part 5--Criteria for Designation of Areas Having Shortages
of Dental Professional(s)

Part I--Geographic Areas

A. Federal and State Correctional Institutions.
1. Criteria
Medium to maximum security Federal and State correctional
institutions and youth detention facilities will be designated as having
a shortage of dental professional(s) if both the following criteria are
met:
(a) The institution has at least 250 inmates.
(b) The ratio of the number of internees per year to the number of
FTE dentists serving the institution is at least 1,500:1.
Here the number of internees is defined as follows:
(i) If the number of new inmates per year and the average length-of-
stay are not specified, or if the information provided does not indicate
that intake dental examinations are routinely performed by dentists upon
entry, then--Number of internees=average number of inmates.
(ii) If the average length-of-stay is specified as one year or more,
and intake dental examinations are routinely performed upon entry, then-
-Number of internees=average number of inmates+number of new inmates per
year.
(iii) If the average length-of-stay is specified as less than one
year, and intake dental examinations are routinely performed upon entry,
then--Number of internees=average number of inmates+\1/
3\x(1+2xALOS)xnumber of new inmates per year where ALOS=average length-
of-stay (in fraction of year).

(The number of FTE dentists is computed as in part I, section B,
paragraph 3 above.)

2. Determination of Degree of Shortage.
Designated correctional institutions will be assigned to degree-of-
shortage groups based on the number of inmates and/or the ratio (R) of
internees to dentists, as follows:
Group 1--Institutions with 500 or more inmates and no dentists.
Group 2--Other institutions with no dentists and institutions with R
greater than (or equal to) 3,000:1.
Group 3--Institutions with R greater than (or equal to) 1,500:1 but
less than 3,000:1.
B. Methodology.
In determining whether an area meets the criteria established by
paragraph A of this part, the following methodology will be used:
1. Rational Area for the Delivery of Dental Services.
(a) The following areas will be considered rational areas for the
delivery of dental health services:
(i) A county, or a group of several contiguous counties whose
population centers are within 40 minutes travel time of each other.
(ii) A portion of a county (or an area made up of portions of more
than one county) whose population, because of topography, market or
transportation patterns, distinctive population characteristics, or
other factors, has limited access to contiguous area resources, as
measured generally by a travel time of greater than 40 minutes to such
resources.
(iii) Established neighborhoods and communities within metropolitan
areas which display a strong self-identity (as indicated by a homogenous
socioeconomic or demographic structure and/or a traditional of
interaction or intradependency), have limited interaction with
contiguous areas, and which, in general, have a minimum population of
20,000.

[[Page 41]]

(b) The following distances will be used as guidelines in
determining distances corresponding to 40 minutes travel time:
(i) Under normal conditions with primary roads available: 25 miles.
(ii) In mountainous terrain or in areas with only secondary roads
available: 20 miles.
(iii) In flat terrain or in areas connected by interstate highways:
30 miles.
Within inner portions of metropolitan areas, information on the
public transportation system will be used to determine the distance
corresponding to 40 minutes travel time.
2. Population Count.
The population count use will be the total permanent resident
civilian population of the area, excluding inmates of institutions, with
the following adjustments:
(a) Seasonal residents, i.e., those who maintain a residence in the
area but inhabit it for only 2 to 8 months per year, may be included but
must be weighted in proportion to the fraction of the year they are
present in the area.
(b) Migratory workers and their families may be included in an
area's population using the following formula: Effective migrant
contribution to population=(fraction of year migrants are present in
area)x(average daily number of migrants during portion of year that
migrants are present).
3. Counting of Dental Practitioners.
(a) All non-Federal dentists providing patient care will be counted,
except in those areas where it is shown that specialists (those dentists
not in general practice or pedodontics) are serving a larger area and
are not addressing the general dental care needs of the area under
consideration.
(b) Full-time equivalent (FTE) figures will be used to reflect
productivity differences among dental practices based on the age of the
dentists, the number of auxiliaries employed, and the number of hours
worked per week. In general, the number of FTE dentists will be computed
using weights obtained from the matrix in Table 1, which is based on the
productivity of dentists at various ages, with different numbers of
auxiliaries, as compared with the average productivity of all dentists.
For the purposes of these determinations, an auxiliary is defined as any
non-dentist staff employed by the dentist to assist in operation of the
practice.

Table 1--Equivalency Weights, by Age and Number of Auxiliaries
------------------------------------------------------------------------
<55 55-59 60-64 65+
------------------------------------------------------------------------
No auxiliaries.......................... 0.8 0.7 0.6 0.5
One auxiliary........................... 1.0 0.9 0.8 0.7
Two auxiliaries......................... 1.2 1.0 1.0 0.8
Three auxiliaries....................... 1.4 1.2 1.0 1.0
Four or more auxiliaries................ 1.5 1.5 1.3 1.2
------------------------------------------------------------------------

If information on the number of auxiliaries employed by the dentist
is not available, Table 2 will be used to compute the number of full-
time equivalent dentists.

Table 2--Equivalency Weights, by Age
------------------------------------------------------------------------
55 55-59 60-64 65+
------------------------------------------------------------------------
Equivalency weights..................... 1.2 0.9 0.8 0.6
------------------------------------------------------------------------

The number of FTE dentists within a particular age group (or age/
auxiliary group) will be obtained by multiplying the number of dentists
within that group by its corresponding equivalency weight. The total
supply of FTE dentists within an area is then computed as the sum of
those dentists within each age (or age/auxiliary) group.
(c) The equivalency weights specified in tables 1 and 2 assume that
dentists within a particular group are working full-time (40 hours per
week). Where appropriate data are available, adjusted equivalency
figures for dentists who are semi-retired, who operate a reduced
practice due to infirmity or other limiting conditions, or who are
available to the population of an area only on a part-time basis will be
used to reflect the reduced availability of these dentists. In computing
these equivalency figures, every 4 hours (or \1/2\ day) spent in the
dental practice will be counted as 0.1 FTE except that each dentist
working more than 40 hours a week will be counted as 1.0. The count
obtained for a particular age group of dentists will then be multiplied
by the appropriate equivalency weight from table 1 or 2 to obtain a
full-time equivalent figure for dentists within that particular age or
age/auxiliary category.
4. Determination of Unusually High Needs for Dental Services.
An area will be considered as having unusually high needs for dental
services if at least one of the following criteria is met:
(a) More than 20% of the population (or of all households) has
incomes below the poverty level.
(b) The majority of the area's population does not have a
fluoridated water supply.
5. Determination of Insufficient Capacity of Existing Dental Care
Providers.
An area's existing dental care providers will be considered to have
insufficient capacity if at least two of the following criteria are met:
(a) More than 5,000 visits per year per FTE dentist serving the
area.
(b) Unusually long waits for appointments for routine dental
services (i.e., more than 6 weeks).

