Kara Martin
Assistant Director of Financial Aid/Financial Literacy Coordinator
Tufts University School of Medicine
kara.martin@tufts.edu
medicine.tufts.edu/finaid
136 Harrison Ave, Boston, MA 02111
T: 617-636-6574
F: 617-636-3447
General email: med-finaid@tufts.edu
PRIMARY CARE
INFORMATION SESSION
Top Points to Take Away
1. Don’t try to learn everything you wish to know
about affording a career in primary care today—this
is a primer.
2. Come talk to us! We can walk you through a
customized plan for your future.
3. Don’t let the financials guide your career decisions.
4. Understand that the financial plan you have in
mind today may change many times over due to
future legislation, your own desires, and the economy.
MYTH #1: TRUE OR FALSE?
Indebtedness prevents most MD’s from choosing a
specialty that they’re passionate about…
FALSE
MYTH #1: OPTIONS ARE AVAILABLE
There are many options available to assist with the
financial obligations of loan repayment and the
expected salary of a primary care physician.
MYTH #2: TRUE OR FALSE?
Indebtedness is one of the top factors in selecting a
specialty:
FALSE
MYTH #2: DEBT SHOULD NOT BE
THE DRIVING FACTOR
According to the 2012 GQ, this was the least considered
factor with moderate or strong influence.
Top five factors were:
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Personality fit
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Specialty Content
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Role model influence
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Work/life balance
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Future family plans
MYTH #3: TRUE OR FALSE?
Loan Forgiveness programs are available so I may
borrow whatever amount I want and not worry at all
about the repayment amount.
FALSE
MYTH #3: YOU MUST PLAN TO
REPAY WHAT YOU BORROW
Loan Forgiveness programs are available to assist
borrowers who want to work in public service but they
are not there to avoid repayment down the road.
Borrowers must remain focused on the long term
obligations of loans and be fiscally responsible to
avoid unintended consequences
Options Available to You
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National Health Service Corps (NHSC) Loan Repayment
National Health Service Corps (NHSC) Student to Service Loan Repayment
National Health Service Corps (NHSC) Scholarship
Primary Care Loans (PCL)
Public service Loan forgiveness (PSLF)
State loan repayment options
Tufts LRAP
Income based Repayment (IBR)/Pay As You Earn (PAYE)
What Are These Programs?
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NHSC: Primary care clinicians are eligible for loan repayment
assistance in exchange for working in an HPSA (Health Professional
Shortage Areas) and with underserved communities
PCL: The Primary Care Loan (PCL) program is a low cost federal
loan program for medical students committed to primary health care
practice
PSLF (Public Service Loan Forgiveness): Federal program that
provides for forgiveness or cancellation of remaining balance due
on eligible federal Direct student loans after the borrower has made
120 monthly payments to Direct Loans while employed in qualifying
public service jobs.
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Loan repayment plans can include IBR (Income Based Repayment) and PAYE (Pay
As You Earn) based on income versus debt.
