[Federal Register Volume 75, Number 101 (Wednesday, May 26, 2010)]
[Rules and Regulations]
[Pages 29447-29451]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-12557]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

42 CFR Part 5a

RIN 0906-AA86


Public Health Service Act, Rural Physician Training Grant 
Program, Definition of ``Underserved Rural Community''

AGENCY: Health Resources and Services Administration (HRSA), Department 
of Health and Human Services (HHS).

ACTION: Interim final rule with request for comment.

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SUMMARY: This interim final rule (IFR) with request for comment is 
meant to comply with the statutory directive to issue a regulation 
defining ``underserved rural community'' for purposes of the Rural 
Physician Training Grant Program in section 749B of the Public Health 
Service Act, as amended by the Patient Protection and Affordable Care 
Act of 2010. This IFR is technical in nature. It will not change grant 
or funding eligibility for any other grant program currently available 
through the Office of Rural Health Policy (ORHP) or HRSA. For purposes 
of the Rural Physician Training Grant Program only, HRSA has combined 
existing definitions of ``underserved'' and ``rural'' by using the 
definition of rural utilized by the ORHP Rural Health Grant programs 
and the definition of ``underserved'' established by HRSA's Office of 
Shortage Designation (OSD) in the Bureau of Health Professions (BHPr).

DATES: Effective Date: This interim final rule is effective 30 days 
after May 26, 2010.
    Comment Date: To be assured consideration, written or electronic 
comments must be received at one of the addresses provided below, no 
later than 5 p.m. on July 26, 2010.

ADDRESSES: You may submit comments, identified by the Regulatory 
Information Number (RIN), by any of the following methods:
     Federal eRulemaking Portal: http://www.regulations.gov. 
Follow the instructions for submitting comments.
     E-mail: [email protected]. Include RIN 0906-AA86 in the 
subject line of the message.
     Mail: Michelle Goodman, MAA, Office of Rural Health 
Policy, Health Resources and Services Administration, 5600 Fishers 
Lane, Parklawn Building, 10B-45, Rockville, MD 20857.
    Instructions: All submissions received must include the agency name 
and RIN for this rulemaking. All comments received will be available 
for public inspection and copying, including any personal information 
provided, at Parklawn Building, 5600 Fishers Lane, Room 10B-45, 
Rockville, Maryland 20857, weekdays (Federal holidays excepted) between 
the hours of 8:30 a.m. and 5 p.m.

FOR FURTHER INFORMATION CONTACT: Michelle Goodman, MAA, at the mail or 
e-mail address above or by telephone at 301-443-0835.

SUPPLEMENTARY INFORMATION: 

Table of Contents

I. Background
II. Waiver of Proposed Rulemaking and Comment
III. Definition of ``Underserved Rural Community''
    A. Definition of Rural
    B. Definition of Underserved
IV. Collection of Information Requirements
V. Regulatory Impact Analysis
    A. Introduction
    B. Why Is This Rule Needed?
    C. Costs and Benefits
    D. Regulatory Flexibility Act Analysis
    E. Executive Order 13132--Federalism
    F. Unfunded Mandates Reform Act of 1995
     Regulation Text

I. Background

    The ORHP was authorized in December 1987 through Public Law 100-203 
and is located in the HRSA. Congress charged ORHP with informing and 
advising HHS on matters affecting rural hospitals and health care and

[[Page 29448]]

coordinating activities within HHS that relate to rural health care.
    Section 10501(l) of Public Law 111-148 adds Section 749B to the 
Public Health Service Act (42 U.S.C. 293k et seq.) by authorizing the 
Rural Physician Training Grant Program. HRSA is authorized to establish 
this new grant program for the purposes of assisting eligible entities 
in recruiting students most likely to practice medicine in underserved 
rural communities; providing rural-focused training and experience; and 
increasing the number of recent allopathic and osteopathic medical 
school graduates who practice in underserved rural communities. As 
required by section 749B(f), not later than 60 days after the date of 
enactment of Public Law 111-148, the Secretary shall, by regulation, 
define ``underserved rural community'' for purposes of this section. 
HRSA must create an operational definition of ``underserved rural 
community'' to help in determining how to allocate funding for the 
approved activities in the grant.

