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:
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.)
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
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
State Primary Care Offices for designation application help and State shortage information
Exchange Visitor Program for physicians with J-1 visas working in HPSAs
National Health Service Corps scholarships & loan repayment in return for service at NHSC-approved sites in greatest-need HPSAs