Original Notice.

     Preproposal statement of inquiry was filed as WSR 05-03-10 [05-03-010].

     Title of Rule and Other Identifying Information: Chapter 246-562 WAC, Physician visa waivers.

     Hearing Location(s): Washington State Department of Health, Town Center 1, Room 163, 310 Israel Road S.E., Tumwater, WA 98501, on January 24, 2006, at 1:00 p.m.

     Date of Intended Adoption: January 25, 2006.

     Submit Written Comments to: Jennell Prentice, Office of Community and Rural Health, P.O. Box 47834, Olympia, WA 98504-7834, e-mail http://www3.doh.wa.gov/policyreview/, fax (360) 664-9273 by January 24, 2006.

     Assistance for Persons with Disabilities: Contact Nicole Fernandus by January 9, 2006, TTY (800) 833-6388 or 711.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Federal legislation passed in December 2004 specifically allows states to sponsor specialists based on need criteria developed by the state. The amendments to the federal law also allow up to five waivers per year to go to physicians practicing in nondesignated health professional shortage areas that serve designated shortage areas.

     The proposed amendments add need criteria for specialists, expanding to all physician specialties based on need. The amendments also allow up to five waivers to be approved for physicians practicing in nondesignated areas who meet the nondesignated area criteria. Other amendments include: Changing the application timing to allow physicians to submit an application once they are in the final year of their training, moving the date from June 1 to April 1 for unfilled waivers, expanding the number of specialist waivers to ten from eight, and general edits for clarity.

     The anticipated effect is that Washington rules will be consistent with and meet the intent of the federal law authorizing the program.

     Reasons Supporting Proposal: The proposed amendments are in response to changes in the federal law which authorizes the J-1 waiver program, Public Law 108-441.

     Statutory Authority for Adoption: Chapter 70.185 RCW.

     Statute Being Implemented: Chapter 70.185 RCW and Public Law 108-441.

     Rule is necessary because of state court decision, Public Law 108-441.

     Name of Proponent: Department of health, governmental.

     Name of Agency Personnel Responsible for Drafting and Implementation: Jennell Prentice, Tumwater, Washington, (360) 236-2814; and Enforcement: Kristina Sparks, Tumwater, Washington, (360) 236-2800.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. A small business economic impact statement is not required because the amendments to chapter 246-562 WAC do not impose more than a minor cost on the affected industry, pursuant to RCW 19.85.030. Also, this is not a mandatory program. It is strictly voluntary in nature intended to provide additional physician resources to underserved communities.

     A cost-benefit analysis is not required under RCW 34.05.328. The amendments to this chapter are primarily clarifying and corrective in nature to comply with the federal authorizing statute. The nonhousekeeping amendments increase eligibility and only change procedures for application timing.

December 20, 2005

B. White

for Mary C. Selecky

Secretary

OTS-8016.6

AMENDATORY SECTION(Amending WSR 03-19-054, filed 9/11/03, effective 10/12/03)

WAC 246-562-010   Definitions.   The following definitions ((shall)) apply in the interpretation and implementation of these rules.

     (1) "Applicant" means a health care facility that seeks to employ a physician and is requesting state sponsorship or concurrence of a visa waiver.

     (2) "Department" means the department of health.

     (3) "Board eligible" means having satisfied the requirements necessary to sit for board examinations.

     (4) "Employment contract" means a legally binding agreement between the applicant and the physician named in the visa waiver application which contains all terms and conditions of employment, including, but not limited to, the salary, benefits, length of employment and any other consideration owing under the agreement.

     (5) "Full time" means a minimum forty hours of medical practice per week, not including call coverage, consisting of at least thirty-two hours seeing patients on an ambulatory or in-patient basis and may include up to eight hours administrative work for at least forty-eight weeks per year.

     (6) "Health care facility" means an entity with an active Washington state business license doing business or proposing to do business in the practice location where the physician would be employed, whose stated purposes include the delivery of medical care.

     (((6))) (7) "Health professional shortage area" (HPSA) means an area federally designated as having a shortage of primary care physicians or mental health care.

     (((7))) (8) "Hospitalist" means a physician, usually an internist, who specializes in the care of hospitalized patients.

     (9) "Low income" means that a family's total household income is less than two hundred percent of the federal poverty level as defined by the U.S. Federal Poverty Guidelines published annually.

