PURPOSE: This rule establishes the requirements for implementing recent changes to section 212(e) of the Immigration and Nationality Act made by section 220 of the Immigration and Nationality Technical Corrections Act of 1994, P.L. No. 103-416, 108 Stat. 4319-20 that allows state departments of public health to request a waiver of the two-year home presence requirement of foreign medical graduates who are in the United States in J-1 visa status to serve in federally designated health professional shortage areas.

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

   1. (A) Department means the Missouri Department of Health and Senior Services;
   2. (B) Director means the director of the Missouri Department of Health and Senior Services; and
   3. (C) Health professional shortage area (HPSA) means those counties or parts of counties designated by the United States Department of Health and Human Services as having a shortage of physicians as published in the Code of Federal Regulations.

2. (2) The department is committed to assisting all residents of Missouri to have access to quality, affordable health care. Therefore, under certain conditions, the department is prepared to consider recommending a waiver of the foreign residence requirement on behalf of physicians holding J-1 visas.

   1. (A) A waiver request must come from a Missouri health care facility on behalf of a J- 1 physician and not directly from a J-1 physician. All of the required information and documentation must be submitted in a single package with the documents presented in the order in paragraphs (2)(A)1.–14. Waiver requests that do not comply with these requirements will not be considered. The required documents include:

      1. 1. A letter from the head of the facility

at which the physician will be employed that—

1. A. Requests that the department act as

an interested government agency and recommend a waiver for the J-1 physician;

1. B. Summarizes how the health care

facility has attempted to locate qualified United States physicians;

1. C. Describes the physician’s qualifi-

cations, proposed responsibilities and how his/her employment will satisfy important unmet health care needs of a medically underserved rural community; and

1. D. States unequivocally that the facil-

ity is offering the physician at least three (3) years of employment in a job consistent with the department’s mission;

1. 2. A detailed description of the health

care facility will be provided, including the nature and extent of the facility’s medical services;

1. 3. Valid contract of employment with the

health care organization for not less than three (3) years;

1. 4. List of HPSAs or documentation from

state and local health care officials stating need for services of the physician;

1. 5. Recruitment and retention efforts

including copies of advertisements, agreements with placements services or other like documentation, and if these are not available, a detailed statement describing recruitment efforts. A statement should be submitted detailing the plans for retaining the physician during and beyond the three (3)-year obligation;

1. 6. Effect on area of waiver denial;
2. 7. Qualifications, including proof of

Missouri medical licensure eligibility;

1. 8. Physician’s curriculum vitae and let-

ters of recommendation;

1. 9. Copies of all IAP-66s of physician,

copies of l-94s of physician and family members, and proof of passage of examinations required by the United States Immigration and Naturalization Service;

1. 10. Valid offer of employment with

health care organization for at least three (3) years;

1. 11. A copy of the notice from the

department that the facility has been predetermined eligible for participation in the program; and

1. 12. An original and one (1) unbound

copy of the entire package should be included.

1. (3) Missouri health care facilities seeking to employ a foreign medical graduate holding a J-1 visa must be pre-determined by the department as eligible for participation in the J-1 Visa Waiver Program.

   1. (A) Eligible applicants will provide the department the following information and assurances:

      1. 1. Estimated enumeration of the patient

population to be served.

1. 2. Description of demographic charac-

teristics of the population(s) to be served, including age groups, ethnicity, poverty status, health status and insurance coverage.

1. 3. A copy of the sliding fee scale and the

applicable policy utilized by the facility.

1. (B) Eligible applicants may request a packet of materials and instructions detailing the information and documentation that is required in order to submit an appropriate case file for review from the department.

1. (4) Each case file received by the center will be reviewed for completeness and forwarded for approval to the director or his/her designee. Upon approval, the department will request the appropriate federal authorities for a waiver of the residence requirement.

2. (5) The department’s J-1 Visa Waiver Program in Missouri will give priority to those physicians who are board-eligible or boardcertified in one (1) of the following specialties: Family Practice, General Practice, General Pediatrics, Obstetrics/Gynecology, or Psychiatry and providing services in a primary care clinical setting. The credentials of the J-1 physician must be confirmed by the Missouri Board of Healing Arts. The physician must be eligible for licensure in Missouri.

   1. (A) The department may determine emergency rooms to be primary care clinical settings where substantial amounts of primary care services are delivered in that setting. In order to qualify for participation, the sponsoring facility must provide the following:

      1. 1. The number and types of primary

care encounters in the emergency room.

1. 2. The demographic characteristics of

the populations accessing primary care services in the emergency room.

1. 3. The payor source for primary care

services in the emergency room.

1. 4. Documentation that primary care ser-

vices for the identified population(s) are not available in the community.

1. (6) In addition to the eligible physicians set forth in section (5), waivers may be recommended for other specialties and subspecialties.