[[Page 42]]

(c) A substantial proportion (\2/3\ or more) of the area's dentists
do not accept new patients.
6. Contiguous Area Considerations.
Dental professional(s) in areas contiguous to an area being
considered for designation will be considered excessively distant,
overutilized or inaccessible to the population of the area under
consideration if one of the following conditions prevails in each
contiguous area:
(a) Dental professional(s) in the contiguous area are more than 40
minutes travel time from the center of the area being considered for
designation (measured in accordance with Paragraph B.1.(b) of this
part).
(b) Contiguous area population-to-(FTE) dentist ratios are in excess
of 3,000 : 1, indicating that resources in contiguous areas cannot be
expected to help alleviate the shortage situation in the area being
considered for designation.
(c) Dental professional(s) in the contiguous area are inaccessible
to the population of the area under consideration because of specified
access barriers, such as:
(i) Significant differences between the demographic (or
socioeconomic) characteristics of the area under consideration and those
of the contiguous area, indicating that the population of the area under
consideration may be effectively isolated from nearby resources. Such
isolation could be indicated, for example, by an unusually high
proportion of non-English-speaking persons.
(ii) A lack of economic access to contiguous area resources,
particularly where a very high proportion of the population of the area
under consideration is poor (i.e., where more than 20 percent of the
population or of the households have incomes below the poverty level)
and Medicaid-covered or public dental services are not available in the
contiguous area.
C. Determination of Degree of Shortage.
The degree of shortage of a given geographic area, designated as
having a shortage of dental professional(s), will be determined using
the following procedure:
Designated areas will be assigned to degree-of-shortage groups,
based on the ratio (R) of population to number of full-time-equivalent
dentists and the presence or absence of unusually high needs for dental
services, or insufficient capacity of existing dental care providers
according to the following table:

------------------------------------------------------------------------
High needs or
insufficient High needs or
capacity not insufficient
indicated capacity indicated
------------------------------------------------------------------------
Group 1......................... No dentists....... No dentists or
R[ge]8,000.
Group 2......................... R[ge]8,000........ 8,000R[
ge]6,000.
Group 3......................... 8,000R[ 6,000R[
ge]6,000. ge]5,000.
Group 4......................... 6,000R[ 5,000R[
ge]5,000. ge]4,000.
------------------------------------------------------------------------

D. Determination of size of dental shortage. Size of Dental Shortage
(in number of FTE dental practitioners needed) will be computed using
the following formulas:
(1) For areas without unusually high need:
Dental shortage=area population/5,000-number of FTE dental practitioners
(2) For areas with unusually high need:
Dental shortage=area population/4,000-number of FTE dental practitioners

Part II--Population Groups

A. Criteria.
1. In general, specified population groups within particular
geographic areas will be designated as having a shortage of dental care
professional(s) if the following three criteria are met:
a. The area in which they reside is rational for the delivery of
dental care services, as defined in paragraph B.1 of part I of this
appendix.
b. Access barriers prevent the population group from use of the
area's dental providers.
c. The ratio (R) of the number of persons in the population group to
the number of dentists practicing in the area and serving the population
group is at least 4,000:1.
2. Indians and Alaska Natives will be considered for designation as
having shortages of dental professional(s) as follows:
(a) Groups of members of Indian tribes (as defined in section 4(d)
of Pub. L. 94-437, the Indian Health Care Improvement Act of 1976) are
automatically designated.
(b) Other groups of Indians or Alaska Natives (as defined in section
4(c) of Pub. L. 94-437) will be designated if the general criteria in
paragraph 1 are met.
B. Determination of Degree of Shortage.
Each designated population group will be assigned to a degree-of-
shortage group as follows:

Group 1--No dentists or R[ge]8,000.
Group 2--8,000R[ge]6,000.
Group 3--6,000R[ge]5,000.
Group 4--5,000R[ge]4,000.

Population groups which have received ``automatic'' designation will be
assigned to degree-of-shortage group 4 unless information on the ratio
of the number of persons in the group to the number of FTE dentists
serving them is provided.
C. Determination of size of dental shortage. Size of dental shortage
will be computed as follows:
Dental shortage=number of persons in population group/4,000-number of
FTE dental practitioners

Part III--Facilities

A. Federal and State Correctional Institutions.
1. Criteria.

[[Page 43]]

Medium to maximum security Federal and State correctional
institutions and youth detention facilities will be designated as having
a shortage of dental professional(s) if both the following criteria are
met:
(a) The institution has at least 250 inmates.
(b) The ratio of the number of internees per year to the number of
FTE dentists serving the institution is at least 1,500:1. (Here the
number of internees is the number of inmates present at the beginning of
the year plus the number of new inmates entering the institution during
the year, including those who left before the end of the year; the
number of FTE dentists is computed as in part I, section B, paragraph 3
above.)
2. Determination of Degree-of-Shortage.
Designated correctional institutions will be assigned to degree-of-
shortage groups as follows, based on number of inmates and/or the ratio
(R) of internees to dentists:

Group 1--Institutions with 500 or more inmates and no dentists.
Group 2--Other institutions with no dentists and institutions with R
^ls-thn-eq 3,000.
Group 3--Institutions with 3,000 ^ls-thn-eq R ^ls-thn-eq
1,500.