     (((8))) (10) "Medically underserved area" (MUA) means a federally designated area based on whether the area exceeds a score for an Index of Medical Underservice, a value based on infant mortality, poverty rates, percentage of elderly and primary care physicians to population ratios.

     (((9))) (11) "Physician" means the foreign physician, named in the visa waiver application, who requires a waiver to remain in the United States to practice medicine.

     (((10))) (12) "Primary care physician" means a physician board certified or board eligible in family practice, general internal medicine, pediatrics, obstetrics/gynecology, geriatric medicine or psychiatry. Physicians who have completed any subspecialty or fellowship training, excluding OB training, are not considered primary care physicians for the purpose of this chapter.

     (13) "Sliding fee discount schedule" means a written delineation documenting the value of charge discounts granted to patients based upon financial hardship.

     (((11))) (14) "Specialist" means a physician board certified or board eligible in a specialty other than family practice, general internal medicine, pediatrics, obstetrics/gynecology, geriatric medicine or psychiatry (the current definition of "primary care" for the waiver program).

     (15) "Sponsorship" means a request by the department on behalf of a health care facility to federal immigration authorities to grant a visa waiver for the purpose of recruiting and retaining physicians.

     (((12))) (16) "Visa waiver" means a federal action that waives the requirement for a foreign physician, in the United States on a J-1 visa, to return to his/her home country for a two-year period following medical residency training.

     (((13))) (17) "Vacancy" means a full-time physician practice opportunity that is based on a planned retirement, a loss of an existing physician, or an expansion of physician services in the service area.

[Statutory Authority: Chapter 70.185 RCW. 03-19-054, § 246-562-010, filed 9/11/03, effective 10/12/03; 00-15-082, § 246-562-010, filed 7/19/00, effective 8/19/00; 98-20-067, § 246-562-010, filed 10/2/98, effective 11/2/98.]

     (2) The department may acknowledge sponsorship proposed by federal agencies, including the United States Department of Health and Human Services.

     (3) The department may carry out a visa waiver program, or, in the event of resource limitations or other considerations, may discontinue the program. Purposes of the program are:

     (a) To increase the availability of physician services in existing federally designated shortage areas for health care facilities that have long standing vacancies;

     (b) To improve access to physician services for communities and specific ((under-served)) underserved populations that are having difficulty finding physician services;

     (c) To serve Washington communities which have identified a physician currently holding a J-1 visa as an ideal candidate to meet the community's need for primary health care services or specialist services as allowed by WAC 246-562-080.

     (4) The department may only sponsor a visa waiver request when:

     (a) The application contains all of the required information and documentation;

     (b) The application meets the criteria contained in chapter 246-562 WAC.

     (5) The department will limit its activities:

     (a) Prior to submission of an application, the department may provide information on preparing a complete application;

     (b) For applicants that have benefited from department sponsorship previously, the applicant's history of compliance will be a consideration in future sponsorship decisions;

     (c) Because the number of sponsorships the department may provide is limited, and because the number of shortage areas is great, sponsorship will be limited. In any single program year, a health care facility in any one designated health professional shortage area or medically underserved area:

     (i) Will not be allotted more than two sponsorships; ((and))

     (ii) Will not be allotted more than one specialist sponsorship as allowed by WAC 246-562-080(4); and

     (iii) Will not be allotted more than one hospitalist sponsorship per hospital;

     (d) In any given program year ((seventy-five percent)) twenty of the federally allocated sponsorships will be allotted for primary care physicians and ((twenty-five percent)) ten of the federally allocated sponsorships will be allotted for specialists through ((May)) March 31. Any waiver sponsorships that remain unfilled on ((June)) April 1 of each program year will be available to:

     (i) Both primary care and specialist physicians consistent with the provisions of this chapter; and

     (ii) Physicians intending to practice in nondesignated shortage areas in health care facilities that meet the criteria in WAC 246-562-075.

[Statutory Authority: Chapter 70.185 RCW. 03-19-054, § 246-562-020, filed 9/11/03, effective 10/12/03; 00-15-082, § 246-562-020, filed 7/19/00, effective 8/19/00; 98-20-067, § 246-562-020, filed 10/2/98, effective 11/2/98.]