II. Waiver of Proposed Rulemaking and Comment

    We note that ordinarily we publish a notice of proposed rulemaking 
in the Federal Register and invite public comment on the proposed rule. 
However, for the reasons that follow, the agency has determined to 
proceed directly with this IFR with request for comment pursuant to 5 
U.S.C. 553(b)(3)(B) because it has determined that good cause exists 
which makes the usual notice and comment procedure impractical, 
unnecessary, and contrary to the public interest. Nevertheless, we are 
providing the public with a 60-day period following publication of this 
document to submit comments on the IFR, and appropriate comments 
received will be used to determine whether to amend this rule and/or 
will be used to inform the development of the program guidance which 
will delineate the structure and requirements for the grant program 
(upon appropriation of funds to implement the grant).
    As mentioned above, section 749B(f) requires the Secretary to 
publish this regulation 60 days after the date of enactment of Public 
Law 111-148. We have determined that the usual notice and comment 
procedure would be impractical in this case because those procedures 
take significantly longer than 60 days.
    We also believe it is unnecessary to undertake rulemaking involving 
prior notice and comment because this IFR will have limited impact, as 
it defines ``underserved rural communities'' only for purposes of the 
Rural Physician Training Grant Program and will not change grant or 
funding eligibility for any other grant program currently available 
through ORHP or HRSA.
    Additionally, we believe it is unnecessary to undertake prior 
notice and comment rulemaking because, while funds for this program 
have not yet been appropriated, such funds might become available with 
little notice and awarding the funds quickly would serve an important 
public interest because of the necessity of assisting underserved rural 
communities to attract and retain needed allopathic and osteopathic 
medical school graduates to serve in their communities.

III. Definition of ``Underserved Rural Community''

    HRSA proposes to combine two existing definitions for 
``underserved'' and ``rural'' by using the rural definition utilized by 
the ORHP Rural Health Grant Programs and the geographic based Health 
Professions Shortage Area (HPSA) and Medically Underserved Area (MUA) 
definitions as established by HRSA's OSD in the BHPr.

A. Definition of Rural

    For the purposes of the Rural Physician Training Grant Program 
outlined in section 749B of the Public Health Services Act, HRSA must 
define ``underserved rural communities.'' In order to maintain 
consistency through the various Rural Health Grant Programs, we propose 
to use the definition for ``rural'' that is used for the ORHP Rural 
Health Grant Programs. ORHP uses a two-tiered method to determine 
geographic eligibility for its grant programs. All counties that are 
not designated as part of a Metropolitan Statistical Area (MSAs) by the 
Office of Management and Budget (OMB) are considered rural. This means 
that counties classified as part of a Micropolitan area are also 
considered rural. Metropolitan and Micropolitan statistical areas 
(metro and micro areas) are geographic entities defined by the OMB for 
use by Federal statistical agencies in collecting, tabulating, and 
publishing Federal statistics. A metro area contains a core urban area 
of 50,000 or more population, and a micro area contains an urban core 
of at least 10,000 (but less than 50,000) population. Each metro or 
micro area consists of one or more counties and includes the counties 
containing the core urban area, as well as any adjacent counties that 
have a high degree of social and economic integration (as measured by 
commuting to work) with the urban core. The current list of MSAs and 
updates are available on the Internet at http://www.census.gov/population/www/metroareas/metrodef.html.
    Due to the fact that entire counties are designated as Metropolitan 
when, in fact, large parts of many of these counties may be rural in 
nature, ORHP has sought a method of identifying sub-county sections of 
these Metropolitan counties that should also be considered/designated 
as rural. Rather than exclude large numbers of arguably rural citizens 
from eligibility for the Rural Health Grant Programs, ORHP sought a 
rational, data-driven method to identify/designate rural areas inside 
of Metropolitan counties. ORHP funded the development of ``Rural/Urban 
Commuting Area Codes'' (RUCAs), by the WWAMI Rural Research Center at 
the University of Washington in cooperation with the Department of 
Agriculture's Economic Research Service, to categorize various levels 
of rurality and make possible designation of ``rural'' areas within 
MSAs. Using commuting data from the Census Bureau, every census tract 
in the United States is assigned a RUCA code. Currently, there are ten 
primary RUCA codes with 30 secondary codes based on 2000 Census data 
and 2004 ZIP Code areas (see Table 1).