NHSC Loan Repayment Program
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Tax-free loan repayment assistance
Apply at end of residency or as board certified physician
Determined by HPSA score of employer (14+ and 0 – 13):
 FT: $30K - $50K/ for 2 year period
 HT: $15K - $25K/ for 2 year period
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Additional years 3 – 4: $20K/ for 1 year period
Additional years 5 – 6: $10K/for 1 year period
Specialties Include: Family Medicine ∙ General Internal Medicine ∙
General Pediatrics ∙ Obstetrics/Gynecology ∙ Geriatrics ∙ Psychiatry
Eligible loans borrowed during undergrad, graduate, and/or during
medical school include: Federal Stafford, Federal Direct, Private
Loans, Institutional Loans
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PRIMARY CARE LOANS, RESIDENCY/RELOCATION LOANS, CREDIT
CARDS, LINES OF CREDIT ARE NOT ELIGIBLE
NHSC Loan Repayment Program
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Must pass credit check – no default on any federal obligations
Must show proof, funds utilized annually and still qualify
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Must be employed at NHSC-approved service site at time of
application
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If working multiple jobs, all current employment sites MUST be
included and MUST be eligible
Website for available jobs at approved sites:
http://nhscjobs.hrsa.gov/external/search/index.seam
Priority will be granted to during application to those:
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Less expensive to apply as a lump sum vs. monthly
Likelihood of applicant to continue to work in HPSA and/or comes
from disadvantaged background
Website: NHSC.hrsa.gov/loanrepayment
NHSC Loan Repayment Program
Pros
Cons
Tax-free
If working multiple jobs, then all positions
must be included in application and be
eligible
Can wait until end of or after residency to
apply
Must pass credit check to be eligible
Includes private loans
Will not include Primary Care Loans
Students can be employed FT or HT
NHSC Students to Service Program
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LRP) for 4th year students in return for serving in eligible Health
Professional Shortage Areas (HPSAs) of greatest need
The S2S LRP will provide loan repayment up to $120,000 (4 payments
@ $30K/each) tax-free
 Three (3) years FT service (Six (6) years HT service may be
approved)
Specialties Include: Family Medicine ∙ General Internal Medicine ∙
General Pediatrics ∙ Obstetrics/Gynecology ∙ Geriatrics ∙ Psychiatry*
Eligible loans borrowed during undergrad, graduate, and/or during
medical school include Federal Stafford, Federal Direct, Private Loans,
Institutional Loans
 PRIMARY CARE LOANS, RESIDENCY/RELOCATION LOANS, CREDIT
CARDS, LINES OF CREDIT ARE NOT ELIGIBLE
(S2S
NHSC Students to Service Program
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Application process is typically mid-Sept – mid-Nov
Looking for applicants with commitment to PC in HPSAs and are willing to relocate based on
the needs of the NHSC, however:
 Specific fellowships may be allowed (approval necessary)
 Specialization may cause default
 Will need to find employment that meets requirements within 3 mos of residency
completion or will be placed by NHSC
 Eligible employer must have HPSA score of 14+ (currently over 100 in or around Boston)
Priority will also be granted to applicants who have:
 Likelihood of applicant to continue to work in HPSA and/or comes from disadvantaged
background
Applicants should expect to fulfill 3 year repayment at one site – transfer may be granted
with approval
NHSC anticipates making 100 awards annually through this program
Additional information about the S2S LRP program can be found at:
http://nhsc.hrsa.gov/loanrepayment/studentstoserviceprogram/index.html
NHSC Students to Service Program
Pros
Cons
Includes private loans
Will not include Primary Care Loans
Students can commit to the program in
their 4th year
For those not fully sure, commitment may
be a negative factor
Tax-free
Must find employment within 3 mos of
residency completion
Significant upfront loan repayment amount Participants must be willing to relocate
(up to $120k)
Primary Care Loan Program
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Low-interest loan for those dedicated to primary care
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0% interest during school/residency
5% interest rate in repayment
Students may apply for loan beginning in 3rd year of
medical school.
Students in 4th year may request a SuperPCL to pay off all
loan obligations from medical school. Funds are limited school must approve each individual requests.
Must demonstrate financial need
Parental information may be required.
