Health Professional Loan Repayment Program

PURPOSE: This rule establishes guidelines for implementing the Health Professional Loan Repayment Program (HPLRP) that will reduce the burden of educational debt among selected health care, mental health, and public health professionals in return for providing health care, mental health, and public health services in areas of defined need. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Definitions. The following definitions shall be used in the interpretation and enforcement of this rule: (A) Area of defined need means a geographic area, population, or field of work designated by the Missouri Department of Health and Senior Services as experiencing a shortage of health care, mental health, or public health care services; (B) Awardee means a health care, mental health, or public health professional who applied to and was selected by the department to participate in the Health Professional Loan Repayment Program (HPLRP); (C) Breach of written contract means failing to begin or complete service obligation, failing to submit employment verification surveys to the department annually, upon the request of the department, or within thirty (30) days of any change in employment, or failing to submit verification that awarded funds were applied to educational debt prior to the service obligation end date; (D) Default means failure to repay any amount awarded as a loan, by the department directly to the individual who entered into the contract, which has not yet been forgiven; (E) Department means the Missouri Department of Health and Senior Services; (F) Director means the Director of the Missouri Department of Health and Senior Services; (G) Forgiveness means fulfilling a service obligation through full-time qualifying employment consistent with the terms and conditions in the executed contract for a period no less than twenty-four (24) months as defined in the contract; (H) Greatest need in the best interests of the public is defined by considering a number of factors related to the access to health care, mental health, and public health services and the professional shortages associated with the type of services provided, to determine the areas of most needed services and areas in Missouri with the greatest need, related to increasing access to health care, mental health, or public health services. Factors to be considered are subject to availability and may include but are not limited to census data, designated HPSAs, workforce analysis, and data presented to the director prior to selection of eligible health professional and practitioner types; (I) Health Professional Shortage Area (HPSA) means a geographic area, population group, or facility designated by the United States Department of Health and Human Services’ Health Resources and Services Administration (HRSA) with a shortage of primary care, dental health, or mental health providers and services; (J) Health Professional Shortage Area score is a numerical representation of the shortage level of providers providing services in the HPSA; the higher the score, the greater the need. The score ranges from one (1) to twenty-five (25) for primary care and mental health, and from one (1) to twenty-six (26) for dental health; (K) Health care professional means a licensed provider of health care or dental health treatment and services who has graduated with an associate degree or higher associated with a health care profession. This includes but is not limited to advanced practice registered nurse, assistant physician, dental hygienist, dentist, physician, physician assistant, registered dietitian, registered nurse, physical therapist, occupational therapist, or respiratory therapist; (L) Mental health professional means a licensed mental health practitioner or licensed social and human services provider who offers services for the purpose of improving an individual’s mental health or to treat mental disorders and who has graduated with an associate degree or higher associated with a mental health or health care profession. This includes but is not limited to applied behavior analyst, licensed clinical social worker, licensed professional counselor, psychiatric advanced practice registered nurse, psychiatric assistant physician, psychiatric nurse, psychiatric physician assistant, psychiatric social worker, psychiatrist, or psychologist; (M) Proof of use of funds means documentation provided by the awardee to provide proof that the total funding awarded was utilized to pay on the qualifying educational debt submitted in the awardee’s application; (N) Public health professional, for the purpose of this regulation, means professionals working to analyze, develop, and implement programs that protect the health of individuals, families, and communities with a bachelor’s degree or higher. This includes but is not limited to epidemiologist, health educator, public health administrator, public health laboratorian, public health program specialist, public health service coordinator, public health nurse, public school counselor, public school nurse, or social services professional; (O) Qualifying educational debt means government and commercial loans for actual costs paid for tuition and educational costs for the applicant to obtain a degree relevant to the applicant’s qualifying employment; and (P) Qualifying employment means employment in a health care, mental health, or public health field for a minimum of forty (40) hours per week in an area of need as defined by the department. (2) The department may contract with selected health care, mental health, and public health professionals to repay, in total or in part, qualifying educational debt in exchange for a two- (2-) year service obligation in an area of defined need, per award. (3) Eligibility. Annually, the director will determine the professional and practitioner types eligible to receive HPLRP loans from the department. (A) The director will consult with the Department of Higher Education and Workforce Development, Office of Workforce Development, and Department of Mental Health or their successor agencies. (B) The director will have the sole discretion to make the determination using evidence identifying the greatest needs in the interest of the public. The determination is not subject to appeal. (C) Effective as of May 1, 2024, the eligible professional and practitioner types are as follows: 1. Health Care Professions. A. Cardiologist; B. Physical Therapist; C. Occupational Therapist; and D. Respiratory Therapist. 