           Table 1--Rural-Urban Commuting Areas (RUCAs), 2000
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                --                                   --
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1.................................  Metropolitan area core: Primary flow
                                     within an urbanized area (UA)
                                    1.0 No additional code.
                                    1.1 Secondary flow 30% to 50% to a
                                     larger UA.
2.................................  Metropolitan area high commuting:
                                     Primary flow 30% or more to a UA.
                                    2.0 No additional code.
                                    2.1 Secondary flow 30% to 50% to a
                                     larger UA.
3.................................  Metropolitan area low commuting:
                                     Primary flow 5% to 30% to a UA.
                                    3.0 No additional code.

[[Page 29449]]

 
4.................................  Micropolitan area core: Primary flow
                                     within an Urban Cluster (UC) of
                                     10,000 to 49,999 (large UC).
                                    4.0 No additional code.
                                    4.1 Secondary flow 30% to 50% to a
                                     UA.
                                    4.2 Secondary flow 10% to 30% to a
                                     UA.
5.................................  Micropolitan high commuting: Primary
                                     flow 30% or more to a large UC.
                                    5.0 No additional code.
                                    5.1 Secondary flow 30% to 50% to a
                                     UA.
                                    5.2 Secondary flow 10% to 30% to a
                                     UA.
6.................................  Micropolitan low commuting: Primary
                                     flow 10% to 30% to a large UC.
                                    6.0 No additional code.
                                    6.1 Secondary flow 10% to 30% to a
                                     UA.
7.................................  Small town core: Primary flow within
                                     an Urban Cluster of 2,500 to 9,999
                                     (small UC).
                                    7.0 No additional code.
                                    7.1 Secondary flow 30% to 50% to a
                                     UA.
                                    7.2 Secondary flow 30% to 50% to a
                                     large UC.
                                    7.3 Secondary flow 10% to 30% to a
                                     UA.
                                    7.4 Secondary flow 10% to 30% to a
                                     large UC.
8.................................  Small town high commuting: Primary
                                     flow 30% or more to a small UC.
                                    8.0 No additional code.
                                    8.1 Secondary flow 30% to 50% to a
                                     UA.
                                    8.2 Secondary flow 30% to 50% to a
                                     large UC.
                                    8.3 Secondary flow 10% to 30% to a
                                     UA.
                                    8.4 Secondary flow 10% to 30% to a
                                     large UC.
9.................................  Small town low commuting: Primary
                                     flow 10% to 30% to a small UC.
                                    9.0 No additional code.
                                    9.1 Secondary flow 10% to 30% to a
                                     UA.
                                    9.2 Secondary flow 10% to 30% to a
                                     large UC.
10................................  Rural areas: Primary flow to a tract
                                     outside a UA or UC.
                                    10.0 No additional code.
                                    10.1 Secondary flow 30% to 50% to a
                                     UA.
                                    10.2 Secondary flow 30% to 50% to a
                                     large UC.
                                    10.3 Secondary flow 30% to 50% to a
                                     small UC.
                                    10.4 Secondary flow 10% to 30% to a
                                     UA.
                                    10.5 Secondary flow 10% to 30% to a
                                     large UC.
                                    10.6 Secondary flow 10% to 30% to a
                                     small UC.
------------------------------------------------------------------------