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Students who are 24 years+ and have not been claimed on
parents tax return for at least 3 years may be considered
independent and waive parental data
Primary Care Loan Program
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When compared to other federal student loans and private loans, the PCL provides
significant savings
Deferment of principal and interest while in residency
Must certify service requirement being met every year for duration of loan balance
or max of 10 years (residency counts)
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If annual certification doesn’t occur, borrower will be considered to be in service default
Residency must be completed within 4 years of graduation
Eligible residency programs include: family medicine, internal medicine, pediatrics,
combined medicine/pediatrics, preventive medicine
Eligible specialties include: Clinical Preventive Medicine, Occupational Medicine,
Public Health Public Policy Fellowship, Senior Residencies in one of the above,
Faculty administrators/policy makers certified in one of the primary health care
disciplines, Geriatrics, Adolescent Medicine, Adolescent Pediatrics, Sports Medicine
OB/GYN not eligible specialty
If you fail to meet obligation, there is a 7% interest penalty
Primary Care Loan Program
Pros
Cons
No interest accumulation while in school or
in residency
Parent information may be required
Low interest rate of 5% in repayment
If you fail to meet obligation, there is a
7% penalty
A SuperPCL may pay off all other federal School has a limited amount of funds to
loans
award
Provides substantial savings over other
federal loans
Must certify that service is being met each
year for duration of repayment or
maximum of ten years
OB/GYN not eligible
Public Service Loan Forgiveness Eligibility
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120 ON-TIME full payments required while working
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FT (30 hrs/wk) in a qualifying public service position
At the time you apply for forgiveness
At the time principal and interest are forgiven
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Payments do not need to be consecutive
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Payments must be in qualified repayment plan (IBR, PAYE)
Forbearance/Deferment do not count but $0 payments do
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501(c)(3) = Nonprofit
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Who issues your paycheck? Hospital vs. physician association
Loans Eligible for PSLF
Federal Direct Stafford (Subsidized and Unsubsidized
Loans)
 Federal Direct Grad PLUS Loans
 Federal Direct Consolidation Loans
Loans must be with a Direct Loan Servicer
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Primary Care Loans are NOT eligible
Federal Perkins and FFEL loans (Staffords/GradPLUS
borrowed from lender) are NOT ELIGIBLE but may be
included in consolidation loan to become eligible
PSLF Strategy – Income Based Repayment Plans
Income based repayment (IBR)
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Repayment Plan – Based on income and family size to provide an affordable monthly
payment amount; determined annually
Pros:
 Affordable payments, specifically in residency – caps payments at 10% of discretionary
income
 Monthly payment never exceeds Standard 10-year repayment
 Partial subsidy for first consecutive 3 years
 Capitalization occurrence is limited
 After 25 years, balance is forgiven but taxable
Cons:
 Must show partial financial hardship and reapply annually
 Negative amortization occurs so more interest accrues over life of loan
 More expensive in the long run if loan amounts not forgiven
 Longer than 10 years to repay
www.ibrinfo.org
PSLF Strategy – Income Based Repayment Plans
Pay As You Earn (PAYE)
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Repayment Plan – Based on income and family size to provide an affordable monthly payment amount;
determined annually. Only Federal Direct Loans eligible to be repaid using PAYE.
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Must be new borrower as of 10/1/07 AND received disbursement after 10/1/11
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Pros:
 Affordable payments, specifically in residency – caps payments at 10% of discretionary income
 Monthly payment never exceeds Standard 10-year repayment
 Partial subsidy for first consecutive 3 years
 Capitalization occurrence is limited and limited to 10% of original principal balance
 After 20 years, balance is forgiven but taxable
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Cons:
 Must show partial financial hardship and reapply annually
 Negative amortization occurs so more interest accrues over life of loan
 More expensive in the long run if loan amounts not forgiven
 Longer than 10 years to repay
http://studentaid.ed.gov/repay-loans/understand/plans/pay-as-you-earn#advantages
PSLF Logistics and Strategies
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Married—joint tax return
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Total AGI and total debt
Separate filers
 Student only
Apply annually & provide disclosure of tax info from IRS
Begin payments in residency
Forgiveness is untaxable event
May be especially helpful for borrowers with lower
income, higher debt and/or longer residencies
Massachusetts State Loan Repayment Program
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The State Loan Repayment Program (SLRP) is a federally-funded
grant program to States and Territories that provides cost-sharing
grants to assist them in operating their own state educational loan
repayment programs for primary care providers working in Health
Professional Shortage Areas (HPSAs) within their state
MA = $25K/yr for 2 years ($50K total)
Can’t be participating in another program with service obligation
For additional information, please see attached RFP and visit:
http://www.mass.gov/eohhs/docs/dph/com-health/primarycare/mlrp-program-guidelines.pdf
Other states may participate:
http://nhsc.hrsa.gov/loanrepayment/stateloanrepaymentprogram/i
ndex.html
Tufts LRAP
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The Tufts Loan Repayment Assistance Program (LRAP) is a
university-wide program that helps selected Tufts graduates
working in public service repay a portion of their annual Tufts
incurred education loan debt.
