PURPOSE: This rule establishes the requirements for developing and implementing a system of coordinated health care services available and accessible to all Missourians. This system is referred to as the Primary Care Resource Initiative for Missouri program.

1. (1) The following definitions shall be used in the interpretation and enforcement of this rule:

   1. (A) Approved family practice residency program means a graduate medical education program designed to train family or general practice physicians and approved by the Accreditation Council for Graduate Medical Education for allopathic residencies or by the American Osteopathic Association for osteopathic residencies;
   2. (B) Approved primary care residency program means a graduate medical education program designed to train family practice, general practice, general pediatric or general internal medicine physicians and approved by the Accreditation Council for Graduate Medical Education for allopathic residencies or by the American Osteopathic Association for osteopathic residencies;
   3. (C) Area of defined need means a geographic area or population designated by the Missouri Department of Health as experiencing a shortage of accessible primary and preventive health care providers;
   4. (D) Department means the Missouri Department of Health;
   5. (E) Director means the director of the Missouri Department of Health;
   6. (F) Educational loans means the financial assistance provided by the department for health professional education; or commercial loans made by schools, banks, credit unions, savings and loan associations, insurance companies and other financial institutions for health professional education; or loans made by federal, state, county or city agencies authorized by law to make loans for health professional education;
   7. (G) Eligible resident physician means a physician training in an approved primary care residency program;
   8. (H) Eligible student means a Missouri resident accepted and enrolled in a participating institution in a formal course of instruction leading to a doctor of medicine or a doctor of osteopathic medicine degree or a bachelor of science or a master of science degree in nursing, or a bachelor of science degree in a field leading to acceptance into a school of medicine or osteopathic medicine;
   9. (I) Participating institution means an institution in this state which grants the degree of doctor of medicine, doctor of osteopathic medicine, bachelor of science degree in nursing, master of science degree in nursing, or a bachelor of science degree in a field leading to acceptance into a school of medicine or osteopathic medicine. A participating institution also includes an institution in this state which offers a graduate medical education program designed to train primary care physicians and approved by the Accreditation Council for Graduate Medical Education for allopathic residencies or by the American Osteopathic Association for osteopathic residencies;
   10. (J) Primary health care provider means a generalist physician or a professional specializing in primary and preventive health care in the discipline of nursing, public health or health education;
   11. (K) Qualified employment means employment on a full-time basis in this state providing primary health care services in a public or nonprofit agency, institution or organization located in an area of defined need;
   12. (L) Resident means an individual who has lived in this state for any purpose other than attending an educational institution located within this state for one (1) or more years just before submitting an application for financial assistance from the department;
   13. (M) Rural area means a town or community within this state which is not an urbanized area. An urbanized area is defined as a central city(ies) and its contiguous closely settled territory with a combined population of at least fifty thousand (50,000); and
   14. (N) Stipend means financial assistance provided to an eligible resident physician in return for future service in an area of defined need.

2. (2) The department—in cooperation with appropriate public and nonprofit agencies, institutions and organizations— shall develop and implement a statewide, integrated primary and preventive health care delivery system including education and recruitment and retention of health care professionals, extending from high school student identification and support systems to placement of professionals in areas of defined need.

   1. (A) The department shall contract with appropriate public and/or nonprofit agencies, institutions and organizations to develop and implement a statewide recruitment, education 19 CSR 10-4

and support system for high school students to enter into primary and preventive health care professional education.

1. 1. The system shall assure appropriate

and academically sound precollege academic preparation.

1. 2. The system shall provide experiential,

hands-on learning opportunities.

1. 3. The system shall emphasize recruit-

ment of minority students and students from areas of defined need or rural areas.

1. (B) The department shall provide financial assistance to undergraduate students in a course of study leading to a bachelor of science degree in nursing or in a field leading to acceptance into a school of medicine or a school of osteopathic medicine. Based on documented needs assessments utilizing a scientifically strong methodology, all other health professionals will be considered for funding pending resource availability.

   1. 1. Eligible students may apply for finan-

cial assistance from the Primary Care Resource Initiative for Missouri (PRIMO) program, upon acceptance for admission into a participating institution.

1. 2. Selected full-time students shall

receive five thousand dollars ($5,000) per academic year in forgivable loans, not to exceed four (4) loans per individual, in return for an obligation to provide primary health care services in an area of defined need upon completion of their training.

1. 3. Selected part-time students shall

receive three thousand dollars ($3,000) per academic year in forgivable loans, not to exceed six (6) loans per individual, in return for an obligation to provide primary health care services in an area of defined need upon completion of their training.

1. 4. Interest at the rate of nine and one-

half percent (9 1/2%) per year from the date of check issuance shall be charged on all PRIMO loans.