B. Public or Non-Profit Private Dental Facilities.
1. Criteria.
Public or nonprofit private facilties providing general dental care
services will be designated as having a shortage of dental
professional(s) if both of the following criteria are met:
(a) The facility is providing general dental care services to an
area or population group designated as having a dental professional(s)
shortage; and
(b) The facility has insufficent capacity to meet the dental care
needs of that area or population group.
2. Methodology.
In determining whether public or nonprofit private facilities meet
the criteria established by paragraph B.1. of this part, the following
methodology will be used:
(a) Provision of Services to a Designated Area or Population Group.
A facility will be considered to be providing services to an area or
population group if either:
(i) A majority of the facility's dental care services are being
provided to residents of designated dental professional(s) shortage
areas or to population groups designated as having a shortage of dental
professional(s); or
(ii) The population within a designated dental shortage area or
population group has reasonable access to dental services provided at
the facility. Reasonable access will be assumed if the population lies
within 40 minutes travel time of the facility and non-physical barriers
(relating to demographic and socioeconomic characteristics of the
population) do not prevent the population from receiving care at the
facility.
Migrant health centers (as defined in section 319(a)(1) of the Act)
which are located in areas with designated migrant population groups and
Indian Health Service facilities are assumed to be meeting this
requirement.
(b) Insufficient Capacity To Meet Dental Care Needs.
A facility will be considered to have insufficient capacity to meet
the dental care needs of a designated area or population group if either
of the following conditions exists at the facility.
(i) There are more than 5,000 outpatient visits per year per FTE
dentist on the staff of the facility. (Here the number of FTE dentists
is computed as in part I, section B, paragraph 3 above.)
(ii) Waiting time for appointments is more than 6 weeks for routine
dental services.
3. Determination of Degree of Shortage.
Each designated dental facility will be assigned to the same degree-
of-shortage group as the designated area or population group which it
serves.

[45 FR 76000, Nov. 17, 1980, as amended at 54 FR 8738, Mar. 2, 1989; 57
FR 2480, Jan. 22, 1992]

Appendix C to Part 5--Criteria for Designation of Areas Having Shortages
of Mental Health Professionals

Part I--Geographic Areas

A. Criteria. A geographic area will be designated as having a
shortage of mental health professionals if the following four criteria
are met:
1. The area is a rational area for the delivery of mental health
services.
2. One of the following conditions prevails within the area:
(a) The area has--
(i) A population-to-core-mental-health-professional ratio greater
than or equal to 6,000:1 and a population-to-psychiatrist ratio greater
than or equal to 20,000:1, or
(ii) A population-to-core-professional ratio greater than or equal
to 9,000:1, or
(iii) A population-to-psychiatrist ratio greater than or equal to
30,000:1;
(b) The area has unusually high needs for mental health services,
and has--
(i) A population-to-core-mental-health-professional ratio greater
than or equal to 4,500:1 and
A population-to-psychiatrist ratio greater than or equal to
15,000:1, or
(ii) A population-to-core-professional ratio greater than or equal
to 6,000:1, or
(iii) A population-to-psychiatrist ratio greater than or equal to
20,000:1;

[[Page 44]]

3. Mental health professionals in contiguous areas are overutilized,
excessively distant or inaccessible to residents of the area under
consideration.

B. Methodology.
In determining whether an area meets the criteria established by
paragraph A of this part, the following methodology will be used:
1. Rational Areas for the Delivery of Mental Health Services.
(a) The following areas will be considered rational areas for the
delivery of mental health services:
(i) An established mental health catchment area, as designated in
the State Mental Health Plan under the general criteria set forth in
section 238 of the Community Mental Health Centers Act.
(ii) A portion of an established mental health catchment area whose
population, because of topography, market and/or transportation patterns
or other factors, has limited access to mental health resources in the
rest of the catchment area, as measured generally by a travel time of
greater than 40 minutes to these resources.
(iii) A county or metropolitan area which contains more than one
mental health catchment area, where data are unavailable by individual
catchment area.
(b) The following distances will be used as guidelines in
determining distances corresponding to 40 minutes travel time:
(i) Under normal conditions with primary roads available: 25 miles.
(ii) In mountainous terrain or in areas with only secondary roads
available: 20 miles.
(iii) In flat terrain or in areas connected by interstate highways:
30 miles.
Within inner portions of metropolitan areas, information on the
public transportation system will be used to determine the distance
corresponding to 40 minutes travel time.
2. Population Count.
The population count used will be the total permanent resident
civilian population of the area, excluding inmates of institutions.
3. Counting of mental health professionals. (a) All non-Federal core
mental health professionals (as defined below) providing mental health
patient care (direct or other, including consultation and supervision)
in ambulatory or other short-term care settings to residents of the area
will be counted. Data on each type of core professional should be
presented separately, in terms of the number of full-time-equivalent
(FTE) practitioners of each type represented.
(b) Definitions:
(i) Core mental health professionals or core professionals includes
those psychiatrists, clinical psychologists, clinical social workers,
psychiatric nurse specialists, and marriage and family therapists who
meet the definitions below.
(ii) Psychiatrist means a doctor of medicine (M.D.) or doctor of
osteopathy (D.O.) who
(A) Is certified as a psychiatrist or child psychiatrist by the
American Medical Specialities Board of Psychiatry and Neurology or by
the American Osteopathic Board of Neurology and Psychiatry, or, if not
certified, is ``broad-eligible'' (i.e., has successfully completed an
accredited program of graduate medical or osteopathic education in
psychiatry or child psychiatry); and
(B) Practices patient care psychiatry or child psychiatry, and is
licensed to do so, if required by the State of practice.
(iii) Clinical psychologist means an individual (normally with a
doctorate in psychology) who is practicing as a clinical or counseling
psychologist and is licensed or certified to do so by the State of
practice; or, if licensure or certification is not required in the State
of practice, an individual with a doctorate in psychology and two years
of supervised clinical or counseling experience. (School psychologists
are not included.)
(iv) Clinical social worker means an individual who--
(A) Is certified as a clinical social worker by the American Board
of Examiners in Clinical Social Work, or is listed on the National
Association of Social Workers' Clinical Register, or has a master's
degree in social work and two years of supervised clinical experience;
and
(B) Is licensed to practice as a social worker, if required by the
State of practice.
(v) Psychiatric nurse specialist means a registered nurse (R.N.)
who--
(A) Is certified by the American Nurses Association as a psychiatric
and mental health clinical nurse specialist, or has a master's degree in
nursing with a specialization in psychiatric/mental health and two years
of supervised clinical experience; and
(B) Is licensed to practice as a psychiatric or mental health nurse
specialist, if required by the State of practice.
(vi) Marriage and family therapist means an individual (normally
with a master's or doctoral degree in marital and family therapy and at
least two years of supervised clinical experience) who is practicing as
a marital and family therapist and is licensed or certified to do so by
the State of practice; or, if licensure or certification is not required
by the State of practice, is eligible for clinical membership in the
American Association for Marriage and Family Therapy.
(c) Practitioners who provide patient care to the population of an
area only on a part-time basis (whether because they maintain another
office elsewhere, spend some of their time providing services in a
facility, are semi-retired, or operate a reduced practice for other
reasons), will be counted on a partial basis through the use of full-
time-equivalency calculations based on a 40-hour

