HPSA Regulations - Attachment C

42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR Part 5

This content is from the eCFR and is authoritative but unofficial.

Title 42 - Public Health
Chapter I - Public Health Service, Department of Health and Human Services
Subchapter A - General Provisions
Part 5 Designation of Health Professional(s) Shortage Areas
§ 5.1 Purpose.
§ 5.2 Definitions.
§ 5.3 Procedures for designation of health professional(s) shortage areas.
§ 5.4 Notification and publication of designations and withdrawals.
Appendix A to Part 5
Criteria for Designation of Areas Having Shortages of Primary
Medical Care Professional(s)
Appendix B to Part 5
Criteria for Designation of Areas Having Shortages of Dental
Professional(s)
Appendix C to Part 5
Criteria for Designation of Areas Having Shortages of Mental
Health Professionals
Appendix D to Part 5
Criteria for Designation of Areas Having Shortages of Vision Care
Professional(s)
Appendix E to Part 5
Criteria for Designation of Areas Having Shortages of Podiatric
Professional(s)
Appendix F to Part 5
Criteria for Designation of Areas Having Shortages of Pharmacy
Professional(s)
Appendix G to Part 5
Criteria for Designation of Areas Having Shortages of Veterinary
Professional(s)

PART 5 - DESIGNATION OF HEALTH PROFESSIONAL(S) SHORTAGE
AREAS
Authority: Sec. 215 of the Public Health Service Act, 58 Stat. 690 (42 U.S.C. 216); sec. 332 of the Public Health
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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR 5.1

Service Act, 90 Stat. 2270-2272 (42 U.S.C. 254e).

Source: 45 FR 76000, Nov. 17, 1980, unless otherwise noted.

§ 5.1 Purpose.
These regulations establish criteria and procedures for the designation of geographic areas, population groups,
medical facilities, and other public facilities, in the States, as health professional(s) shortage areas.

§ 5.2 Definitions.
Act

means the Public Health Service Act, as amended.

Health professional(s) shortage area means any of the following which the Secretary determines has a shortage
of health professional(s):
(1) An urban or rural area (which need not conform to the geographic boundaries of a political
subdivision and which is a rational area for the delivery of health services);
(2) a population group; or
(3) a public or nonprofit private medical facility.
Health service area means a health service area whose boundaries have been designated by the Secretary,
under section 1511 of the Act, for purposes of health planning activities.
Health systems agency or HSA means the health systems agency designated, under section 1515 of the Act, to
carry out health planning activities for a specific health service area.
Medical facility means a facility for the delivery of health services and includes:
(1) A community health center, public health center, outpatient medical facility, or community mental
health center;
(2) a hospital, State mental hospital, facility for long-term care, or rehabilitation facility;
(3) a migrant health center or an Indian Health service facility;
(4) a facility for delivery of health services to inmates in a U.S. penal or correctional institution (under
section 323 of the Act) or a State correctional institution;
(5) a Public Health Service medical facility (used in connection with the delivery of health services under
section 320, 321, 322, 324, 325, or 326 of the Act); or
(6) any other Federal medical facility.
Metropolitan area means an area which has been designated by the Office of Management and Budget as a
standard metropolitan statistical area (SMSA). All other areas are “non-metropolitan areas.”
Poverty level means the povery level as defined by the Bureau of the Census, using the poverty index adopted by
a Federal Interagency Committee in 1969, and updated each year to reflect changes in the Consumer
Price Index.
Secretary means the Secretary of Health and Human Services and any other officer or employee of the
Department to whom the authority involved has been delegated.
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42 CFR 5.2 “State”

State includes, in addition to the several States, the District of Columbia, the Commonwealth of Puerto Rico, the
Northern Mariana Islands, the Virgin Islands, Guam, American Samoa, and the Trust Territory of the
Pacific Islands.
State health planning and development agency or SHPDA means a State health planning and development
agency designated under section 1521 of the Act.