    Those Census tracts within MSAs that have RUCA codes 4 through 10 
are considered rural for the purposes of ORHP Rural Health Grant 
Programs. In addition, those Census Tracts within MSAs that have RUCA 
codes 2 or 3, are individually larger than 400 square miles in area, 
and have a population density of less than 30 people per square mile, 
also are considered rural. (More information on RUCAs is available at 
http://www.ers.usda.gov/briefing/Rurality/RuralUrbanCommutingAreas/ or 
at http://depts.washington.edu/uwruca/.) ORHP has previously used this 
definition of rural for Rural Health Grant Programs. The RUCA 
definition is further described in a Federal Register Notice published 
on May 3, 2007 (Vol. 72, No. 85; pgs 24589-24591). In preparing 
guidance for the Rural Physician Training Grant Program, HRSA will use 
the most current list of eligible rural counties as determined by the 
ORHP and published on their Web site at http://datawarehouse.hrsa.gov/RuralAdvisor/RuralHealthAdvisor.aspx.
    In summary, for the purposes of the Rural Physician Training Grant 
Program, HRSA is proposing to define the rural portion of the 
``underserved rural communities'' as:
    (a) Any non-Metropolitan County, including Micropolitan counties; 
or
    (b) Within a Metropolitan county, all Census Tracts that are 
assigned a RUCA code of 4-10; or
    (c) Census Tracts within a Metropolitan Area with RUCA codes 2 and 
3 that are larger than 400 square miles and have population density of 
less than 30 people per square mile.

B. Definition of Underserved

    As previously stated, for the purposes restricted to the Rural 
Physician Training Grant Program, outlined in section 749B of the 
Public Health Services Act, HRSA is also required to define the 
``underserved'' portion of the term ``underserved rural communities.''
    HRSA's OSD in the BHPr is responsible for developing shortage/
underservice designation criteria and for using the established 
criteria to decide if a geographic area, population group, or facility 
is a HPSA or a Medically Underserved Area or Population (MUA/P), or 
both. Three types of HPSAs may be designated: those with shortages of 
primary medical care, dental, or mental health providers. Urban or 
rural geographic areas and population groups may be designated as MUA/P 
or HPSA; certain medical or other public facilities are also eligible 
for HPSA designation.
    Location in a designated HPSA and MUA/P establishes initial 
eligibility for many Federal and State programs (such as National 
Health Service Corps placements, Health Center funding, Federally 
Qualified Health Center and/or Rural Health Clinic certification). The 
criteria established to identify geographic areas, population groups, 
or facilities with shortages of primary health care, dental, or mental 
health providers are located at 42 CFR Part 5. HPSA designations are 
based on the population-to-provider ratio in a defined service area, 
together with other factors indicative of unusually high needs or 
insufficient capacity. More information on all the factors needed to be 
designated as a HPSA can be found at the OSD's Web site: http://bhpr.hrsa.gov/shortage/hpsadesignation.htm. MUA/P designations utilize 
an Index of Medical Underservice to calculate a score for each area, 
based on a weighted combination of four factors: The ratio of primary 
medical care physicians per 1,000 population, infant mortality rate, 
percentage of the population with

[[Page 29450]]