[[Page 45]]

week. Every 4 hours (or \1/2\ day) spent providing patient care services
in ambulatory or inpatient settings will be counted as 0.1 FTE, and each
practitioner providing patient care for 40 or more hours per week as 1.0
FTE. Hours spent on research, teaching, vocational or educational
counseling, and social services unrelated to mental health will be
excluded; if a practitioner is located wholly or partially outside the
service area, only those services actually provided within the area are
to be counted.
(d) In some cases, practitioners located within an area may not be
accessible to the general population of the area under consideration.
Practitioners working in restricted facilities will be included on an
FTE basis based on time spent outside the facility. Examples of
restricted facilities include correctional institutions, youth detention
facilities, residential treatment centers for emotionally disturbed or
mentally retarded children, school systems, and inpatient units of State
or county mental hospitals.
(e) In cases where there are mental health facilities or
institutions providing both inpatient and outpatient services, only
those FTEs providing mental health services in outpatient units or other
short-term care units will be counted.
(f) Adjustments for the following factors will also be made in
computing the number of FTE providers:
(i) Practitioners in residency programs will be counted as 0.5 FTE.
(ii) Graduates of foreign schools who are not citizens or lawful
permanent residents of the United States will be excluded from counts.
(iii) Those graduates of foreign schools who are citizens or lawful
permanent residents of the United States, and practice in certain
settings, but do not have unrestricted licenses to practice, will be
counted on a full-time-equivalency basis up to a maximum of 0.5 FTE.
(g) Practitioners suspended for a period of 18 months or more under
provisions of the Medicare-Medicaid Anti-Fraud and Abuse Act will not be
counted.
4. Determination of unusually high needs for mental health services.
An area will be considered to have unusually high needs for mental
health services if one of the following criteria is met:
(a) 20 percent of the population (or of all households) in the area
have incomes below the poverty level.
(b) The youth ratio, defined as the ratio of the number of children
under 18 to the number of adults of ages 18 to 64, exceeds 0.6.
(c) The elderly ratio, defined as the ratio of the number of persons
aged 65 and over to the number of adults of ages 18 to 64, exceeds 0.25.
(d) A high prevalence of alcoholism in the population, as indicated
by prevalence data showing the area's alcoholism rates to be in the
worst quartile of the nation, region, or State.
(e) A high degree of substance abuse in the area, as indicated by
prevalence data showing the area's substance abuse to be in the worst
quartile of the nation, region, or State.
5. Contiguous area considerations. Mental health professionals in
areas contiguous to an area being considered for designation will be
considered excessively distant, overutilized or inaccessible to the
population of the area under consideration if one of the following
conditions prevails in each contiguous area:
(a) Core mental health professionals in the contiguous area are more
than 40 minutes travel time from the closest population center of the
area being considered for designation (measured in accordance with
paragraph B.1(b) of this part).
(b) The population-to-core-mental-health-professional ratio in the
contiguous area is in excess of 3,000:1 and the population-to-
psychiatrist ratio there is in excess of 10,000:1, indicating that core
mental health professionals in the contiguous areas are overutilized and
cannot be expected to help alleviate the shortage situation in the area
for which designation is being considered. (If data on core mental
health professionals other than psychiatrists are not available for the
contiguous area, a population-to-psychiatrist ratio there in excess of
20,000:1 may be used to demonstrate overutilization.)
(c) Mental health professionals in contiguous areas are inaccessible
to the population of the requested area due to geographic, cultural,
language or other barriers or because of residency restrictions of
programs or facilities providing such professionals.
C. Determination of degree of shortage. Designated areas will be
assigned to degree-of-shortage groups according to the following table,
depending on the ratio (RC) of population to number of FTE
core-mental-health-service providers (FTEC); the ratio
(RP) of population to number of FTE psychiatrists
(FTEP); and the presence or absence of high needs:

High Needs Not Indicated

Group 1--FTEC=0 and FTEP=0
Group 2--RC gte * 6,000:1 and FTEP=0
Group 3--RC gte 6,000:1 and RP gte 20,000
Group 4(a)--For psychiatrist placements only: All other areas with
FTEP=0 or RP gte 30,000
Group 4(b)--For other mental health practitioner placements: All other
areas with RC gte 9,000:1.

* Note: ``gte'' means ``greater than or equal to''.