     The criteria set out in chapter 246-562 WAC must also be met.

[Statutory Authority: Chapter 70.185 RCW. 03-19-054, § 246-562-050, filed 9/11/03, effective 10/12/03; 98-20-067, § 246-562-050, filed 10/2/98, effective 11/2/98.]

     (a) Are licensed to do business in Washington state; and

     (b) Have provided medical care in Washington state for a minimum of twelve months prior to submitting the application.

     (2) Applicants may be for-profit, nonprofit, or government organizations.

     (3) Except for state institutional and correctional facilities designated as federal shortage areas, the applicant must:

     (a) Currently serve:

     (i) Medicare clients;

     (ii) Medicaid clients;

     (iii) Low-income clients, such as subsidized basic health plan enrollees;

     (iv) Uninsured clients; and

     (v) The population of the federal designation.

     (b) Demonstrate that during the twelve months prior to submitting the application, the health care facility was providing a minimum of ten percent of the applicant's total patient visits to Medicaid clients, and/or other low-income clients.

     (c) Agree to implement a sliding fee discount schedule for the physician named in the J-1 visa waiver application. The schedule must be:

     (i) Available in the client's principal language and English; and

     (ii) Posted conspicuously; and

     (iii) Distributed in hard copy to individuals making or keeping appointments with that physician.

     (4) Applicants must ((have been actively recruiting to fill the practice vacancy from among)) provide documentation demonstrating that the employer made a good faith effort to recruit a qualified ((physicians who are)) graduate((s)) of a United States medical school((s)) for a physician vacancy in the same salary range. Active recruitment, specific to the location and physician specialty, must be for a period of not less than six months in the twelve months prior to submitting a visa waiver application to the department. Active recruitment documentation can ((be demonstrated by)) include one or more of the following ((methods)):

     (a) Listings in national publications;

     (b) Web-based advertisements;

     (c) Statewide newspaper advertisements;

     (d) Contractual agreement with a recruiter or recruitment firm; or

     (e) Listing the position with the office of community and rural health, recruitment and retention program.

     In-house job postings and word-of-mouth recruitment are not considered active recruitment for the purpose of the J-1 physician visa waiver program; however, they can be used in addition to the methods described in (a) through (e) of this subsection.

     (5) Applicants must have a signed employment contract with the physician. ((Throughout the period of obligation, regardless of physician's visa status,)) The employment contract must:

     (a) Meet state and federal requirements throughout the period of obligation, regardless of physician's visa status;

     (b) Not prevent the physician from providing medical services in the designated shortage area after the term of employment (i.e., no noncompete clauses);

     (c) Specify the period of employment:

     (i) Three years minimum for primary care sponsorship; or

     (ii) Five years minimum for specialist sponsorship.

     (6) Any amendments made to the required elements of the employment contract, subsection (5) of this section, during the first three years for primary care physicians or five years for nonprimary care specialist ((and subspecialist)) physicians of contracted employment must be reported to the department for review and approval. The department will complete review and approval of such amendments within thirty calendar days of receipt.

     (7) Applicants must pay the physician prevailing wage as determined and approved by U.S. Department of Labor. Approval must be documented on a U.S. Department of Labor form ETA 9035 signed by an authorized official.

     (8) If the applicant has previously requested sponsorship of a physician, WAC 246-562-020 will apply.

     (9) If the applicant is not a publicly funded provider, additional criteria apply. The applicant must provide documentation of notification of intent to submit application for J-1 visa physician waiver to all publicly funded providers who provide medical care in HPSA or MUA designated area. Publicly funded providers include, but are not limited to, public hospital districts, local health departments, or community and/or migrant health centers.

     Notification must:

     (a) Be sent at least thirty days prior to submitting the application to the department;

     (b) Include a statement giving the publicly funded providers thirty days to provide comment to the department regarding the J-1 physician visa application; and

     (c) Provide the department's address.

     (10) ((Applicants must provide written notice to the department and all publicly funded providers in the health care facility's HPSA or MUA designated area within thirty days of the physician's start-date of employment.

     The notice must include:

     (a) The physician's name, employment start-date and practice location;

     (b) Services to be provided; and

     (c) Identification of accepted patients, such as Medicaid, Medicare, or basic health plan.