TUSM: 47 awards in FY14; ranged from $1K to $4K; average
award $2K
TUSM awards represent grads from MD, MBS, Masters and
PhD recipients in Health Science programs. To include PA
grads in future.
Awards based on number of applicants, IBR/PAYE minimum
payment, funds available, and overall indebtedness.
Must apply annually
Sample Repayment: PSLF through IBR/PAYE & NHSC w/ $250k in Federal Direct Loan debt
Description
Repayment Years
Monthly Payment
Interest Cost
Total Repayment
PAYE for full
repayment; $170
starting salary after
residency
Residency: 3
$290 - $340
$376,000
$377,000
Post-residency: 17
$1,400 - $2,200
Forbearance during
residency, then
extended repayment
Residency: 3
$0
Post-residency: 25
$2,300
Forbearance during
residency, then
extended repayment
with 2 year NHSC
($50k)
Residency: 3
$0
Post-residency: 17.5
$2,300
NHSC S2S: $120k S2S
award paid out as
$30k four times during
residency
Residency: 3
$0
Post-residency: 10
$2,400
PSLF with $170k
starting salary after
residency (PAYE)
Residency: 3
$270-$320
Post-residency: 7
$1,250-$1,700
PCL of $150k with
salary of $170k
Post-residency: 10
$1,591
Forgiven: $293,000
$451,000
$701,000
$244,000
$494,000
$161,000
$291,000
Forgiven: $120,000
3 years of S2S service after
residency, & you could do
NHSC LR after that to repay
the rest of the balance while
staying at the same S2S site
$141,000
$141,000, then
$351,000 forgiven
$40,918
$190,418
Please Remember:
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You should first pursue the specialty that you are passionate about and is a good fit for other reasons than just
financials (i.e. family, lifestyle)
There are several options available – PSLF, Income driven repayment options, lower interest loans, loan repayment
programs, etc.
Nothing is guaranteed in the future – we can simply inform you of options today based on current law. PSLF is a
concern for many of our students and alumni but we feel it will remain a viable option for many as the law is written
and with the addition of the Affordable Care Act
PLEASE BORROW RESPONSIBLY – you need to assume you’ll repay everything borrowed or at least equivalent to
original principal borrowed
We are here to assist you while you are a student and after graduation
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Utilize the Medloans Calculator and Organizer often to review scenarios
4th years attend group session and most sit with us to do a one-on-one.
All students are welcomed and encouraged to speak with us individually along the way
We believe that financial planners are a necessity for those with significant debt and higher incomes
Additional Resources
 State Loan Repayment:
http://nhsc.hrsa.gov/loanrepayment/stateloanrepaymentprogram/index.html
 MA State Loan Repayment:
http://www.mass.gov/eohhs/docs/dph/com-health/primary-care/mlrp-program-guidelines.pdf
 Tufts LRAP: http://lrap.tufts.edu/default.asp
 TUSM Office of Financial Aid: http://medicine.tufts.edu/finaid
 NHSC: www.nhsc.hrsa.gov
 NHSC jobs: http://nhscjobs.hrsa.gov/external/search/index.seam
 PSLF FAQs:
http://studentaid.ed.gov/students/attachments/siteresources/PSLF_QAs_final_02%2012%2010.
pdf
 IBR FAQs: http://studentaid.ed.gov/students/attachments/siteresources/IBR_QA_Final22011.pdf
 PAYE FAQs: http://studentaid.ed.gov/repay-loans/understand/plans/pay-as-you-earn
 AAMC FIRST: https://www.aamc.org/services/first/first_for_students/
 AAMC Medloans Calculator/Organizor: https://www.aamc.org/services/first/medloans/