incomes below the poverty level, and percentage of the population age 
65 or over.
    Information on HPSA and MUA/P designation status, including the 
date of the most recent designation or update, is available on the HRSA 
Data Warehouse Web site: http://datawarehouse.hrsa.gov/GeoAdvisor/ShortageDesignationAdvisor.aspx, or at the HRSA Web site http://hpsafind.hrsa.gov/ and http://muafind.hrsa.gov. In preparing guidance 
for the Rural Physician Training Grant Program, HRSA will use the most 
current list of eligible HPSAs and MUAs as determined by the OSD and 
published on their Web site. The OSD Web site list is the most up-to-
date list available and removes areas that no longer qualify for 
designation, even if the Federal Register list has not yet been 
updated.
    As required by Section 5602 of Public Law 111-148, HRSA plans to 
establish a comprehensive methodology and criteria for designation of 
MUPs and Primary Care HPSAs [under sections 330(b)(3) and 332 of the 
Public Health Service (PHS) Act, respectively], using a Negotiated 
Rulemaking process as outlined in the Federal Register on May 11, 2010 
(Volume 75, Number 90). Any change that HRSA makes to the methodology 
used to determine designations will not alter the definition for the 
Rural Physician Training Grant Program.
    For the purposes of the Rural Physician Training Grant Program, 
HRSA is defining the ``underserved'' portion of the term ``underserved 
rural community'' to include current:
    (a) Geographic Primary Care Health Professions Shortage Areas 
(HPSAs), (Federally designated under section 332(a)(1)(A) of the PHS 
Act) located in rural areas as defined above; or
    (b) Medically Underserved Areas (MUAs) (Federally designated under 
section 330(b)(3) of the PHS Act) located in rural areas as defined 
above.
    HRSA is not including Federally-designated Dental or Mental Health 
HPSAs for purposes of defining ``underserved rural communities'' for 
the Rural Physician Training Grant Program, as this Program is 
specifically targeted to students at or recent graduates of schools of 
allopathic and osteopathic medicine (Sec. 749B (a-b)), and therefore 
not focusing on Mental Health or Dental Health providers.
    For purposes of defining ``underserved rural communities'' for the 
Rural Physician Training Grant Program, HRSA is not including 
population-based HPSA designations, MUP designations, or facility-based 
HPSA designations.
    The operational definition of ``underserved rural community'' will 
be applied to determine whether applicants meet the statutory 
eligibility and priority criteria of the Rural Physician Training Grant 
program. These requirements are based on the ability to identify 
geographic places. The MUP and population HPSA designations are used to 
target a group of people, not a geographic place. The facility-based 
designation is given to an actual facility. While there is a geographic 
boundary within which qualifying underserved populations are located, 
this boundary also contains many people who are not underserved (e.g. 
homeless populations within a community that would otherwise not be 
underserved). Using this boundary as if it captures the same level of 
underservice as geographic shortage areas (without additional 
restrictions on the specific patient population within that boundary) 
could easily result in qualifying programs and program designs which do 
not fulfill the grant program's intended purpose.
    HRSA is seeking public comments, through this IFR, on the following 
definition for ``Underserved Rural Community--Those communities that:
    (a) Located in:
    i. Any non-Metropolitan County, including Micropolitan counties; or
    ii. Within a Metropolitan county, all Census Tracts that are 
assigned Rural-Urban Commuting Area Codes (RUCAs) code of 4-10; or
    iii. Census Tracts within a Metropolitan Area with RUCA codes 2 and 
3 that are larger than 400 square miles and have population density of 
less than 30 people per square mile; and
    (b) Being in a current:
    i. Federally-designated Primary Health Care Geographic Health 
Professions Shortage Area (HPSA), (under section 332(a)(1)(A) of the 
PHS Act) or
    ii. Federally-designated Medically Underserved Area (MUA) (under 
section 330(b)(3) of the PHS Act).

IV. Collection of Information Requirements

    This IFR contains no new information collection requirements 
subject to review by OMB under the Paperwork Reduction Act.

V. Regulatory Impact Analysis

A. Introduction

    This IFR is technical in nature. This new regulation is meant to 
define ``underserved rural communities'' solely for purposes related to 
the Rural Physician Training Grant Program, as outlined in section 749B 
of the Public Health Service Act. This will not change grant or funding 
eligibility for any other grant program administered through ORHP or 
HRSA.
    We have examined the impacts of this rule as required by Executive 
Order 12866 on Regulatory Planning and Review (September 30, 1993, as 
further amended), the Regulatory Flexibility Act (5 U.S.C. 601 et 
seq.), section 202 of the Unfunded Mandates Reform Act of 1995 (2 
U.S.C. 1532) (UMRA), Executive Order 13132 on Federalism (August 4, 
1999), and the Congressional Review Act (5 U.S.C. 804(2)).

B. Why Is This Rule Needed?

    This regulation is required to implement section 749B of the Public 
Health Service Act (42 U.S.C. 293) as amended by section 10501(l) of 
Public Law 111-148.