     (11))) Applicants must submit status reports to the department every six months, with required supporting documentation, during the initial term of employment, three years for primary care physicians or five years for specialists.

     (((12))) (11) Applicants must cooperate in providing the department with clarifying information, verifying information already provided, or in any investigation of the applicant's financial status.

[Statutory Authority: Chapter 70.185 RCW. 03-19-054, § 246-562-060, filed 9/11/03, effective 10/12/03; 00-15-082, § 246-562-060, filed 7/19/00, effective 8/19/00; 98-20-067, § 246-562-060, filed 10/2/98, effective 11/2/98.]

     (a) A federally designated primary care health professional shortage area(s); or

     (b) A federally designated mental health professional shortage area(s) for psychiatrists; or

     (c) A federally designated whole-county medically ((under-served)) underserved area(s); or

     (d) A combination of federally designated areas.

     (2) If the federal designation is based on a specific population, the health care facility must serve the designated population.

     (3) If the practice location is in both a population designation area and a medically ((under-served)) underserved area, the designated population must be served.

     (4) If the practice location is not located in a federally designated shortage area or whole-county medically underserved area, the applicant must meet the criteria in WAC 246-562-075.

     (5) The health care facility named in the visa waiver application may be an existing practice location or a new practice location ((for the health care facility named in the visa waiver application)). If a new practice location is planned, additional criteria apply. New practice locations must:

     (a) Have the legal, financial, and organizational structure necessary to provide a stable practice environment, and must provide a business plan that supports this information;

     (b) Support a full-time physician practice;

     (c) Have written referral plans that describe how patients using the new primary care location will be connected to existing secondary and tertiary care if needed.

[Statutory Authority: Chapter 70.185 RCW. 98-20-067, § 246-562-070, filed 10/2/98, effective 11/2/98.]

     (1) Provide care to patients who reside in designated shortage areas.

     (a) Describe the facility's service area.

     (b) Provide a patient visit report that identifies total patient visits in last six months of service by patient origin zip code.

     (2) Describe who will benefit from the physician's services.

     (a) Identify the percentage of Medicaid and Medicare patients who will have access to this physician.

     (b) Describe how the facility will assure access to this physician for low-income or uninsured patients.

     (c) Explain if the physician has language skills that will benefit patients at this facility.

     (3) Provide a detailed report of the extensive recruitment efforts made to recruit a U.S. physician for the specific position that the J-1 physician will fill.

     (a) Explain why this physician is necessary at this location.

     (b) Explain why it is difficult to recruit a U.S. physician for this location.

     (c) Provide the number of physicians interviewed for this position.

     (d) Provide the number of physicians offered this position.

[]

     (2) Physicians must have the qualifications described in recruitment efforts for a specific vacancy.

     (3) Physicians are considered eligible to apply for a waiver when:

     (a) They have successfully completed their residency or fellowship program; or

     (b) They are in the ((last six months)) final year of a residency or fellowship program, and the physician provides a letter from their program that:

     (i) Identifies the date the physician will complete the residency or fellowship program; and

     (ii) Confirms the physician is in good standing with the program.

     (4) Physicians ((applying as primary care physicians)) must((: (a))) provide direct patient care((; and

     (b) Be trained in:

     (i) Family practice; or

     (ii) General internal medicine; or

     (iii) Pediatrics; or

     (iv) Geriatric medicine; or

     (v) Obstetrics and gynecology; or

     (vi) Psychiatry and its subspecialties; and

     (c) Except for geriatric medicine and psychiatrists, not have any additional specialty training. Continuing medical education (CME) will not be considered specialty training for the purposes of this rule.

     (5) Physicians applying as specialists must:

     (a) Provide direct patient care;

     (b) Be trained in a subspecialty as defined by the Accreditation Council for Graduate Medical Education and published in the 1999-2000 Graduate Medical Education Directory, which is hereby incorporated by reference of:

     (i) Internal medicine, except for geriatric medicine; or

     (ii) Family practice, except for geriatric medicine; or a specialty as defined by the Accreditation Council for Graduate Medical Education and published in the 1999-2000 Graduate Medical Education Directory, which is hereby incorporated by reference of

     (iii) General surgery;

     (iv) Radiology-diagnostic;

     (v) Anesthesiology;

     (vi) Otolaryngology (ENT); or

     (vii) Urology.

