These guidelines are for use in applying the established
Criteria for Designation of Medically Underserved
Areas (MUAs) and Populations (MUPs), based on the
Index of Medical Underservice (IMU), published in
the Federal Register on October 15, 1976, and
in submitting requests for exceptional MUP designations
based on the provisions of Public Law 99-280, enacted
in 1986.
The three methods for designation of MUAs or MUPs
are as follows:
I. MUA Designation
This involves application of the Index of Medical
Underservice (IMU) to data on a service area to obtain
a score for the area. The IMU scale is from 0 to 100,
where 0 represents completely underserved and 100
represents best served or least underserved. Under
the established criteria, each service area found
to have an IMU of 62.0 or less qualifies for designation
as an MUA.
The IMU involves four variables - ratio of primary
medical care physicians per 1,000 population, infant
mortality rate, percentage of the population with
incomes below the poverty level, and percentage of
the population age 65 or over. The value of each of
these variables for the service area is converted
to a weighted value, according to established criteria.
The four values are summed to obtain the area's IMU
score.
The MUA designation process therefore requires the
following information:
(1) Definition of the service area being requested
for designation. These may be defined in terms of:
(a) a whole county (in non-metropolitan
areas);
(b) groups of contiguous counties, minor civil
divisions (MCDs), or census county divisions (CCDs)
in non-metropolitan areas, with population centers
within 30 minutes travel time of each other;
(c) in metropolitan areas, a group of census tracts
(C.T.s) which represent a neighborhood due to homogeneous
socioeconomic and demographic characteristics.
In addition, for non-single-county service areas,
the rationale for the selection of a particular service
area definition, in terms of market patterns or composition
of population, should be presented. Designation requests
should also include a map showing the boundaries of
the service area involved and the location of resources
within this area.
(2) The latest available data on:
(a) the resident civilian, non-institutional
population of the service area (aggregated from
individual county, MCD/CCD or C.T. population data)
(b) the percent of the service area's population
with incomes below the poverty level
(c) the percent of the service area's population
age 65 and over
(d) the infant mortality rate (IMR) for the service
area, or for the county or subcounty area which
includes it. The latest five-year average should
be used to ensure statistical significance. Subcounty
IMRs should be used only if they involve at least
4000 births over a five-year period. (If the service
area includes portions of two or more counties,
and only county-level infant mortality data is available,
the different county rates should be weighted according
to the fraction of the service area's population
residing in each.)
(e) the current number of full-time-equivalent
(FTE) primary care physicians providing patient
care in the service area, and their locations of
practice. Patient care includes seeing patients
in the office, on hospital rounds and in other settings,
and activities such as laboratory tests and X-rays
and consulting with other physicians. To develop
a comprehensive list of primary care physicians
in an area, an applicant should check State and
local physician licensure lists, State and local
medical society directories, local hospital admitting
physician listings, Medicaid and Medicare provider
lists, and the local yellow pages.
(3) The computed ratio of FTE primary care physicians
per thousand population for the service area (from
items 2a and 2e above).
(4) The IMU for the service area is then computed
from the above data using the attached conversion
Tables V1-V4, which translate the values of each of
the four indicators (2b, 2c, 2d, and 3) into a score.
The IMU is the sum of the four scores. (Tables V1-V4
are reprinted from earlier Federal Register publications.)
II. MUP Designation,
using IMU
This involves application of the Index of Medical
Underservice (IMU) to data on an underserved population
group within an area of residence to obtain a score
for the population group. Population groups requested
for MUP designation should be those with economic
barriers (low-income or Medicaid-eligible populations),
or cultural and/or linguistic access barriers to primary
medical care services.
This MUP process involves assembling the same data
elements and carrying out the same computational steps
as stated for MUAs in section I above. The population
is now the population of the requested group within
the area rather than the total resident civilian population
of the area. The number of FTE primary care physicians
would include only those serving the requested population
group. Again, the sample survey on page 8 may be used
as a guide for this data collection. The ratio
of the FTE primary care physicians serving the
population group per 1,000 persons in the group is
used in determining weighted value V4. The weighted
value for poverty (V1) is to be based on the percent
of population with incomes at or below 100 percent
of the poverty level in the area of residence for
the population group. The weighted values for percent
of population age 65 and over (V2) and the infant
mortality rate (V3) would be those for the requested
segment of the population in the area of residence,
if available and statistically significant; otherwise,
these variables for the total resident civilian population
in the area should be used. If the total of weighted
values V1 - V4 is 62.0 or less, the population group
qualifies for designation as an IMU-based MUP.