[[Page 46]]

High Needs Indicated

Group 1--FTEC=0 and FTEP=0
Group 2--RC gte 4,500:1 and FTEP=0
Group 3--RC gte 4,500:1 and RP gte 15,000
Group 4(a)--For psychiatrist placements only: All other areas with
FTEP=0 or RP gte 20,000
Group 4(b)--For other mental health practitioner placements: All other
areas with RC gte 6,000:1.
D. Determination of Size of Shortage. Size of Shortage (in number of
FTE professionals needed) will be computed using the following formulas:
(1) For areas without unusually high need:

Core professional shortage=area population/6,000-number of FTE core
professionals
Psychiatrist shortage=area population/20,000-number of FTE psychiatrists

(2) For areas with unusually high need:

Core professional shortage=area population/4,500-number of FTE core
professionals
Psychiatrist shortage=area population/15,000-number of FTE psychiatrists

Part II--Population Groups

A. Criteria. Population groups within particular rational mental
health service areas will be designated as having a mental health
professional shortage if the following criteria are met:
1. Access barriers prevent the population group from using those
core mental health professionals which are present in the area; and
2. One of the following conditions prevails:
(a) The ratio of the number of persons in the population group to
the number of FTE core mental health professionals serving the
population group is greater than or equal to 4,500:1 and the ratio of
the number of persons in the population group to the number of FTE
psychiatrists serving the population group is greater than or equal to
15,000:1; or,
(b) The ratio of the number of persons in the population group to
the number of FTE core mental health professionals serving the
population group is greater than or equal to 6,000:1; or,
(c) The ratio of the number of persons in the population group to
the number of FTE psychiatrists serving the population group is greater
than or equal to 20,000:1.
B. Determination of degree of shortage. Designated population groups
will be assigned to the same degree-of-shortage groups defined in part
I.C of this appendix for areas with unusually high needs for mental
health services, using the computed ratio (RC) of the number
of persons in the population group to the number of FTE core mental
health service providers (FTEC) serving the population group,
and the ration (RP) of the number of persons in the
population group to the number of FTE psychiatrists (FTEP)
serving the population group.
C. Determination of size of shortage. Size of shortage will be
computed as follows:
Core professional shortage=number of persons in population group/4,500-
number of FTE core professionals
Psychiatrist shortage=number of persons in population group/15,000-
number of FTE psychiatrists

Part III--Facilities

A. Federal and State Correctional Institutions
1. Criteria.
Medium to maximum security Federal and State correctional
institutions for adults or youth, and youth detention facilities, will
be designated as having a shortage of psychiatric professional(s) if
both of the following criteria are met:
(a) The institution has more than 250 inmates, and
(b) The ratio of the number of internees per year to the number of
FTE psychiatrists serving the institution is at least 2,000:1. (Here the
number of internees is the number of inmates or residents present at the
beginning of the year, plus the number of new inmates or residents
entering the institution during the year, including those who left
before the end of the year; the number of FTE psychiatrists is computed
as in part I, section B, paragraph 3 above.)
2. Determination of Degree of Shortage.
Correctional facilities and youth detention facilities will be
assigned to degree-of-shortage groups, based on the number of inmates
and/or the ratio (R) of internees to FTE psychiatrists, as follows:

Group 1--Facilities with 500 or more inmates or residents and no
psychiatrist.
Group 2--Other facilities with no psychiatrists and facilities with
500 or more inmates or residents and R3,000.
Group 3--All other facilities.

B. State and County Mental Hospitals.
1. Criteria.
A State or county hospital will be designated as having a shortage
of psychiatric professional(s) if both of the following criteria are
met:
(a) The mental hospital has an average daily inpatient census of at
least 100; and
(b) The number of workload units per FTE psychiatrists available at
the hospital exceeds 300, where workload units are calculated using the
following formula:
Total workload units = average daily inpatient census + 2 x (number
of inpatient admissions per year) + 0.5 x (number of admissions to day
care and outpatient services per year).
2. Determination of Degree of Shortage.
State or county mental hospitals will be assigned to degree-of-
shortage groups, based

[[Page 47]]

on the ratio (R) of workload units to number of FTE psychiatrists, as
follows:

Group 1--No psychiatrists, or R1,800.
Group 2--1,800R1,200.
Group 3--1,200R600.
Group 4--600R300.

C. Community Mental Health Centers and Other Public or Nonprofit
Private Facilities.
1. Criteria.
A community mental health center (CMHC), authorized by Pub. L. 94-
63, or other public or nonprofit private facility providing mental
health services to an area or population group, may be designated as
having a shortage of psychiatric professional(s) if the facility is
providing (or is responsible for providing) mental health services to an
area or population group designated as having a mental health
professional(s), and the facility has insufficient capacity to meet the
psychiatric needs of the area or population group.
2. Methodology.
In determining whether CMHCs or other public or nonprofit private
facilities meet the criteria established in paragraph C.1 of this Part,
the following methodology will be used.
(a) Provision of Services to a Designated Area or Population Group.
The facility will be considered to be providing services to a
designated area or population group if either:
(i) A majority of the facility's mental health services are being
provided to residents of designated mental health professional(s)
shortage areas or to population groups designated as having a shortage
of mental health professional(s); or
(ii) The population within a designated psychiatric shortage area or
population group has reasonable access to mental health services
provided at the facility. Such reasonable access will be assumed if the
population lies within 40 minutes travel time of the facility and
nonphysical barriers (relating to demographic and socioeconomic
characteristics of the population) do not prevent the population from
receiving care at the facility.
(b) Responsibility for Provision of Services.
This condition will be considered to be met if the facility, by
Federal or State statute, administrative action, or contractual
agreement, has been given responsibility for providing and/or
coordinating mental health services for the area or population group,
consistent with applicable State plans.
(c) Insufficient capacity to meet mental health service needs. A
facility will be considered to have insufficient capacity to meet the
mental health service needs of the area or population it serves if:
(i) There are more than 1,000 patient visits per year per FTE core
mental health professional on staff of the facility, or
(ii) There are more than 3,000 patient visits per year per FTE
psychiatrist on staff of the facility, or
(iii) No psychiatrists are on the staff and this facility is the
only facility providing (or responsible for providing) mental health
services to the designated area or population.
3. Determination of Degree-of-Shortage.
Each designated facility will be assigned to the same degree-of-
shortage group as the designated area or population group which it
serves.