     (6) Copies of the 1999-2000 Graduate Medical Education Directory are available from the American Medical Association or can be viewed at the Washington State Department of Health, Office of Community and Rural Health, 310 Israel Road SE, Tumwater WA 98501)).

     (((7))) (5) The physician must comply with all provisions of the employment contract.

     (6) The physician must:

     (a) Accept Medicaid assignment; and

     (b) Post and implement a sliding fee discount schedule; and

     (c) Serve the low-income population; and

     (d) Serve the uninsured population; and

     (e) Serve the shortage designation population; or

     (f) Serve the population of a local, state, or federal governmental institution or corrections facility as an employee of the institution.

     (7) Physicians must have an active Washington state medical license((, unless unusual circumstances delay licensing. If the application for a Washington state medical license has been received by the Washington state medical quality assurance commission four or more weeks prior to submission of the visa waiver application,)). The applicant may substitute a copy of the license application and request an exception if the application for a Washington state medical license was submitted to the Washington state medical quality assurance commission four or more weeks prior to submission of the visa waiver application.

     (8) Physicians must be an active candidate for board certification on or before the start date of employment.

     (9) ((Physicians must have at least one letter of recommendation from their residency program if applying as a primary care physician or from their fellowship program if applying as a specialist that:

     (a) Addresses the physician's interpersonal and professional ability to effectively care for diverse and low-income people in the United States; and

     (b) Describes an ability to work well with supervisory and subordinate medical staff, and adapt to the culture of United States health care facilities; and

     (c) Documents level of specialty training, if any; and

     (d) Is prepared on residency program letterhead and is signed by residency program staff or faculty; and

     (e) Includes name, title, relationship to physician, address and telephone number of signatory.

     (10) The physician must comply with all provisions of the employment contract.

     (11) Physician must:

     (a) Accept Medicaid assignment; and

     (b) Post and implement a sliding fee discount schedule; and

     (c) Serve the low-income population; and

     (d) Serve the uninsured population; and

     (e) Serve the shortage designation population; or

     (f) Serve the population of a local, state, or federal governmental institution or corrections facility as an employee of the institution.)) Physicians must provide the following documentation:

     (a) A current Curriculum Vitae;

     (b) U.S. Department of State Data Sheet, Form DS-3035;

     (c) All DS-2019/IAP-66 Forms (Certificate of Exchange visitor status);

     (d) Letter from residency program if applying as a primary care physician or from fellowship program if applying as a specialist that:

     (i) Addresses the physician's interpersonal and professional ability to effectively care for diverse and low-income people in the United States; and

     (ii) Describes an ability to work well with supervisory and subordinate medical staff, and adapt to the culture of United States health care facilities; and

     (iii) Documents level of specialty training, if any; and

     (iv) Is prepared on residency or fellowship program letterhead and is signed by residency or fellowship program staff or faculty; and

     (v) Includes name, title, relationship to physician, address and telephone number of signatory.

     (e) Physician attestation statement;

     (f) No objection statement;

     (g) Personal statement from physician regarding reason for requesting waiver;

     (h) I-94 Entry and Departure cards; and

     (i) G-28 from attorney, when applicable.

[Statutory Authority: Chapter 70.185 RCW. 03-19-054, § 246-562-080, filed 9/11/03, effective 10/12/03; 02-19-084, § 246-562-080, filed 9/16/02, effective 10/17/02; 00-15-082, § 246-562-080, filed 7/19/00, effective 8/19/00; 98-20-067, § 246-562-080, filed 10/2/98, effective 11/2/98.]

     (a) Primary care waivers are available to the following physician specialties:

     (i) Family medicine;

     (ii) General internal medicine;

     (iii) Pediatrics;

     (iv) Geriatric medicine;

     (v) Obstetrics and gynecology; or

     (vi) Psychiatry and its subspecialties.

     (b) Physicians who have completed any additional subspecialty training are not eligible for a primary care waiver, with the exception of geriatric medicine and psychiatry. Continuing medical education (CME) will not be considered subspecialty training for the purposes of this rule.

     (2) Specialist waivers. Specialist waivers are available to nonprimary care physician specialties. Applicants submitting an application for a specialist physician must:

     (a) Demonstrate a need for the nonprimary care specialty by addressing one of the following need criteria:

     (i) The physician specialty is needed to meet state or federal health care facility regulations, for example to maintain the hospital trauma designation level.

