BHW HRSA-22-051 (T23) CHGME_FINAL.pdf

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Bureau of Health Workforce Division of Medicine and Dentistry

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2022

Phase 1: Application Due Date in Grants.gov: July 15, 2021 Phase 2: Supplemental Information Due Date in EHBs: August 30, 2021

Ensure your SAM.gov and Grants.gov registrations and passwords are current immediately!

Deadline extensions are not granted for lack of registration.

Registration in all systems, including SAM.gov and Grants.gov, may take up to 60 days to complete.

Issuance Date: May 07, 2021

Lisa Flach-Fulcher, Budget Analyst Graduate Medical Education Branch Division of Medicine and Dentistry Telephone: (301) 443-0365 E-mail: aflach-fulcher@hrsa.gov

Authority: 42 U.S.C. § 256e (§ 340E of the Public Health Service Act)

Children’s Hospitals Graduate Medical Education (CHGME)

Payment Program

Funding Opportunity Number: HRSA-22-051 Funding Opportunity Type: New and Competing Continuation

Assistance Listings (CFDA) Number: 93.255

Children’s Hospitals Graduate Medical Education (CHGME)

Funding Opportunity Type: New and Competing Continuation

Assistance Listings (CFDA) Number: 93.255 mailto:aflach-fulcher@hrsa.gov

HRSA-22-051 i

EXECUTIVE SUMMARY

The Health Resources and Services Administration (HRSA) is accepting applications for the fiscal year (FY) 2022 Children’s Hospitals Graduate Medical Education (CHGME) Payment Program. The purpose of this program is to fund freestanding children’s hospitals to support the training of pediatric and other residents in graduate medical education (GME) programs.

The actual amount of CHGME Payment Program funding available, if any, will not be determined until the enactment of the final FY 2022 federal appropriation. This notice is a contingency action taken to ensure that, should funds become available for this purpose, HRSA can process applications and award funds appropriately.

Funding Opportunity Title: Children’s Hospitals Graduate Medical Education

Due Date for Applications: Grants.gov (Phase 1): July 15, 2021 at 11:59 p.m. ET.

HRSA EHBs (Phase 2): August 30, 2021 at 5:00 p.m. ET.

Anticipated Total Annual Available FY22 Funding:

$332,000,000

Estimated Number and Type of Award(s):

59-62 grant awards

Estimated Award Amount: Formula Awards, varies; subject to the availability of appropriated funds

Cost Sharing/Match Required: No Period of Performance: October 1, 2021 through September 30, 2022

(One year) Eligible Applicants: Freestanding children’s hospitals whose inpatients are predominantly under 18 years of age, who participate in an approved GME program, and who have a Medicare payment agreement.

See Section III-1 of this notice of funding opportunity (NOFO), for complete eligibility information.

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Application Guide

You (the applicant organization) are responsible for reading and complying with the instructions included in HRSA’s SF-424 R&R Two-Tier Application Guide, available online at https://www.hrsa.gov/sites/default/files/hrsa/grants/apply/applicationguide/sf- 424-research-related-2tier-guide-v2.pdf, except where instructed in this NOFO to do otherwise.

Submissions

The CHGME Payment Program requires two submissions during the federal FY: (1) an initial application to determine interim payments, and (2) a reconciliation application to finalize the number of full-time equivalent (FTE) resident counts and subsequently determine final payments. CHGME Payment Program awardees applying for the Quality Bonus System (QBS) payment must submit complete individual level documentation for all residents supported by the CHGME Payment Program in the FY 2022 Annual Performance Report (AY 2021-2022). See NOFO Section V.3 Quality Bonus System for more information.

If you fail to comply with all requirements, including federal registrations stated in this NOFO, your application will be deemed non-responsive, and your application will not be considered for funding under this notice. Please note that registration or renewals in SAM.gov and Grants.gov may take up to 60 days to complete.

Technical Assistance

HRSA will hold a pre-application technical assistance (TA) webinar(s) for applicants seeking funding through this opportunity. The webinar(s) will provide an overview of pertinent information in the NOFO and an opportunity for applicants to ask questions.