C. Costs and Benefits

    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any one year). We have 
determined that this IFR is not an economically significant rule. 
Moreover, the Secretary has determined that this IFR is not a ``major 
rule'' within the meaning of the statute providing for Congressional 
Review of Agency Rulemaking, 5 U.S.C. 801.

D. Regulatory Flexibility Act Analysis

    The Regulatory Flexibility Act requires agencies to analyze options 
for regulatory relief of small businesses if a rule has a significant 
impact on a substantial number of small entities. The Secretary has 
determined that no resources are required to implement the requirements 
in this IFR. Therefore, in accordance with the Regulatory Flexibility 
Act of 1980 and the Small Business Regulatory Enforcement Act of 1996, 
which amended the Regulatory Flexibility Act, the Secretary certifies 
that this IFR will not, if implemented, have a significant impact on a 
substantial number of small entities.

E. Executive Order 13132--Federalism

    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final

[[Page 29451]]

rule) that imposes substantial direct requirement costs on State and 
local governments, preempts State law, or otherwise has federalism 
implications. The Secretary has reviewed this IFR in accordance with 
Executive Order 13132 regarding federalism, and has determined that it 
does not have ``federalism implications.'' This rule would not ``have 
substantial direct effects on the States, or on the relationship 
between the national government and the States, or on the distribution 
of power and responsibilities among the various levels of government.''

F. Unfunded Mandates Reform Act of 1995

    Title II of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-
4) requires cost-benefit and other analyses before any rulemaking if 
the rule includes a ``Federal mandate that may result in the 
expenditure by State, local, and Tribal governments, in the aggregate, 
or by the private sector, of $100,000,000 or more (adjusted annually 
for inflation) in any 1 year.'' The current inflation adjusted 
statutory threshold is approximately $130 million. The Department has 
determined that this rule would not constitute a significant rule under 
the Unfunded Mandates Reform Act, because it would impose no mandates.
    In accordance with the provisions in Executive Order 12866, this 
IFR was reviewed by OMB.

    Dated: May 18, 2010.
Mary Wakefield,
Administrator, Health Resources and Services Administration.
    Approved: May 20, 2010.
Kathleen Sebelius,
Secretary.

List of Subjects in 42 CFR Part 5a

    Grants administration, Health professions, Physicians, Rural areas, 
Shortages, Underserved.

0
For the reasons set forth in the preamble, the Department amends 42 CFR 
Chapter I to add Part 5a as follows:

PART 5a--RURAL PHYSICIAN TRAINING GRANT PROGRAM

Sec.
5a.1 Statutory basis and purpose.
5a.2 Applicability.
5a.3 Definition of Underserved Rural Community.

    Authority: Sec. 749B of the Public Health Service Act (42 U.S.C. 
293k) as amended.


Sec.  5a.1  Statutory basis and purpose.

    This part implements section 749B(f) of the Public Health Service 
Act. These provisions define ``underserved rural community'' for 
purposes of the Rural Physician Training Grant Program.


Sec.  5a.2  Applicability.

    This part applies to grants made under section 749B of the Public 
Health Service Act.


Sec.  5a.3  Definition of Underserved Rural Community.

    Underserved Rural Community means a community:
    (a) Located in:
    (1) A non-Metropolitan County or Micropolitan county; or
    (2) If it is within a Metropolitan county, all Census Tracts that 
are assigned a Rural-Urban Commuting Area (RUCAs) codes of 4-10; or
    (3) Census Tracts within a Metropolitan Area with RUCA codes 2 and 
3 that are larger than 400 square miles and have population density of 
less than 30 people per square mile; and
    (b) Located in a current:
    (1) Federally-designated Primary Health Care Geographic Health 
Professions Shortage Area, (under section 332(a)(1)(A) of the Public 
Health Service Act) or
    (2) Federally-designated Medically Underserved Area (under section 
330(b)(3) of the Public Health Service Act).

[FR Doc. 2010-12557 Filed 5-21-10; 11:15 am]
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