   1. (A) Physicians trained in other specialties may be considered for placement in the J-1 Visa Program in Missouri based on the following criteria:

      1. 1. Vacant slots in the program must be

available; and 19 CSR 10-4

1. 2. The employer must demonstrate that

the specialist services are essential to the medical needs of the underserved; and

1. 3. The specialty physician’s application

must have the concurrence in writing of the primary care physicians practicing in the community that the specialty is needed in the area; and

1. 4. The specialty physician’s application

must comply with all other requirements of the J-1 Visa Program.

1. (B) The number of specialty placements in any given program year will be determined by the quantifiable need for health care services in the state as a whole and the identified placement community.

1. (7) It is the responsibility of the physician and the employer to meet Missouri’s licensing and credentialing requirements as delineated by the Missouri Board of Healing Arts.

2. (8) A request for a J-1 visa waiver for a physician to enter private practice shall comply with the following:

   1. (A) The practice must be located in a HPSA;
   2. (B) The owner of the practice must be the employer for the J-1 physician and must submit a letter of support for the J-1 visa waiver request;

   3. (C) The practice employer must—

      1. 1. Certify that it will provide health care

services to all patients, including Medicare and Medicaid patients, without regard to ability to pay or the source of payment and must include a sliding fee scale for adjusting patient bills for those who are unable to pay; and

1. 2. Conspicuously post the sliding fee

scale in the practice site, in the language(s) of patients receiving services; and

1. 3. Provide the department two (2)

reports each calendar year detailing the following:

1. A. The number of patients covered by

sliding fee scale services;

1. B. The number of Medicaid patients

served;

1. C. The number of Medicare patients

served;

1. D. The total number of patients

served;

1. E. The demographic characteristics of

patients served, including data on age, gender, and ethnicity; and

1. F. Evaluation of services provided and

community need; and

1. (D) All other J-1 visa waiver requirements remain in effect.

1. (9) A physician must work at the facility for a minimum of three (3) years. If the physician fails to fulfill the terms of the contract with the facility, the facility must notify the department. This information will be forwarded to Immigration and Naturalization Services and other agencies as necessary.

2. (10) A physician who is practicing under a J- 1 visa in another state who wishes to practice in a HPSA in Missouri and obtain a J-1 visa waiver may do so only under the following conditions:

   1. (A) The physician must complete the J-1 visa waiver application process in Missouri and obtain a Missouri medical license prior to commencing practice;
   2. (B) The physician should make no plans for the transfer or to move personal possessions until the department has approved the request. The physician retains sole responsibility for notifying the employer of the intent to transfer, and payment of any financial penalty caused by a breach of contract, as determined by the employer; and
   3. (C) All other J-1 visa waiver requirements remain in effect.

3. (11) A physician with a J-1 visa waiver who is practicing in Missouri who wishes to transfer to another HPSA in Missouri may do so under the following conditions:

   1. (A) At least sixty (60) days in advance of the proposed change, the physician must notify the department of the new practice site address, telephone number, site director and the effective date of the proposed change;
   2. (B) The reason for the transfer must be explained in the written notice;
   3. (C) A new J-1 visa waiver employer contract must be submitted to the department prior to approval of the transfer; and
   4. (D) The physician should make no plans for the transfer or moving of personal possessions until the department has issued written approval of the transfer. The physician retains sole responsibility for notifying the employer of the intent to transfer and payment of any financial penalty caused by a breach of contract, as determined by the original employer.
4. (12) The department is not responsible for exceptions to or interpretations of these policies which have occurred without the written approval of the director of the department or his/her designee. Applicants should be aware that hospitals or physician recruiters are not expert in the requirements of each state, and should contact the department with any questions.
5. (13) The department is not responsible for any practice arrangements or contractual obligations entered into by the physician prior to approval of a J-1 visa waiver request.

6. (14) In order to assist and facilitate the placement of practitioners in designated HPSAs in Missouri, the department will provide, upon request, the following information:

   1. (A) List of designated HPSAs in Missouri;
   2. (B) List of hospitals located in HPSAs;
   3. (C) List of community health centers in HPSAs in Missouri; and
   4. (D) Procedure to request a J–1 visa waiver.

AUTHORITY: section 191.411.1, RSMo Supp. 2001.* This rule was previously filed as 19 CSR 50-4.020. Emergency rule filed April 17, 1995, effective April 27, 1995, expired Aug. 24, 1995. Original rule filed April 17, 1995, effective Oct. 30, 1995. Changed to 19 CSR 10-4.020 July 30, 1998. Emergency amendment filed Sept. 19, 2000, effective Sept. 29, 2000, expired March 27, 2001. Amended: Filed Sept. 19, 2000, effective Feb. 28, 2001. Emergency amendment filed Dec. 16, 2002, effective Dec. 26, 2002, expired June 23, 2003. Amended: Filed Dec. 16, 2002, effective May 30, 2003.

*Original authority: 191.411, RSMo 1993, amended 2001.