[45 FR 76000, Nov. 17, 1980, as amended at 54 FR 8738, Mar. 2, 1989; 57
FR 2477, Jan. 22, 1992]

Appendix D to Part 5--Criteria for Designation of Areas Having Shortages
of Vision Care Professional(s)

Part I--Geographic Areas

A. Criteria.
A geographic area will be designated as having a shortage of vision
care professional(s) if the following three criteria are met:
1. The area is a rational area for the delivery of vision care
services.
2. The estimated number of optometric visits supplied by vision care
professional(s) in the area is less than the estimated requirements of
the area's population for these visits, and the computed shortage is at
least 1,500 optometric visits.
3. Vision care professional(s) in contiguous areas are excessively
distant, overutilized, or inaccessible to the population of the area
under consideration.
B. Methodology.
In determining whether an area meets the criteria established by
paragraph A of this part, the following methodology will be used:
1. Rational Areas for the Delivery of Vision Care Services.
(a) The following areas will be considered rational areas for the
delivery of vision care services:
(i) A county, or a group of contiguous counties whose population
centers are within 40 minutes travel time of each other;
(ii) A portion of a county (or an area made up of portions of more
than one county) whose population, because of topography, market or
transportation patterns, or other factors, has limited access to
contiguous area resources, as measured generally by a travel time of
greater than 40 minutes to these resources.
(b) The following distances will be used as guidelines in
determining distances corresponding to 40 minutes travel time:
(i) Under normal conditions with primary roads available: 25 miles.

[[Page 48]]

(ii) In mountainous terrain or in areas with only secondary roads
available: 20 miles.
(iii) In flat terrain or in areas connected by interstate highways:
30 miles.
Within inner portions of metropolitan areas, information on the
public transportation system will be used to determine the distance
corresponding to 40 minutes travel time.
2. Determination of Estimated Requirement for Optometric Visits.
The number of optometric visits required by an area's population
will be estimated by multiplying each of the following visit rates by
the size of the population within that particular age group and then
adding the figures obtained together.

----------------------------------------------------------------------------------------------------------------
Annual number of optometric visits required per person, by age
-----------------------------------------------------------------------
Age 60 and
Under 20 20-29 30-39 40-49 50-59 over
----------------------------------------------------------------------------------------------------------------
Number of visits........................ 0.11 0.20 0.24 0.35 0.41 0.48
----------------------------------------------------------------------------------------------------------------

For geographic areas where the age distribution of the population is
not known, it will be assumed that the percentage distribution, by age
groups, for the area is the same as the distribution for the county of
which it is a part.
(3) Determination of Estimated Supply of Optometric Visits.
The estimated supply of optometric services will be determined by
use of the following formula:

Optometric visits supplied = 3,000 x (number of optometrists under
65)
Optometric visits supplied + 2,000 x (number of optometrists 65 and
over)
Optometric visits supplied + 1,500 x (number of ophthamologists)

(4) Determination of Size of Shortage.
Size of shortage (in number of optometric visits) will be computed
as follows:
Optometric visit shortage = visits required - visits supplied
(5) Contiguous Area Considerations.
Vision care professional(s) in area contiguous to an area being
considered for designation will be considered execessively distant,
overutilized or inaccessible to the population of the area if one of the
following conditions prevails in each contiguous area:
(a) Vision care professional(s) in the contiguous area are more than
40 minutes travel time from the center of the area being considered for
designation (measured in accordance with paragraph B.1(b) of this part).
(b) The estimated requirement for vision care services in the
contiguous area exceeds the estimated supply of such services there,
based on the requirements and supply calculations previously described.
(c) Vision care professional(s) in the contiguous area are
inaccessible to the population of the area because of specified access
barriers (such as economic or cultural barriers).
C. Determination of Degree-of-Shortage.
Designated areas (and population groups) will be assigned to degree-
of-shortage groups, based on the ratio of optometric visits supplied to
optometric visits required for the area (or group), as follows:

Group 1--Areas (or groups) with no optometric visits being supplied
(i.e., with no optometrists or ophthalmologists).
Group 2--Areas (or groups) where the ratio of optometric visits
supplied to optometric visits required is less than 0.5.
Group 3--Areas (or groups) where the ratio of optometric visits
supplied to optometric visits required is between 0.5 and 1.0.

Part II--Population Groups

A. Criteria.
Population groups within particular geographic areas will be
designated if both the following criteria are met:
(1) Members of the population group do not have access to vision
care resources within the area (or in contiguous areas) because of non-
physical access barriers (such as economic or cultural barriers).
(2) The estimated number of optometric visits supplied to the
population group (as determined under paragraph B.3 of part I of this
Appendix) is less than the estimated number of visits required by that
group (as determined under paragraph B.2 of part I of this Appendix),
and the computed shortage is at least 1,500 optometric visits.
B. Determination of Degree of Shortage.
The degree of shortage of a given population group will be
determined in the same way as described for areas in paragraph C of part
I of this appendix.