     (A) Identify the regulation; and

     (B) Address how the facility is currently meeting this regulation.

     (ii) The physician specialty is needed to address a major health problem in the facility service area.

     (A) Identify the health problem and how this specialty will address it;

     (B) Provide incident rates of the pathology and tie diagnosis codes to payer mix (i.e., how many patients are affected and how many are low-income or uninsured?); and

     (C) If this specialty is not available in the community, identify the nearest location where this specialty service can be obtained.

     (iii) The physician specialty is needed to address population-to-physician ratio because the current ratio does not meet national standards.

     (A) Provide the population-to-physician ratio for the specialty, include source for data provided;

     (B) Provide the number of physicians (FTE) practicing this specialty in the same health professional shortage area/facility service area;

     (C) Provide the distance to the nearest physician practicing the same specialty; and

     (D) Describe how the demand for the specialty has been handled in the past.

     (b) Describe the referral system that includes:

     (i) On-call sharing;

     (ii) Affiliation agreements with other health care entities in the service area, specifically with publicly funded employers, such as public hospital districts, community health centers, local, state, or federal governmental institutions or correctional facilities, who have an obligation to provide care to underserved populations.

     (c) Provide at least one letter of support for this type of physician specialty from a primary care provider practicing with publicly funded employers, such as public hospital districts, community health centers, local, state, or federal governmental institutions or correctional facilities, who have an obligation to provide care to underserved populations outside of the applicant's organization.

     (d) Provide written notice to the department and all publicly funded providers in the health care facility's HPSA or MUA designated area within thirty days of the physician's start-date of employment. The notice must include:

     (i) The physician's name, employment start date and practice location;

     (ii) Services to be provided; and

     (iii) Identification of accepted patients, such as Medicaid, Medicare, or basic health plan.

[]

     (2) A facility may only use inpatient data on the patient visit report required in WAC 246-562-060 to demonstrate that ten percent of applicant's total patient visits were to Medicaid and/or other low-income patients.

     (3) A facility must identify primary care physicians in the community who will accept unattached Medicaid, Medicare or uninsured patients for follow-up care.

[]

     (2) Applications must be completed ((in their entirety, addressing)), address all state and federal requirements, and must include all required documents as specified in the application form.

[Statutory Authority: Chapter 70.185 RCW. 98-20-067, § 246-562-090, filed 10/2/98, effective 11/2/98.]

     (2) Applications must be mailed, sent by commercial carrier, or delivered in person. Applications may not be sent by telefax, or electronically.

     (3) The department may limit the time period during which applications may be submitted including cutting off applications after the state has sponsored all applications allowed in a given federal fiscal year.

     (4) Should multiple primary care physician applications arrive at the department on the same day, the department will rank those applications according to the following criteria:

     (a) Facilities located in federally designated shortage ((facilities)) areas will rank ((first)) ahead of those facilities located in nondesignated areas.

     (b) ((Those applicants serving shortage areas that require the greatest number of physicians relative to population to remove them from federal shortage status will rank second.

     (c))) Federally designated shortage facilities will rank first.

     (c) Publicly funded employers, such as public hospital districts, community health centers, local, state, or federal governmental institutions or correctional facilities, who have an obligation to provide care to ((under-served)) underserved populations, will rank ((third)) second.

     (d) Critical access hospitals and rural health clinics will rank third.

     (e) All other private practice, for profit facilities will rank last.

     (f) If multiple applications within a designated category arrive on the same day((, those applications will be ranked within that category based on random selection.

     (e))) or if a ranked order cannot be determined by using the criteria in (a) through (((d))) (f) of this subsection, then applications will be ranked ((based on random selection)) by:

     (i) Percentage of services provided to low-income, uninsured and sliding fee based patients;

     (ii) Distance from applicant's practice location to nearest publicly funded provider;

     (iii) Language skill of provider matching those significantly represented in the community;

     (iv) Type of services provided, outpatient versus inpatient; and

     (v) Facility location, rural versus urban based on RUCA codes to most current census data.

     (5) Should multiple specialist applications arrive at the department on the same day, the department will rank these applications according to the following criteria:

     (a) Facilities located in federally designated shortage areas will rank ahead of those facilities located in nondesignated areas.