2. Mental Health Professions that treat substance use and opioid use disorders. A. Licensed and provisional professional counselor; B. Licensed behavior analyst; C. Licensed assistant behavior analyst; and D. Licensed and provisional licensed psychologist. 3. Public Health Professions— AND SENIOR SERVICES A. Public Health Nurse. (D) All applicants must meet the following criteria: 1. Missouri licensed, if applicable to profession; 2. A United States citizen, or authorized to work in the United States; 3. A Missouri resident; 4. Qualifying employment in a Missouri area of defined need as determined by the department; 5. Have obtained an associate degree or higher; and 6. Have qualifying educational debt. (4) Application Process. Applications will be accepted September 1 through November 1 each year. Applications will be accepted via electronic submission to DHSS.LoanRepayment@ health.mo.gov or mail to PO Box 570, Jefferson City, MO 65102. It is the responsibility of the applicant to verify that an application has been received timely by the department. Applications and verification instructions can be found on the HPLRP webpage at https://health.mo.gov/living/families/primarycare/ hplrp/index.php. (A) Applicants must submit an application that contains all of the following information and documentation presented in the order they are listed in subsection (4)(A). Applications that do not include the required documentation will not be considered. Each application request shall contain— 1. Completed and signed application; 2. Current job description, title, name, and location of employment; 3. Proof of Missouri professional license, if applicable; 4. Proof of qualifying educational debt; 5. Proof of U.S. citizenship, or authorization to work in the United States; 6. Proof of Missouri residency; and 7. Copy of the applicant’s federal tax return for most recent tax year. (5) Selection Process. The department will allocate one-third (1/3) of the appropriated funding for each of the health professional categories: one-third (1/3) for health care loan repayment awards, one-third (1/3) for mental health loan repayment awards, and one-third (1/3) for public health loan repayment awards. In the event that allocated funding from any of the health professional categories is not awarded, the funds not awarded may be split equally between the other health professional categories, if they have unfunded qualifying applicants. Funding received through donation, gift, grant award, or any means other than general revenue will be utilized for awards as specified by the donor or grantor per appropriation authority. The department intends to fully allocate all funding in any given year provided that sufficient qualifying applications are received. (A) Selection of health care professionals will be prioritized using the following criteria: 1. The greatest degree of need for health professional services, utilizing a workforce shortage analysis by qualifying health professional type to population ratios and HPSA scoring if available; 2. Applicant’s financial need based on the applicant’s adjusted gross income and number of dependents as filed on their most recent federal tax return to determine the applicant’s federal poverty level (FPL) percentage. To calculate the FPL percentage, the applicant’s income is divided by the federal poverty guideline for their household size, as determined annually by the federal Department of Health and Human Services (HHS), and multiplied by one hundred (100); and 3. If the number of applicants exceeds the amount of appropriated funding, and there are applicants demonstrating the same need in their health professional category and equal FPL percentage, the awardee will be selected through a lottery by the department. (B) Selection of mental health professionals will be prioritized by using the following criteria: 1. Mental health professionals working in a state or local health department, public school, or a state-owned and/or operated health facility will be given priority; 2. The greatest degree of need for mental health professional services, utilizing a workforce shortage analysis by qualifying health professional type to population ratios and HPSA scoring if available; 3. Applicant’s financial need based on the applicant’s adjusted gross income and number of dependents as filed on their most recent federal tax return to determine the applicant’s FPL percentage. To calculate the FPL percentage, the applicant’s income is divided by the federal poverty guideline for their household size, as determined annually by the federal Department of Health and Human Services (HHS), and multiplied by one hundred (100); and 4. If the number of applicants exceeds the amount of appropriated funding, and there are applicants demonstrating the same need in their health professional category and equal FPL percentage, the awardee will be selected through a lottery by the department. (C) Selection of public health professionals will be prioritized by using the following criteria: 1. Public health professionals working in a state or local health department or public school; 2. The greatest degree of need for public health professional services, utilizing a workforce shortage analysis by qualifying health professional type to population ratios and HPSA scoring if available; 3. Applicant’s financial need based on the applicant’s adjusted gross income and number of dependents as filed on their most recent federal tax return to determine the applicant’s FPL percentage. To calculate the FPL percentage, the applicant’s income is divided by the federal poverty guideline for their household size, as determined annually by the federal Department