1. 5. The department may grant a deferral

of repayment of principal and interest when deferral is in the best interests of the state and the PRIMO program.

1. 6. Interest accrued during a deferral

period by a PRIMO scholar shall be forgiven on the same basis as the original principal and interest.

1. 7. Forgiveness of interest and principal

for financial assistance recipients engaged in qualified employment shall occur at the rate of twenty percent (20%) per calendar year of the total financial assistance provided through the PRIMO program. If a recipient receives assistance for less than five (5) years, forgiveness shall occur on a year-for-year basis.

1. 8. Forgiveness and cash repayment peri-

ods shall begin the first day of the calendar year following the completion of training.

1. 9. Cash repayment periods shall not

exceed forty-eight (48) months beginning the first day of the calendar year following the completion of training.

1. 10. Recipients found to be in default of

their contracts shall be allowed a repayment period of up to forty-eight (48) months. The repayment period shall begin the date the recipient is out of compliance.

1. 11. Preference for financial assistance

shall be given to—

1. A. Students previously participating

in the PRIMO program;

1. B. Minority students and students

from areas of defined need or rural areas;

1. C. Students with an interest in pro-

viding primary health care services in areas of defined need; and

1. D. Students participating in preadmis-

sion programs of a medical/osteopathic school or advanced practice nursing.

1. (C) The department shall provide financial assistance to students in a graduate course of study leading to a master of science degree in primary care nursing or a doctor of medicine or doctor of osteopathic medicine degree. Based on documented needs assessments utilizing a scientifically strong methodology, all other health professionals will be considered for funding pending resource availability.

   1. 1. Eligible students may apply for finan-

cial assistance from the PRIMO program upon acceptance for admission into a participating institution.

1. 2. Selected full-time graduate nursing

students shall receive five thousand dollars ($5,000) per academic year in forgivable loans, not to exceed two (2) loans per individual, in return for an obligation to provide primary health care services in an area of defined need upon completion of their training.

1. 3. Selected part-time graduate nursing

students shall receive three thousand dollars ($3,000) per academic year in forgivable loans, not to exceed four (4) loans per individual, in return for an obligation to provide primary health care services in an area of defined need upon completion of their training.

1. 4. Selected graduate nursing students

engaged in a clinical experience with a preceptor shall receive an additional five thousand dollars ($5,000) in return for an obligation to provide primary health care services in an area of defined need.

1. 5. Selected medical and osteopathic stu-

dents shall receive up to twenty thousand dollars ($20,000) per academic year in forgivable loans, not to exceed four (4) loans per individual, in return for an obligation to provide primary health care services in an area of defined need upon completion of their training.

1. 6. Loans to a medical or osteopathic

student shall not exceed the cost of tuition at the participating institution.

1. 7. Interest at the rate of nine and one-

half percent (9 1/2%) per year from the date of check issuance shall be charged on all PRIMO loans.

1. 8. The department may grant a deferral

of repayment of principal and interest when the deferral is in the best interests of the state and the PRIMO program.

1. 9. Interest accrued during a deferral

period by a PRIMO scholar shall be forgiven on the same basis as the original principal and interest.

1. 10. Forgiveness of interest and principal

for financial assistance recipients engaged in qualified employment shall occur at the rate of twenty percent (20%) per calendar year of the total financial assistance provided through the PRIMO program. If a recipient receives assistance for less than five (5) years, forgiveness shall occur on a year-for-year basis.

1. 11. Forgiveness and cash repayment

periods shall begin the first day of the calendar year following completion of training.

1. 12. Cash repayment periods shall not

exceed forty-eight (48) months beginning the first day of the calendar year following completion of training.

1. 13. Recipients found to be in default of

their contracts shall be allowed a repayment period of up to forty-eight (48) months. The repayment period shall begin the date the recipient is out of compliance.

1. 14. Preference for financial assistance

shall be given to students listed in subparagraphs (2)(B)11.A.–D. of this rule.

1. (D) The department shall provide stipends to eligible resident physicians.

   1. 1. Eligible resident physicians may

apply for financial assistance from the PRIMO program upon acceptance for admission into a participating institution.

1. 2. Selected postgraduate year two (PGY

II) resident physicians shall receive up to ten thousand dollars ($10,000) per academic year in forgivable loans in return for an obligation to provide primary health care services in an area of defined need upon completion of their training.

1. 3. Selected postgraduate year three

(PGY III) resident physicians shall receive up to fifteen thousand dollars ($15,000) per academic year in forgivable loans in return for an obligation to provide primary health care services in an area of defined need upon completion of their training.

