Section 491.5 - Location of clinic(a)Basic requirements.(1) An RHC is located in a rural area that is designated as a shortage area.(2) An FQHC is located in a rural or urban area that is designated as either a shortage area or an area that has a medically underserved population.(3) Both the RHC and the FQHC may be permanent or mobile units.(i)Permanent unit. The objects, equipment, and supplies necessary for the provision of the services furnished directly by the clinic or center are housed in a permanent structure.(ii)Mobile unit. The objects, equipment, and supplies necessary for the provision of the services furnished directly by the clinic or center are housed in a mobile structure, which has fixed, scheduled location(s).(iii)Permanent unit in more than one location. If clinic or center services are furnished at permanent units in more than one location, each unit is independently considered for approval as a rural health clinic or for approval as an FQHC.(b)Exceptions.(1) CMS does not disqualify an RHC approved under this subpart if the area in which it is located subsequently fails to meet the definition of a rural, shortage area.(2) A private, nonprofit facility that meets all other conditions of this subpart except for location in a shortage area will be certified if, on July 1, 1977, it was operating in a rural area that is determined by the Secretary (on the basis of the ratio of primary care physicians to the general population) to have an insufficient supply of physicians to meet the needs of the area served.(3) Determinations on these exceptions will be made by the Secretary upon application by the facility.(c)Criteria for designation of rural areas.(1) Rural areas are areas not delineated as urbanized areas in the last census conducted by the Census Bureau.(2) Excluded from the rural area classification are:(i) Central cities of 50,000 inhabitants or more;(ii) Cities with at least 25,000 inhabitants which, together with contiguous areas having stipulated population density, have combined populations of 50,000 and constitute, for general economic and social purposes, single communities;(iii) Closely settled territories surrounding cities and specifically designated by the Census Bureau as urban.(3) Included in the rural area classification are those portions of extended cities that the Census Bureau has determined to be rural.(d)Criteria for designation of shortage areas.(1) The criteria for determination of shortage of personal health services (under section 1302(7) of the Public Health Services Act), are:(i) The ratio of primary care physicians practicing within the area to the resident population;(ii) The infant mortality rate;(iii) The percent of the population 65 years of age or older; and(iv) The percent of the population with a family income below the poverty level.(2) The criteria for determination of shortage of primary medical care manpower (under section 332(a)(1)(A) of the Public Health Services Act) are:(i) The area served is a rational area for the delivery of primary medical care services;(ii) The ratio of primary care physicians practicing within the area to the resident population; and(iii) The primary medical care manpower in contiguous areas is overutilized, excessively distant, or inaccessible to the population in this area.(e)Medically underserved population. A medically underserved population includes the following: (1) A population of an urban or rural area that is designated by PHS as having a shortage of personal health services.(2) A population group that is designated by PHS as having a shortage of personal health services.(f)Requirements specific to FQHCs. An FQHC approved for participation in Medicare must meet one of the following criteria: (1) Furnish services to a medically underserved population.(2) Be located in a medically underserved area, as demonstrated by an application approved by PHS.43 FR 5375, Feb. 8, 1978. Redesignated at 50 FR 33034, Aug. 16, 1985, and amended at 57 FR 24982, June 12, 1992; 61 FR 14658, Apr. 3, 1996; 68 FR 74816 , Dec. 24, 2003; 71 FR 55346 , Sept. 22, 2006 See 42 CFR 110.203(g) (41 FR 45718, Oct. 15, 1976) and 42 CFR Part 5 (42 FR 1586, Jan. 10, 1978).