Appendix E to Part 5--Criteria for Designation of Areas Having Shortages
of Podiatric Professional(s)

Part I--Geographic Areas

A. Criteria.
A geographic area will be designated as having a shortage of
podiatric professional(s) if the following three criteria are met:

[[Page 49]]

1. The area is a rational area for the delivery of podiatric
services.
2. The area's ratio of population to foot care practitioners is at
least 28,000:1, and the computed podiatrist shortage to meet this ratio
is at least 0.5.
3. Podiatric professional(s) in contiguous areas are overutilized,
excessively distant, or inaccessible to the population of the area under
consideration.
B. Methodology.
In determining whether an area meets the criteria established by
paragraph A of this Part, the following methodology will be used:
1. Rational Areas for the Delivery of Podiatric Services.
(a) The following areas will be considered rational areas for the
delivery of podiatric services:
(i) A county or a group of contiguous counties whose population
centers are within 40 minutes travel time of each other.
(ii) A portion of a county, or an area made up of portions of more
than one county, whose population, because of topography, market and/or
transportation patterns or other factors, has limited access to
contiguous area resources, as measured generally by a travel time of
greater than 40 minutes from its population center to these resources.
(b) The following distances will be used as guidelines in
determining distances corresponding to 40 minutes travel time:
(i) Under normal conditions with primary roads available: 25 miles.
(ii) In mountainous terrain or in areas with only secondary roads
available: 20 miles.
(iii) In flat terrain or in areas connected by interstate highways:
30 miles.
Within inner portions of metropolitan areas, information on the
public transportation system will be used to determine the area
corresponding to 40 minutes travel time.
2. Population Count.
The population count used will be the total permanent resident
civilian population of the area, excluding inmates of institutions,
adjusted by the following formula to take into account the differing
utilization rates of podiatric services by different age groups within
the population:

Adjusted population=total population x (1 + 2.2 x (percent of population
65 and over) - 0.44 x (percent of population under 17)).

3. Counting of Foot Care Practitioners.
(a) All podiatrists providing patient care will be counted. However,
in order to take into account productivity differences in podiatric
practices associated with the age of the podiatrists, the following
formula will be utilized:

Number of FTE podiatrists = 1.0 x (podiatrists under age 55)
+ .8 x (podiatrists age 55 and over)

(b) In order to take into account the fact that orthopedic surgeons
and general and family practitioners devote a percentage of their time
to foot care, the total available foot care practitioners will be
computed as follows:

Number of foot care practitioners = number of FTE podiatrists
+ .15 x (number of orthopedic surgeons)
+ .02 x (number of general and family practioners).

4. Determination of Size of Shortage.
Size of shortage (in number of FTE podiatrists) will be computed as
follows:

Podiatrist shortage = adjusted population/28,000 - number of FTE foot
care practitioners.

5. Contiguous Area Considerations.
Podiatric professional(s) in areas contiguous to an area being
considered for designation will be considered excessively distant,
overutilized or inaccessible to the population of the area under
consideration if one of the following conditions prevails in each
contiguous area:
(a) Podiatric professional(s) in the contiguous area are more than
40 minutes travel time from the center of the area being considered for
designation.
(b) The population-to-foot care practitioner ratio in the contiguous
areas is in excess of 20,000 : 1, indicating that contiguous area
podiatric professional(s) cannot be expected to help alleviate the
shortage situation in the area for which designation is requested.
(c) Podiatric professional(s) in the contiguous area are
inaccessible to the population of the area under consideration because
of specified access barriers (such as economic or cultural barriers).
C. Determination of Degree of Shortage.
Designated areas will be assigned to groups, based on the ratio (R)
of adjusted population to number of foot care practitioners, as follows:

Group 1 Areas with no foot care practitioners, and areas with R
50,000 and no podiatrists.
Group 2 Other areas with R 50,000.
Group 3 Areas with 50,000 R 28,000.

Appendix F to Part 5--Criteria for Designation of Areas Having Shortages
of Pharmacy Professional(s)

Part I--Geographic Areas

A. Criteria.

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A geographic area will be designated as having a shortage of
pharmacy professional(s) if the following three criteria are met:
1. The area is a rational area for the delivery of pharmacy
services.
2. The number of pharmacists serving the area is less than the
estimated requirement for pharmacists in the area, and the computed
pharmacist shortage is at least 0.5.
3. Pharmacists in contiguous areas are overutilized or excessively
distant from the population of the area under consideration.
B. Methodology.
In determining whether an area meets the criteria established by
paragraph A of this Part, the following methodology will be used:
1. Rational Areas for the Delivery of Pharmacy Services.
(a) The following areas will be considered rational areas for the
delivery of pharmacy services:
(i) A county, or a group of contiguous counties whose population
centers are within 30 minutes travel time of each other; and
(ii) A portion of a county, or an area made up of portions of more
than one county, whose population, because of topography, market or
transportation patterns or other factors, has limited access to
contiguous area resources, as measured generally by a travel time of
greater than 30 minutes to these resources.
(b) The following distances will be used as guidelines in
determining distances corresponding to 30 minutes travel time:
(i) Under normal conditions with primary roads available: 20 miles.
(ii) In mountainous terrain or in areas with only secondary roads
available: 15 miles.
(iii) In flat terrain or in areas connected by interstate highways:
25 miles.
Within inner portions of metropolitan areas, information on the
public transportation system will be used to determine the area
corresponding to 30 minutes travel time.
2. Counting of Pharmacists.
All active pharmacists within the area will be counted, except those
engaged in teaching, administration, or pharmaceutical research.
3. Determination of Estimated Requirement for Pharmacists.
(a) Basic estimate. The basic estimated requirement for pharmacists
will be calculated as follows:

Basic pharmacist requirement = .15 x (resident civilian population/
1,000) + .035 x (total number of physicians engaged in patient
care in the area).

(b) Adjusted estimate. For areas with less than 20,000 persons, the
following adjustment is made to the basic estimate to compensate for the
lower expected productivity of small practices.

Estimated pharmacist requirement = (2 - population/20,000) x basic
pharmacist requirement.

4. Size of Shortage Computation.
The size of the shortage will be computed as follows:

Pharmacist shortage = estimated pharmacist requirement - number of
pharmacists available.