1. 4. Interest at the rate of nine and one-

half percent (9 1/2%) per year from the date of check issuance shall be charged on all PRIMO loans.

1. 5. The department shall defer repayment

of principal and interest when participants are in an approved primary care residency program that exceeds three (3) years in length.

1. 6. The department may grant a deferral

of repayment of principal and interest when the deferral is in the best interests of the state and the PRIMO program.

1. 7. Interest accrued during a deferral

period by a PRIMO scholar shall be forgiven on the same basis as the original principal and interest.

1. 8. Forgiveness of interest and principal

for financial assistance recipients engaged in qualified employment shall occur at the rate of twenty percent (20%) per calendar year of the total financial assistance provided through the PRIMO program. If a recipient receives assistance for less than five (5) years, forgiveness shall occur on a year-for-year basis.

1. 9. Cash repayment periods shall not

exceed forty-eight (48) months beginning the first day of the calendar year following completion of training.

1. 10. Forgiveness and cash repayment

periods shall begin the first day of the calendar year following completion of training.

1. 11. Recipients in default of their con-

tracts shall be allowed a repayment period of up to forty-eight (48) months. The repayment period shall begin the date the recipient is out of compliance.

1. 12. Preference for financial assistance

shall be given to—

1. A. Resident physicians previously

participating in the PRIMO program;

1. B. Resident physicians from areas of

defined need, rural areas and minority resident physicians; and

1. C. Resident physicians with an inter-

est in providing primary health care services in areas of defined need.

1. (E) The department shall provide support to approved family practice residency programs to facilitate training of primary health care providers in rural areas and areas of defined need.

   1. 1. Funding to approved family practice

residency programs shall be allocated on the basis of a point system with greatest funding going to those with the highest number of points—

1. A. One (1) point for each annual full-

time equivalent resident physician training in or providing services in an area of defined need;

1. B. Five (5) points for each recent

graduate of the approved family practice residency program practicing in a rural area; and

1. C. Ten (10) points for each recent

graduate of the approved family practice residency program practicing in an area of defined need.

1. 2. Approved family practice residency

programs shall provide information annually to the PRIMO program to facilitate determination of funding levels.

1. 3. Approved family practice residency

programs shall provide to the department an annual detailed record of the expenditure of PRIMO funds.

1. (F) The department shall provide support to participating institutions to facilitate training of primary health care advanced practice nurses in rural areas and areas of defined need.

   1. 1. Funding to participating institutions

shall be allocated on the basis of a point system with greatest funding going to those with the highest number of points—

1. A. One (1) point for each annual full-

time equivalent nursing student training in an area of defined need;

1. B. Five (5) points for each primary

care advanced practice nurse from a recent graduating class practicing in a rural area; and

1. C. Ten (10) points for each primary

care advanced practice nurse from a recent graduating class practicing in an area of defined need.

1. 2. Participating institutions shall provide

information annually to the PRIMO program to facilitate determination of funding levels.

1. 3. Participating institutions shall provide

to the department an annual detailed record of the expenditure of PRIMO funds.

1. (G) The department shall develop a program to facilitate the development of community-based, comprehensive primary health care delivery systems throughout the state.

   1. 1. The department shall publish a

request annually for proposals from communities seeking support for the development of community-based, comprehensive primary health care delivery systems.

1. 2. Proposals shall be processed and

scored by a review committee appointed by the director.

1. 3. Funding levels shall be determined by

the extent to which the proposals address the program requirements and the funding available for the program.

1. 4. Project periods shall be for three (3)

years with continued funding contingent upon—

1. A. Availability of state funds; 19 CSR 10-4
2. B. Participant’s documented accom-

plishments and adherence to project activities; and

1. C. Annual detailed record to the

department of the expenditure of PRIMO funds.

1. (3) PRIMO program participants shall file with the department the following completed forms:

   1. (A) All applicants for financial assistance shall file form MO 580-1968 (10-94);
   2. (B) Applicants approved for financial assistance shall file the contract form MO 580- 1966 (10-94); and
   3. (C) Participating institutions shall complete form MO 580-1969 (10-94) or form MO 580-1970 (9-94) to provide program information for future funding of approved family practice residency or primary care advanced practice nursing programs, respectively.

AUTHORITY: section 191.411.1, RSMo 1994. This rule was previously filed as 19 CSR 50- 4.010. Emergency rule filed Nov. 1, 1994, effective Nov. 11, 1994, expired March 10, 1995. Emergency rule filed Feb. 23, 1995, effective March 5, 1995, expired July 2, 1995. Original rule filed Nov. 1, 1994, effective June 30, 1995. Changed to 19 CSR 10- 4.010 July 30, 1998.