Presentation by: Marlene A. Janssen Health Program Manager Nebraska Office of Rural Health For UNMC COD August 20, 2015

The ACT:  Created Rural Health Advisory Commission  Established a forgivable medical STUDENT LOAN program  Established the LOAN REPAYMENT program for certain licensed health professionals Sections to Nebraska Revised Statutes

Thirteen (13) members appointed by the Governor for 3- year terms and include:  Two Representatives from DHHS - DHHS Director of Public Health and Another DHHS Representative;  One Representative from each Nebraska medical school;  One physician in family practice residency training; and  From rural areas (counties under 15, 000 population), physician, hospital administrator, nursing home administrator, nurse, physician assistant, mental health practitioner or psychologist, dentist, and consumer.

“The purpose of the commission shall be to advise the department (DHHS), the Legislature, the Governor, the University of Nebraska, and the citizens of Nebraska regarding all aspects of rural health care and to advise the office (Office of Rural Health) regarding the administration of the Rural Health Systems and Professional Incentive Act.” § Ne Rev Statutes

Some of the statutory powers and duties of the commission include:  Prepare recommendations to the appropriate bodies to alleviate identified problems  Designate state-designated shortage areas in Nebraska  Select recipients of financial incentives available under the ACT

 Nebraska Rural Health Student Loan Program for certain health professional students  Nebraska Loan Repayment Program for eligible licensed health professionals

 Must be a Nebraska resident and  Enrolled or Accepted for enrollment in a Nebraska medical, dental, physician assistant, or graduate-level mental health training program

 Medical and PA students agree to practice one of the following specialties: family practicegeneral internal medicine general pediatricsobstetrics/gynecology general surgerypsychiatry  Dental students agree to practice: general dentistrypediatric dentistry oral surgery

 Graduate-level mental health students agree to practice the scope of practice of a Licensed Mental Health Practitioner or Psychologist  All student loan recipients agree to practice, in a state-designated shortage area, the equivalent of one year of full-time practice for each year a student loan is received

 Application period April 1 – June 1 each year  Interviewed by members of the Rural Health Advisory Commission  Rural Health Advisory Commission awards student loans

The maximum amount of student loan awards is up to:  $30,000 for medical, dental, and doctorate-level mental health student loan recipients  $15,000 to full-time masters level mental health and physician assistant student loan recipients (Legislation passed in 2015 (effective August 29, 2015) increases maximum amount to $30,000/$15,000) Rural Health Advisory Commission awards approximately 6 new student loans and 10 continuation student loans each year. The amount of student loan awards is based on the total appropriation for the rural incentive programs.

 Student Loans are forgiven if recipient practices the equivalent of full-time (40 hours/week) in a state-designated shortage area the equivalent of one year for each year a loan was awarded.  A student loan recipient may practice part- time (minimum 20 hours/week) which will extend the forgiveness period.

What if I decide to pursue a non-primary care field or practice in a non-shortage area? What happens to my Nebraska rural health student loan?

Contract Buyout Provisions – Doctorate-level before end of second year: ◦ Must notify Office of Rural Health, in writing, of intent to buyout ◦ Repay principal plus 6 percent simple interest from date loan was granted ◦ Must be repaid before graduation

Contract Buyout Provision for Doctorate-level after end of second year and master’s level ◦ 150% of principal plus 8 percent interest from the date of default ◦ Double the number of years loans granted to repay

For eligible licensed health professionals (do not have to be a Nebraska resident or graduate of a Nebraska college)

Eligible Health Professionals –  Physicians, Nurse Practitioners, Physician Assistants practicing one of the following specialties ◦ Family Practice ◦ General Internal Medicine ◦ General Pediatrics ◦ OB/GYN ◦ General Surgery ◦ Psychiatry

Eligible Health Professionals -  Dentists practicing one of the following specialties: ◦ General Dentistry ◦ Pediatric Dentistry ◦ Oral Surgery

Eligible Health Professionals –  Clinical Psychologists  Master’s Level Mental Health (LMHP)  Pharmacists  Occupational Therapists  Physical Therapists

 Government or Commercial educational loans - only educational loans to student in student’s name are eligible - loans to parents, consumer loans (ex: credit card), mortgage loans, and private loans are not eligible  Local entity must agree to provide local match and verify practice

 3-year practice obligation in a state-designated shortage area  Part-time practice (minimum 20 hours/week) reduces benefit  Rural Health Advisory Commission approves loan repayment applications

 Maximum of $60,000 per year in loan repayment (state and local match) for physicians, dentists, and psychologists  Maximum of $30,000 per year in loan repayment (state and local match) for all other eligible professions (Legislative changes effective August 29, 2015, changes maximum amounts $60,000/$30,000 per year (state and local match).)

 Applications are accepted year round The only “deadlines” are for the Rural Health Advisory Commission’s agenda items prior to each meeting.  Rural Health Advisory Commission awards loan repayment  May apply up to 18 months prior to being eligible to practice  Loan repayment no longer taxable income (effective January 1, 2009 as per P.L , 3/23/10)

 Cannot serve practice obligation under Student Loan and Loan Repayment programs simultaneously  Cannot receive loan repayment during residency training or under provisional license

Contract Buyout Provisions – (Legislative changes effective August 29, 2015, changed the buyout provisions)  150% of all funds received  8% interest from the date of default  Same number of months to repay as received loan repayment FACT: 483 loan repayment participants ( ) FACT: 91 in practice under obligation FACT: 92 percent complete the practice obligation December 2014 Annual Report

 Guidelines are established by the Rural Health Advisory Commission  Statutory authorization and guidance for defining shortage areas  Statewide review of all shortage areas every 3 years

 Service area: county, partial county, identified population group within a defined area  Designation based on ratio of service area (county) population to full-time equivalency (FTE) of family practice physicians

 Population to FTE FP Physician >= 2000:1 or no physician in service area  OR population to FTE FP Physician is between 1500:1 – 1999:1 AND service area (county) has one of the following high need indicators

High Need Indicators:  Population 65+ in the highest quartile for the state  Poverty level ranks in the highest quartile for the state  Frontier Area (< 6 people per square mile)

High Need Indicators (continued):  Infant Mortality Rate ranks in the highest quartile for the state  Low Birth Weight Rate ranks in the highest quartile for the state  More than 50% of physicians are over 60 years old

 Counties with population >= 15,000 will not be designated  Areas within a 25-mile radius of Lincoln and Omaha will not be designated  State employees are not eligible for the Nebraska rural incentive programs

 Federally designated (HPSA), primary care shortage areas may be designated as “State- Designated” ◦ If requested by the community or clinic ◦ And approved by the Rural Health Advisory Commission ◦ Example: Community Health Centers – Panhandle, One World, Charles Drew, Good Neighbor

Created: 1. Rural Health Advisory Commission (RHAC) 2. Forgivable Student Loan Program for certain health professional students 3. Loan Repayment Program for certain licensed health professionals

Nebraska Office of Rural Health (402) State-Funded Programs & Shortage Areas: Marlene Janssen