5. Contiguous Area Considerations.
Pharmacists in areas contiguous to an area being considered for
designation will be considered excessively distant or overutilized if
either:
(a) Pharmacy professional(s) in contiguous areas are more than 30
minutes travel time from the center of the area under consideration, or
(b) The number of pharmacists in each contiguous area is less than
or equal to the estimated requirement for pharmacists for that
contiguous area (as computed above).
C. Determination of Degree-of-Shortage.
Designated areas will be assigned to degree-of-shortage groups,
based on the proportion of the estimated requirement for pharmacists
which is currently available in the area, as follows:

Group 1--Areas with no pharmacists.
Group 2--Areas where the ratio of available pharmacists to
pharmacists required is less than 0.5.
Group 3--Areas where the ratio of available pharmacists to
pharmacists required is between 0.5 and 1.0.

Appendix G to Part 5--Criteria for Designation of Areas Having Shortages
of Veterinary Professional(s)

Part I--Geographic Areas

A. Criteria for Food Animal Veterinary Shortage.
A geographic area will be designated as having a shortage of food
animal veterinary professional(s) if the following three criteria are
met:
1. The area is a rational area for the delivery of veterinary
services.
2. The ratio of veterinary livestock units to food animal
veterinarians in the area is at least 10,000 : 1, and the computed food
animal veterinarian shortage to meet this ratio is at least 0.5.
3. Food animal veterinarians in contiguous areas are overutilized or
excessively distant from the population of the area under consideration.
B. Criteria for Companion Animal Veterinary Shortage.

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A geographic area will be designated as having a shortage of
companion animal veterinary professional(s) if the following three
criteria are met:
1. The area is a rational area for the delivery of veterinary
services.
2. The ratio of resident civilian population to number of companion
animal veterinarians in the area is at least 30,000 : 1 and the computed
companion animal veterinary shortage to meet this ratio is at least 0.5.
3. Companion animal veterinarians in contiguous areas are
overutilized or excessively distant from the population of the area
under consideration.
C. Methodology.
In determining whether an area meets the criteria established by
paragraphs A and B of this part, the following methodology will be used:
1. Rational Areas for the Delivery of Veterinary Services.
(a) The following areas will be considered rational areas for the
delivery of veterinary services:
(i) A county, or a group of contiguous counties whose population
centers are within 40 minutes travel time of each other.
(ii) A portion of a county (or an area made up of portions of more
than one county) which, because of topography, market and/or
transportation patterns or other factors, has limited access to
contiguous area resources, as measured generally by a travel time of
greater than 40 minutes to these resources.
(b) The following distances will be used as guidelines in
determining distances corresponding to 40 minutes travel time:
(i) Under normal conditions with primary roads available: 25 miles.
(ii) In mountainous terrain or in areas with only secondary roads
available: 20 miles.
(iii) In flat terrain or in areas connected by interstate highways:
30 miles.
2. Determination of Number of Veterinary Livestock Units (VLU)
Requiring Care.
Since various types of food animals require varying amounts of
veterinary care, each type of animal has been assigned a weight
indicating the amount of veterinary care it requires relative to that
required by a milk cow. Those weights are used to compute the number of
``Veterinary Livestock Units'' (VLU) for which veterinary care is
required.
The VLU is computed as follows:

Veterinary Livestock Units (VLU)=(number of milk cows)
+.2x(number of other cattle and calves)
+.05x(number of hogs and pigs)
+.05x(number of sheep)
+.002x(number of poultry).

3. Counting of Food Animal Veterinarians.
The number of food animal veterinarians is determined by weighting
the number of veterinarians within each of several practice categories
according to the average fraction of practice time in that category
which is devoted to food animal veterinary care, as follows:

Number of Food Animal Veterinarians=(number of veterinarians in large
animal practice, exclusively)
+(number of veterinarians in bovine practice, exclusively)
+(number of veterinarians in poultry practice, exclusively)
+.75x(mixed practice veterinarians with greater than 50% of practice in
large animal care)
+.5x(mixed practice veterinarians with approximately 50% of practice in
large animal care)
+.25x(mixed practice veterinarians with less than 50% of practice in
large animal care).

4. Counting of Companion Animal Veterinarians (that is, those who
provide services for dogs, cats, horses, and any other animals
maintained as companions to the owner rather than as food animals).
The number of full-time equivalent companion animal veterinarians is
determined by weighting the number of veterinarians within each of
several practice categories by the average portion of their practice
which is devoted to companion animal care by the practitioners within
that category, as follows:

Number of Companion Animal Veterinarians=(number of veterinarians in
large animal practice, exclusively)
+(number of veterinarians in equine practice, exclusively)
+.75x(mixed practice veterinarians with greater than 50% of practice in
small animal care)
+.5x(mixed practice veterinarians with approximately 50% of practice in
small animal care)
+.25x(mixed practice veterinarians with less than 50% of practice in
small animal care).

5. Size of Shortage Computation.
The size of shortage will be computed as follows:
(a) Food animal veterinarian shortage=(VLU/10,000)-(number of food
animal veterinarians).
(b) Companion animal veterinarian shortage=(resident civilian pop./
30,000)-(number of companion animal veterinarians).
6. Contiguous Area Considerations.
Veterinary professional(s) in areas contiguous to an area being
considered for designation will be considered excessively distant from
the population of the area or overutilized if one of the following
conditions prevails in each contiguous area:

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(a) Veterinary professional(s) in the contiguous area are more than
60 minutes travel time from the center of the area being considered for
designation (measured in accordance with paragraph C.1.(b) of this
part).
(b) In the case of food animal veterinary professional(s), the VLU-
to-food animal veterinarian ratio in the contiguous area is in excess of
5,000 : 1.
(c) In the case of companion animal veterinary professional(s), the
population-to-companion animal veterinarian ratio in the contiguous area
is in excess of 15,000 : 1.
C. Determination of Degree-of-Shortage.
Designated areas will be assigned to degree-of-shortage groups as
follows:

Group 1--Areas with a food animal veterinarian shortage and no
veterinarians.
Group 2--Areas (not included above) with a food animal veterinarian
shortage and no food animal veterinarians.
Group 3--All other food animal veterinarian shortage areas.
Group 4--All companion animal shortage areas (not included above)
having no veterinarians.
Group 5--All other companion animal shortage areas.