§ 5.3 Procedures for designation of health professional(s) shortage areas.
(a) Using data available to the Department from national, State, and local sources and based upon the criteria
in the appendices to this part, the Department will annually prepare listings (by State and health service
area) of currently designated health professional(s) shortage areas and potentially designatable areas,
together with appropriate related data available to the Department. Relevant portions of this material will
then be forwarded to each health systems agency, State health planning and development agency, and
Governor, who will be asked to review the listings for their State, correct any errors of which they are
aware, and offer their recommendations, if any, within 90 days, as to which geographic areas, population
groups, and facilities in areas under their jurisdiction should be designated. An information copy of these
listings will also be made available, upon request, to interested parties for their use in providing
comments or recommendations to the Secretary and/or to the appropriate HSA, SHPDA, or Governor.
(b) In addition, any agency or individual may request the Secretary to designate (or withdraw the designation
of) a particular geographic area, population group, or facility as a health professional(s) shortage area.
Each request will be forwarded by the Secretary to the appropriate HSA, SHPDA, and Governor, who will be
asked to review it and offer their recommendations, if any, within 30 days. An information copy will also
be made available to other interested parties, upon request, for their use in providing comments or
recommendations to the Secretary and/or to the appropriate HSA, SHPDA, or Governor.
(c) In each case where the designation of a public facility (including a Federal medical facility) is under
consideration, the Secretary will give written notice of the proposed designation to the chief
administrative officer of the facility, who will be asked to review it and offer their recommendations, if any,
within 30 days.
(d) After review of the available information and consideration of the comments and recommendations
submitted, the Secretary will designate health professional(s) shortage areas and withdraw the
designation of any areas which have been determined no longer to have a shortage of health
professional(s).

§ 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 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

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(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. Criteria
A geographic area will be designated as having a shortage of primary medical care manpower if the
following three criteria are met:
1.

The area is a rational area for the delivery of primary medical care services.

2.

One of the following conditions prevails within the area:
(a) The area has population to full-time-equivalent primary care physician ratio of at least 3,500:1.
(b) The area has a population to full-time-equivalent primary care physician ratio of less than
3,500:1 but greater than 3,000:1 and has usually high needs for primary care services or
insufficient capacity of existing primary care providers.

3.
B.

Primary medical care manpower in contiguous areas are overutilized, excessively distant, or
inaccessible to the population of the area under consideration.

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.

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(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.
(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.

Sex

Age groups
Under 5

5-14

15-24

25-44

45-64

65 and 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 = 0.25 ×
(fraction of year tourists are present in area) × (average daily number of tourists during
portion of year that tourists are present).
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(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) × (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 fulltime-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 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.

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(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.

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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 indicated

D.

High needs indicated

Group 1

No physicians

No physicians; or R≥5,000

Group 2

R≥5,000

5,000>R≥4,000

Group 3

5,000>R≥4,000

4,000>R≥3,500

Group 4

4,000>R≥3,500

3,500>R≥3,000

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
(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.

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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 R>5,000.
Group 2 - 5,000>R≥4,000.
Group 3 - 4,000>R≥3,500.
Group 4 - 3,500>R≥3,000.
Population groups which have received “automatic” designation will be assigned to degree-ofshortage 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
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) × number of new inmates per year.

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(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) × (1 + ALOS/2) × number 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.

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 has reasonable access to primary care services provided at the facility.
Reasonable access will be assumed if the area within which the population

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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. Criteria
A geographic area will be designated as having a dental manpower shortage if the following three criteria
are met:
1.

The area is a rational area for the delivery of dental services.

2.

One of the following conditions prevails in the area:
(a) The area has a population to full-time-equivalent dentist ratio of less than 5,000:1 or

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(b) The area has a population to full-time-equivalent dentist ratio of less than 5,000:1 but greater
than 4,000:1 and has unusually high needs for dental services or insufficient capacity of
existing dental providers.
3.
B.

Dental manpower in contiguous areas are over utilized, excessively distant, or inaccessible to the
population of the area under consideration.

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.
(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) × (average daily number of migrants during portion of year that migrants are present).

3.

Counting of Dental Practitioners.

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(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 nondentist 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
Equivalency weights

1.2

55-59

60-64
0.9

65 +
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.

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR 5.4(d)

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).
(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:

42 CFR 5.4(d) (enhanced display)

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR 5.4(d)

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 capacity not indicated

D.

High needs or insufficient capacity indicated

Group 1 No dentists

No dentists or R≥8,000.

Group 2 R≥8,000

8,000>R≥6,000.

Group 3 8,000>R≥6,000

6,000>R≥5,000.

Group 4 6,000>R≥5,000

5,000>R≥4,000.

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.

2.

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.

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≥8,000.

42 CFR 5.4(d) (enhanced display)

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR 5.4(d)

Group 2 - 8,000>R≥6,000.
Group 3 - 6,000>R≥5,000.
Group 4 - 5,000>R≥4,000.
Population groups which have received “automatic” designation will be assigned to degree-ofshortage 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

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 × (1 + 2 × ALOS) × number 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.

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR 5.4(d)

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.

