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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:

(1) 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 11censes to practice, will be counted on a fulltime-equivalency basis up to a maximum of 0.5 FTE.

(8) 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-healthprofessional 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 profes

sionals in the contiguous areas overutilized and cannot be expected to alleviate the shortage situation in the a. for which designation is being considers data on core mental health professica other than psychiatrists are not avaistis" the contiguous area, a population--a chiatrist ratio there in excess of 20.000) D be used to demonstrate overutilizata os.)

(c) Mental health professionals in uous areas are inaccessible to the popaks of the requested area due to geographics tural, language or other barriers or becs of residency restrictions of programs & cilities providing such professionals.

c. Determination of degree of shortage Dignated areas will be assigned to deare: shortage groups according to the folios table, depending on the ratio (R) of po lation to number of FTE core-mental-beaservice providers (FTEC); the ratio (R: population to number of FTE psychiatrs. (FTEP); and the presence or absence of E needs:

High Needs Not Indicated Group 1-FTEC=0 and FTE=0 Group 2—Rcgte* 6,000:1 and FTEP=0 Group 3—Rc gte 6,000:1 and Rp gte 20.000 Group 4(a)-For psychiatrist placeresz

only: All other areas with FTEP=0 or Regist

30,000 Group 4(b)-For other mental health pract

tioner placements: All other areas with Be gte 9,000:1. *Note: "gte" means "greater than or equal to".

High Needs Indicated Group 1-FTEC=0 and FTEP=0 Group 2—Rcgte 4,500:1 and FTEP=0 Group 3Rc gte 4,500:1 and Rp gte 15.000 Group 4(a)For psychiatrist placements

only: All other areas with FTEP=O or Rp te

20,000 Group 4(b)-For other mental health practi

tioner placements: All other areas with Roc gte 6.000:1.

D. Determination of Size of Shortage. Size o! 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 shortagerarea 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 IIPopulation Groups A. Criteria. Population groups within particular rational mental health service areas

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be designated as having a mental health

essional shortage if the following cri12 a are met:

Access barriers prevent the population up from using those core mental health fessionals which are present in the area; 11

One of the following conditions prevails: ***) The ratio of the number of persons in Z population group to the number of FTE

e mental health professionals serving the pulation group is greater than or equal to *1200:1 and the ratio of the number of persons

the population group to the number of E psychiatrists serving the population up is greater than or equal to 15,000:1; or, b) The ratio of the number of persons in

e population group to the number of FTE mire mental health professionals serving the the Epulation group is greater than or equal to 2000:1; or, X2(C) The ratio of the number of persons in De population group to the number of FTE Tisychiatrists serving the population group is

reater than or equal to 20,000:1.

B. Determination of degree of shortage. Dessegnated population groups will be assigned to

he same degree-of-shortage groups defined en part I.C of this appendix for areas with unbisually high needs for mental health servu.ces, using the computed ratio (Rc) of the te gaumber of persons in the population group to

che number of FTE core mental health serva vice providers (FTEC) serving the population the group, and the ration (Rp) of the number of persons in the population group to the num

ber of FTE psychiatrists (FTEP) serving the al population group.

C. Determination of size of shortage. Size of shortage will be computed as follows: 4 Core professional shortage=number of per

sons 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 psy

chiatric 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 2Other 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 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 ~ (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 on the ratio (R) of workload units to number of FTE psychiatrists, as follows:

Group 1—No psychiatrists, or R>1,800.
Group 2-1,800>R>1,200.
Group 3—1,200>R>600.
Group 4600>R>300.

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 est

graph C.1 of this Part, th

will be used.

(a) Provis of Populatio

2

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The facility will be considered to be providing services to a designated area or population group if either:

(1) 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:

(1) There are more than 1.000 patient visits per year per FTE core mental health professional on staff of the facility, or

(11) 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)

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

1. The area is a rational area for the delis. ery of vision care services.

2. The estimated number of optometric vis its supplied by vision care professional(s) : the area is less than the estimated requirt ments of the area's population for these vis its, and the computed shortage is at leas 1,500 optometric visits.

3. Vision care professional(s) in contigoon areas are excessively distant, overu tilized, at inaccessible to the population of the ares 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:

(1) 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:

(1) Under normal conditions with primary roads available: 25 miles.

(11) In mountainous terrain or in areas with only secondary roads available: 20 miles.

(111) 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 par. ticular age group and then adding the figures obtained together.

APPENDIX D TO PART 5 CRITERIA FOR DESIGNATION

OF

AREAS HAVING SHORTAGES OF VISION CARE PROFESSIONAL(S)

Part 1Geographic Areas A. Criteria.

Age

Annual number of optometric visits required per person, by age Under 20

60 and 20-29 30-39 40-49

50-59

over

Number of visits

0.11

0.20

0.24

0.35

0.41

0.48

(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.

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For geographic areas where the age disibution of the population is not known, it 11 be assumed that the percentage distribuon, by age groups, for the area is the same

the distribution for the county of which it a part. (3) Determination of Estimated Supply of Opmetric Visits. The estimated supply of optometric serves will be determined by use of the followig formula: Optometric visits supplied = 3,000 (num

ber of optometrists under 65) Optometric visits supplied + 2,000 (num

ber of optometrists 65 and over) Optometric visits supplied + 1,500 x (num

ber 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 11Population Groups
A. Criteria.

Population groups within particular geographic areas will be designated if both the following criteria are met:

APPENDIX E TO PART 5-CRITERIA FOR

DESIGNATION OF AREAS HAVING
SHORTAGES OF PODIATRIC
PROFESSIONAL(S)

Part 1Geographic Areas
A. Criteria.

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

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:

(1) 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 limit 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:

(1) Under normal conditions with primary roads available: 25 miles.

area podiatric professional(s) cannot be pected to help alleviate the shortege 5 tion in the area for which designation 2 quested.

(c) Podiatric professional(s) in the car uous area are inaccessible to the popus. of the area under consideration becast specified access barriers (such as ecor or cultural barriers).

C. Determination of Degree of Shortage.

Designated areas will be assigned groups, based on the ratio (R) of ac population to number of foot care practii ers, as follows: Group 1 Areas with no foot care practic:

ers, and areas with R > 50,000 and do

diatrists. Group 2 Other areas with R > 50,000. Group 3 Areas with 50,000 > R > 28,000.

>

(ii) In mountainous terrain or in areas with only secondary roads available: 20 miles.

(111) 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 (podia

trists under age 55) +.8 (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 * (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 practi

tioners. 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

APPENDIX F TO PART 5-CRITERIA PE

DESIGNATION OF AREAS HA
SHORTAGES OF

PHARMAC
PROFESSIONAL(S)

Part I-Geographic Areas A. Criteria.

A geographic area will be designated i having а shortage of pharma. professional(s) if the following three crite are met:

1. The area is a rational area for the des ery of pharmacy services.

2. The number of pharmacists serving area is less than the estimated requiremes for pharmacists in the area, and the cor puted pharmacist shortage is at least 0.5.

3. Pharmacists in contiguous areas and 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 Phar. macy Services.

(a) The following areas will be considered rational areas for the delivery of pharmacy services:

(1) 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.

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