Tables V1 - V4 for Determining Weighted Values
TABLE V1
PERCENTAGE OF POPULATION BELOW POVERTY LEVEL
In the left column find the range which includes
the percentage of population below the poverty level
for the area being examined. The corresponding weighted
value found opposite in the right column, should be
used in the formula for determining the IMU.
Percent
Below Poverty |
Weighted
Value V1 |
TABLE V2
PERCENTAGE OF POPULATION AGE 65 AND OVER
In the left column find the range which includes
the percentage of population age 65 and over for the
area being examined. The corresponding weighted value,
found opposite in the right column, should be used
in the formula for determining the IMU.
Percent
Age 65 and Over |
Weighted
Value V2 |
20.2 |
20.1 |
19.9 |
19.8 |
19.6 |
19.4 |
19.1 |
18.9 |
18.7 |
17.8 |
16.1 |
14.4 |
12.8 |
11.1 |
9.8 |
8.9 |
8.0 |
7.0 |
6.1 |
5.1 |
4.0 |
2.8 |
1.7 |
0.6 |
0 |
TABLE V3
INFANT MORTALITY RATE
In the left column find the range which includes
the infant mortality rate for the area being examined
or the area in which it lies. The corresponding weighted
value, found opposite in the right.
TABLE V4
RATIO OF PRIMARY CARE PHYSICIANS PER 1,000
POPULATION
In the left column find the range which includes
the ratio of primary care physicians per 1,000 population
for the area being examined. The corresponding weighted
value found opposite in the right column, should be
used in the formula for determining the IMU.
III. Exceptional MUP designations
Under the provisions of Public law 99-280, enacted
in 1986, a population group which does not meet the
established criteria of an IMU less than 62.0 can
nevertheless be considered for designation if "unusual
local conditions which are a barrier to access to
or the availability of personal health services"
exist and are documented, and if such a designation
is recommended by the chief executive officer and
local officials of the State where the requested population
resides.
Requests for designation under these exceptional
procedures should describe in detail the unusual local
conditions/access barriers/availability indicators
which led to the recommendation for exceptional designation
and include any supporting data.
Such requests must also include a written recommendation
for designation from the Governor or other chief executive
officer of the State (or State-equivalent) and local
health official.
Federal Programs Using MUA/MUP Designations Include:
Recipients of Community Health Center (CHC) grant
funds are legislatively required to serve areas or
populations designated by the Secretary of Health
and Human Services as medically underserved. Grants
for the planning, development, or operation of community
health centers under section 330 of the Public Health
Service Act are available only to centers which serve
designated MUAs or MUPs.
Systems of care which meet the definition of a community
health center contained in Section 330 of the Public
Health Service Act, but are not funded under that
section, and are serving a designated MUA or MUP,
are eligible for certification as a Federally Qualified
Health Center (FQHC) and thus for cost-based reimbursement
of services to Medicaid-eligibles.
Clinics serving rural areas designated as MUAs are
eligible for certification as Rural Health Clinics
by the Centers for Medicare and Medicaid Services
under the authority of the Rural Health Clinics Services
Act (Public Law 95-210, as amended).
PHS Grant Programs administered by HRSA's Bureau
of Health Professions - gives funding preference to
Title VII and VIII training programs in MUA/Ps.
Revised June, 1995
BPHC/Division of Shortage Designation
Sample Survey for Determining Primary
Medical Care FTE
The following may be used as a guide for
MUA and MUP requests. This information should
be collected for each primary care physician
at a practice location. Not all questions
may apply to a specific designation request.
Physician's name:
Specialty:
Percent of
Practice:
Sub-specialty:
Percent
of Practice:
Location of Practice - City:
Zip
How many
hours a week is the physician engaged in
patient care activities at this location?
Additional Office Location - City:
Zip
How many
hours a week is the physician engaged in
patient care activities at this location?
Does the physician have hospital admitting
privileges, and if so, does the physician
follow up with admitted patients
at the hospital?
Yes
No
If a physician works less than a total
of 40 hours a week in patient care, please
provide a brief explanation, i.e. semi-retired,
administration, teaching, other
Does the physician serve Medicaid patients?
Yes
No
If yes, what
percent of his/her practice?
Does the physician offer a sliding fee
scale based on income or ability to pay?
Yes
No
If yes,
what percent of his/her practice?
Does the physician or others on staff offer
language interpretation?
Yes
No
If yes, what languages?
Does the physician see migrant farmworkers
as patients? Yes
No
If yes,
what percent of his/her practice?
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