     (b) Hospitals or other health care facilities at risk of being out of state compliance standards will rank first. For example: The physician specialty is needed to maintain trauma designation or meet certificate of need requirements.

     (c) Federally designated shortage facilities will rank ((first)) second.

     (((b))) (d) Publicly funded employers, such as public hospital districts, community health centers, local, state, or federal governmental institutions or correctional facilities, who have an obligation to provide care to underserved populations will rank ((second)) third.

     (((c))) (e) All other private practice, for profit facilities will rank last.

     (f) If multiple applications within a designated category arrive on the same day, ((those applications will be ranked within that category based on random selection.

     (d))) or if a ranked order cannot be determined by using the criteria in (a) through (((c))) (e) of this subsection, then applications will be ranked ((based on random selection)) by:

     (i) Percentage of services provided to low-income, uninsured and sliding fee based patients;

     (ii) Distance from applicant's practice location to nearest publicly funded provider;

     (iii) Language skill of provider matching those significantly represented in the community;

     (iv) Type of services provided, outpatient versus inpatient; and

     (v) Facility location, rural versus urban based on RUCA codes to most current census data.

     (6) The department will review applications within ten working days of receipt of the application to determine if the application is complete.

     (7) The department will return incomplete applications to the applicant, and provide a written explanation of missing items.

     (8) Incomplete applications may be resubmitted with additional required information. Resubmitted applications will be considered new applications and will be reviewed in date order received on resubmission.

     (9) The department will return applications that are received after the maximum number of sponsorships have been approved. This does not apply to copies of other federal J-1 applications.

     (10) The department will return sponsorship applications to applicants who have had two approved sponsorships in the current year for the shortage area.

     (11) If the Washington state medical license is pending at the time the application is submitted to the department, the department may:

     (a) Sponsor or concur;

     (b) Hold the application in order received; or

     (c) Return the application as incomplete.

     (12) The department will review complete applications against the criteria specified in this chapter.

     (13) The department may:

     (a) Request additional clarifying information;

     (b) Verify information presented;

     (c) Investigate financial status of the applicant;

     (d) Further investigate any comments generated by publicly funded provider notification of application for waiver;

     (e) Return the application as incomplete if the applicant does not supply requested clarifying information within thirty days of request. Incomplete applications must be resubmitted. Resubmitted applications will be considered new applications and will be reviewed in date order received.

     (14) The department will notify the applicant in writing of action taken. If the decision is to decline sponsorship, the department will provide an explanation of how the application failed to meet the stated criterion or criteria.

     (15) The department may deny a visa waiver request or, prior to U.S. Department of State approval, may withdraw a visa waiver recommendation for cause, which shall include the following:

     (a) The application is not consistent with state and/or federal criteria;

     (b) Fraud;

     (c) Misrepresentation;

     (d) False statements;

     (e) Misleading statements; or

     (f) Evasion or suppression of material facts in the visa waiver application or in any of its required documentation and supporting materials.

     (16) Applications denied may be resubmitted with concerns addressed. Resubmitted applications will be considered new applications and will be reviewed in date order received.

[Statutory Authority: Chapter 70.185 RCW. 03-19-054, § 246-562-120, filed 9/11/03, effective 10/12/03; 00-15-082, § 246-562-120, filed 7/19/00, effective 8/19/00; 98-20-067, § 246-562-120, filed 10/2/98, effective 11/2/98.]

     (a) The required six-month reports are not submitted in a complete and timely manner.

     (b) A sponsored physician does not serve the designated shortage area and/or shortage population for the full three years of employment for primary care physicians or the full five years of employment for specialists.

     (c) A sponsored physician does not remain employed by the applicant for the full three years of employment for primary care physicians or the full five years of employment for specialists.

     (d) The applicant has a history of noncompliance with any of the provisions of this chapter or federal labor law requirements.

     (2) A health care facility may request a determination of eligibility prior to submitting an application. The department will review the situation upon receipt of a written request.

[Statutory Authority: Chapter 70.185 RCW. 03-19-054, § 246-562-130, filed 9/11/03, effective 10/12/03; 98-20-067, § 246-562-130, filed 10/2/98, effective 11/2/98.]