of Health and Human Services (HHS), and multiplied by one hundred (100); and 4. If the number of applicants exceeds the amount of appropriated funding, and there are applicants demonstrating the same need in their health professional category and equal FPL percentage, the awardee will be selected through a lottery by the department. (6) Awards. The department will award selected applicants as follows: (A) Licensed health and mental health practitioners with a doctorate degree will be awarded up to sixty-five thousand dollars ($65,000), not to exceed their qualifying educational debt; (B) Licensed health or mental health provider with a bachelor’s or master’s degree will be awarded up to thirtyfive thousand dollars ($35,000), not to exceed their qualifying educational debt; (C) Public health professional with a bachelor’s degree or higher will be awarded up to twenty thousand dollars ($20,000), not to exceed their qualifying educational debt; and (D) Licensed health or mental health provider with an associate’s degree will be awarded up to ten thousand dollars ($10,000), not to exceed their qualifying educational debt. (7) Service Obligation. Participation in the Health Professional Loan Repayment Program shall consist of loan award payments made directly to an awardee under written contract, in the form of direct deposit. (A) The contract shall include the following sections: 1. Awardee’s information; 2. Employer information; 3. Contract terms; 4. Verification, waiver, and deferral; 5. Breach and penalties; 6. Modifications/extension; 7. Execution; and 8. The applicant’s notarized signature. (B) The contract period shall be, at a minimum, two (2) years in length. (C) The contract shall bind the awardee to provisions of the program, including the financial consequences associated with a breach of contract. (D) The contract shall detail that the awardee earns forgiveness on their grant award through a service obligation and the dates of said service obligation shall be prominently shown on the contract. (E) The awardee shall respond to all department correspondence, including but not limited to written in email and letter and telephone communication sent to their last known contact information. If the applicant’s contact information changes, it is the applicant’s responsibility to notify the department within thirty (30) days of change. (F) The contract shall include that the awardee must submit the completed and signed contract to the department by mail to PO Box 570, Jefferson City, MO 65102. (8) The awardee shall earn forgiveness of their service obligation by engaging in qualifying employment as approved by the department. No forgiveness will be granted until proof of use of funds is provided. Repayment through forgiveness shall begin no later than the specific date identified on their executed contract. (A) Forgiveness may be granted upon completion of the two- (2-) year service obligation, as approved and determined by the department. (B) A waiver of the service obligation may be granted in extreme circumstances, as determined by the department. In the event that the awardee is unable to complete the service obligation due to serious debilitating illness or other compelling personal circumstances, the department may waive the remaining service obligation left on the contract. The department can waive, in whole or in part, an awardee’s service or payment obligation in cases where enforcement of the obligation would be impossible or an extreme medical or financial hardship and unconscionable. The department may also choose to defer the service obligation in its sole discretion, for up to one (1) year, if the awardee’s compliance with the obligation is temporarily impossible or an extreme medical or financial hardship, in lieu of permanently waiving the service obligation. (9) The awardee shall provide to the department, annually or upon request by the department, a completed employment Health Professional Loan Repayment Employment Verification Form detailing the awardee’s employment status and dates of service. This form must also be submitted to the department if there are any changes in employment, or at the request of the department. The Health Professional Loan Repayment Employment Verification Form, published 2023, is incorporated by reference in this rule as published by the department and available on the department’s webpage at https:// health.mo.gov/living/families/primarycare/loanrepayment/ pdf/ev-form-hplrp.pdf. This rule does not incorporate any subsequent amendments or additions. A copy of this form may be requested by contacting the department via email at DHSS. LoanRepayment@health.mo.gov. (10) If an awardee under contract violates the written contract and is in breach of any of the requirements outlined in the contract and/or this rule, the state shall be entitled to recover from the awardee an amount equal to the sum of— (A) The total amount of the loan awarded by the department or, if the department had already awarded partial forgiveness or waiver at the time of the breach, the amount of the loan not yet forgiven; (B) The interest on the amounts owed will accrue at the maximum prevailing rate as determined by the Treasurer of the United States on the date awarded to awardee. Interest begins accruing on award date; (C) An amount equal to any damages incurred by the department as a result of the breach; and (D) Any legal fees or associated costs incurred by the department or the state of Missouri in the collection of damages. (11) An awardee who is in breach of contract must pay the total amount owed within twenty-four (24) months from the payment date specified on the cash repayment letter sent by the department to the last known address or email address of the awardee. The cash repayment letter is deemed to have been received by awardee within five (5) calendar days of the date of mailing. AUTHORITY: section 191.430, RSMo Supp. 2023.* Emergency rule filed Oct. 13, 2023, effective Oct. 27, 2023, expired April 23, 2024. Original rule filed Oct. 13, 2023, effective May 30, 2024. *Original authority: 191.430, RSMo 2023.