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.
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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

(i)

42 CFR Appendix-C-to-Part-5 A.

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;
3.
B.

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

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:

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

(i)

42 CFR Appendix-C-to-Part-5 B.1.(a)(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.

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR Appendix-C-to-Part-5 B.3.(b)(iii)

(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 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.
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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR Appendix-C-to-Part-5 B.3.(f)

(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 MedicareMedicaid 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.

42 CFR Appendix-C-to-Part-5 B.5.(c) (enhanced display)

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

C.

42 CFR Appendix-C-to-Part-5 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-mentalhealth-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”.

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
42 CFR Appendix-C-to-Part-5 D.(2) (enhanced display)

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

A.

42 CFR Appendix-C-to-Part-5 D.(2)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 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 1,000:1.
Here the number of internees is defined as follows:
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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

(i)

42 CFR Appendix-C-to-Part-5 A.1.(b)(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 psychiatric 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 the intake psychiatric
examinations are routinely performed upon entry, then Number 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 psychiatric
examinations are routinely performed upon entry, then Number of internees=average number of inmates+ 1⁄3×[1+(2×ALOS)]×number of new
inmates per year
where ALOS=average length-of-stay (in fraction of year) (The number of FTE psychiatrists
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 ration (R) of internees to FTE psychiatrists, as follows:
Group 1 - Institutions with 500 or more inmates and no psychiatrist.
Group 2 - Other institutions with no psychiatrists and institutions with R greater than (or equal to)
3,000:1.
Group 3 - Institutions with R greater than (or equal to) 2,000:1 but less than 3,000:1.
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 × (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.

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42 CFR Part 5 (up to date as of 2/15/2023)
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42 CFR Appendix-C-to-Part-5 C.

Group 4 - 600>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) 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 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.

42 CFR Appendix-C-to-Part-5 C.3. (enhanced display)

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR Appendix-C-to-Part-5 C.3.

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:

B.

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.

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.

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42 CFR Part 5 (up to date as of 2/15/2023)
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42 CFR Appendix-C-to-Part-5 C.3.

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.

Age
Number of visits

Annual number of optometric visits required per person, by age
Under 20
0.11

20-29
0.20

30-39
0.24

40-49

50-59

0.35

60 and over

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 × (number of optometrists under 65)
Optometric visits supplied + 2,000 × (number of optometrists 65 and over)
Optometric visits supplied + 1,500 × (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).

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42 CFR Part 5 (up to date as of 2/15/2023)
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42 CFR Appendix-E-to-Part-5 A.

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:

B.

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.

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:

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

(i)

42 CFR Appendix-E-to-Part-5 B.1.(a)(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 × (1 + 2.2 × (percent of population 65 and over) − 0.44 ×
(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 × (podiatrists 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 × (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 practitioners.

5.

Contiguous Area Considerations.

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR Appendix-E-to-Part-5 B.5.(a)

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

B.

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.

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:

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

(i)

42 CFR Appendix-F-to-Part-5 B.1.(a)(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 × (resident civilian population/1,000) + .035 × (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) × 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:

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42 CFR Part 5 (up to date as of 2/15/2023)
Designation of Health Professional(s) Shortage Areas

42 CFR Appendix-G-to-Part-5 A.

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:

B.

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.

Criteria for Companion Animal Veterinary Shortage.
A geographic area will be designated as having a shortage of companion animal veterinary
professional(s) if the following three criteria are met:

C.

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.

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.
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42 CFR Part 5 (up to date as of 2/15/2023)
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42 CFR Appendix-G-to-Part-5 C.1.(b)

(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)
+ .2 × (number of other cattle and calves)
+ .05 × (number of hogs and pigs)
+ .05 × (number of sheep)
+ .002 × (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)
+ .75 × (mixed practice veterinarians with greater than 50% of practice in large animal care)
+ .5 × (mixed practice veterinarians with approximately 50% of practice in large animal care)
+ .25 × (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).

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42 CFR Part 5 (up to date as of 2/15/2023)
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42 CFR Appendix-G-to-Part-5 C.5.

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)
+ .75 × (mixed practice veterinarians with greater than 50% of practice in small animal care)
+ .5 × (mixed practice veterinarians with approximately 50% of practice in small animal care)
+ .25 × (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:
(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.

42 CFR Appendix-G-to-Part-5 C. (enhanced display)

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42 CFR Part 5 (up to date as of 2/15/2023)
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42 CFR Appendix-G-to-Part-5 C.

Group 5 - All other companion animal shortage areas.

42 CFR Appendix-G-to-Part-5 C. (enhanced display)

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