An area's existing dental care providers I 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). (c) A substantial proportion (% or more) of the area's dentists do not accept new patients. 6. Contiguous Area Considerations. Dental manpower 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 contig uous area: (a) Dental manpower 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 manpower 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 manpower, 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 fulltime-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: 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 manpower 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>8,000. 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. Part III-Facilities A. Federal and State Correctional Institutions. 1. Criteria. Medium to maximum security Federal and State correctional institutions and youth de tention facilities will be designated as having a shortage of dental manpower 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 > 3,000. Group 3-Institutions R>1,500. with 3,000 > 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 manpower 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 manpower 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 manpower shortage areas or to population groups designated as having a shortage of dental manpower; 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 nonphysical 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. APPENDIX C-CRITERIA FOR DESIGNATION OF AREAS HAVING SHORTAGES OF PSYCHIATRIC MANPOWER Part I-Geographic Areas A. Criteria. A geographic area will be designated as having a shortage of psychiatric manpower if the following three criteria are met: 1. The area is a rational area for the delivery of psychiatric services. 2. One of the following conditions prevails within the area: (a) The area has a population to full-timeequivalent psychiatrist ratio of at least 30,000:1; or (b) The area has a population to full-timeequivalent psychiatrist ratio of less than 30,000:1 but greater than 20,000:1 and has unusually high needs for psychiatric services. 3. Psychiatric manpower 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 Psychiatric Services. (a) The following areas will be considered rational areas for the delivery of psychiatric 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 psychiatric 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 Psychiatrists. (a) All non-Federal psychiatrists providing patient care (direct or other, including consultation and supervision) in ambulatory or other short-term care settings to residents of the area more than one-half day per week will be counted. Those psychiatrists 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) psychiatrists: (i) Psychiatric residents will be counted as 0.5 FTE psychiatrists. (ii) Graduates of foreign medical schools who are not citizens or lawful permanent residents of the United States will be excluded from psychiatrist 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 psychiatrists. (b) Psychiatrists who are semi-retired, who operate a reduced practice due to infirmity or other limiting conditions, or who provide patient care to the population of an 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 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 psychiatrist providing patient care 40 or more hours a week will be counted as 1.0 FTE. For cases where data are available only for hours providing care in office settings, equivalencies will be provided in guidelines. (c) In some cases, psychiatrists located within an area may not be accessible to the general population of the area under consideration. Allowances for psychiatrists working in restricted facilities will be made on a case-by-case basis. Examples of restricted practices include staff positions in correctional institutions, youth detention facilities, residential treatment centers for emotionally disturbed or mentally retarded children, and inpatient units of State or county mental hospitals. (d) In cases where there are mental health facilities or institutions providing both inpatient and outpatient services, those psychiatrists assigned to outpatient or other shortterm care units will be counted. If the psychiatric staff is not specifically allocated to one service or the other, the number of psychiatrists in short-term care will be estimated on the basis of the relative workload in each type of setting. (e) Psychiatrists who are suspended for a period of eighteen months or more under provisions of the Medicare-Medicaid AntiFraud and Abuse Act will not be counted. 4. Determination of Unusually High Need for Psychiatric Services. An area will be considered to have unusually high needs for psychiatric services if two or more of the following criteria are met: (a) 20 percent of the population (or of all households) have incomes below the poverty level, or the area has been designated as a poverty area in accordance with section 242 of the Community Mental Health Centers Act. (b) A young dependency ratio (ratio of children under 18 to population 18-64) in excess of 60 percent. (c) An aged dependency ratio (ratio of persons aged 65 and over to population 18-64) in excess of 25 percent. (d) A high prevalence of alcoholism in the population, as indicated by a value of 0.211 for the catchment area's index of relative alcoholism prevalence (as developed by the National Institute of Alcohol Abuse and Alcoholism for the purposes of allocating funds over 42 U.S.C. 4571). 5. Contiguous Area Considerations. Psychiatric manpower in areas contiguous to an area being considered for designation will be considered excessively distant, overu tilized or inaccessible to the population of the area under consideration if one of the following conditions prevails in each contiguous area: (a) Psychiatrists 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 psychiatrist ratios are in excess of 20,000:1, indicating that psychiatrists in contiguous areas cannot be expected to help alleviate the shortage situation in the area for which designation is being considered. (c) Psychiatric manpower in contiguous areas are inaccessible to the population of the requested area because of geographic, cultural, language or other barriers or because of residency restrictions of programs or facilities providing such manpower. 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 FTE psychiatrists and the presence or absence of unusually high needs for psychiatric services, according to the following table: Part II-Population Groups Population groups within particular catchment areas will be designated as having a psychiatric manpower shortage if the following conditions prevail: (a) Access barriers prevent the population group from using those psychiatric manpower which are present in the area, and (b) The ratio of the number of persons in the population group to the number of FTE psychiatrists serving the population group, and practicing within 40 minutes travel time of the center of the area where the population group resides, is at least 30,000: 1 (20,000:1 where unusally high needs for psychiatric services are indicated). B. Determination of Degree of Shortage. Designated population groups will be assigned to degree-of-shortage groups as in Section C of Part I of this Appendix, based on the ratio of the group's population to the number of psychiatrists serving it, together with the presence or absence of unusually high needs for psychiatric services among the population group. 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 manpower 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-ofshortage 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 R>3,000. 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 manpower 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: 1. Criteria. A community mental health center (CMHC), authorized by Pub. L. 94-63, or other public or nonprofit private facility providing psychiatric services to an area or population group, may be designated as having a shortage of psychiatric manpower if the facility is providing (or is responsible for providing) psychiatric services to an area or population group designated as having a psychiatric manpower shortage, 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 psychiatric services are being provided to residents of designated psychiatric manpower shortage areas or to population groups designated as having a shortage of psychiatric manpower; or (ii) The population within a designated psychiatric shortage area or population group has reasonable access to psychiatric 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 psychiatric services for the area or population group, consistent with applicable State plans. (c) Insufficient Capacity to Meet Psychiatric Needs. A facility will be considered to have insufficient capacity to meet the psychiatric needs of the area or population it serves if: (i) There are more than 3,000 patient visits per year per FTE psychiatrist on the staff are under care at the facility, or (ii) No psychiatrists are on the staff and this facility is the only facility providing (or responsible for providing) 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. APPENDIX D-CRITERIA FOR DESIGNATION OF AREAS HAVING SHORTAGES OF VISION CARE MANPOWER Part I-Geographic Areas A. Criteria. A geographic area will be designated as having a shortage of vision care manpower 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 manpower 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 manpower 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. (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 |