Visit the HRSA Bureau of Health Workforce’s open opportunities website at https://bhw.hrsa.gov/funding to learn more about the resources available for this funding opportunity.

https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf https://www.hrsa.gov/sites/default/files/hrsa/grants/apply/applicationguide/sf-424-research-related-2tier-guide-v2.pdf https://www.hrsa.gov/sites/default/files/hrsa/grants/apply/applicationguide/sf-424-research-related-2tier-guide-v2.pdf https://bhw.hrsa.gov/funding

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Table of Contents

I. Program Funding Opportunity Description

1. Purpose

2. Background

II. Award Information

1. Type of Application and Award

2. Summary of Funding

III. Eligibility Information

1. Eligible Applicants

2. Cost Sharing/Matching

3. Other

IV. Application and Submission Information

1. Address to Request Application Package

2. Content and Form of Application Submission

i. Attachments

3. Dun and Bradstreet Data Universal Numbering System (DUNS) Number Transition to the Unique Entity Identifier (UEI) and System for Award Management (SAM)

4. Submission Dates and Times

5. Intergovernmental Review

6. Funding Restrictions

V. Application Review Information

1. Review Criteria

2. Review and Selection Process

3. Quality Bonus System (QBS) Payment

4. Assessment of Risk

VI. Award Administration Information

1. Award Notices

2. Administrative and National Policy Requirements

3. Reporting

VII. Agency Contacts

VIII. Other Information

IX. APPENDIX A

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I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Children’s Hospitals Graduate Medical Education (CHGME) Payment Program.

Program Purpose The purpose of the CHGME Payment Program is to compensate for the disparity in the level of Federal GME funding for freestanding children’s teaching hospitals versus other types of teaching hospitals. Federal funding for graduate medical education (GME) is primarily provided by the Centers for Medicare & Medicaid Services (CMS) and goes to full service teaching hospitals that serve primarily adult patients. Freestanding children’s hospitals receive little to no GME funding from Medicare because children’s hospitals have a low Medicare caseload. The CHGME Payment Program is administered by the Bureau of Health Workforce (BHW), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services

(HHS).

Program Goals To achieve this purpose in a timely and effective manner, the CHGME Payment Program provides support to freestanding children’s teaching hospitals by providing a payment established by a formula in accordance with 42 U.S.C. § 256e.

Program Objective Support the education and training of future pediatricians, pediatric sub-specialists, and other non-pediatric residents in freestanding children’s teaching hospitals, including the training of residents in dentistry and psychiatry. In FY 2020, the CHGME Payment Program distributed approximately $323 million to 59 hospitals nationwide; in which funding assists these hospitals to care for low-income children across the country.

2. Background

This program is authorized by 42 U.S.C. § 256e. In 1999, Congress addressed the difference of explicit GME funding between freestanding children’s teaching hospitals and other teaching hospitals by passing the Healthcare Research and Quality Act, which established the CHGME Payment Program. There have been several amendments to the program’s statutory authority, including in April 2014 where the eligibility of the program was expanded to include certain hospitals (see Section III.

Eligibility Information) and most recently in September 2018, amended by the Dr.

Benjy Frances Brooks Children's Hospital GME Support Reauthorization Act of 2018 (P.L. 115-241), when the CHGME Payment Program was reauthorized for a period of five years.

The CHGME Payment Program supports HRSA’s mission to improve health outcomes and address health disparities through access to quality services, a skilled health

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workforce, and innovative, high-value programs. HRSA improves the health of underserved and vulnerable populations by strengthening the health workforce and connecting skilled professionals to communities in need. HRSA oversees several grant programs that support the placement of providers, provide financial support to students in health professions programs, provide continuing education to current health professionals, and foster the development of curricula that promote quality health care.

The nearly 60 freestanding children’s teaching hospitals across the country train about 43 percent of all pediatric residents and 55 percent of pediatric specialists training in the United States (U.S.) annually, and provide valuable training for physicians in many other specialties.1 These are the physicians who care for America’s youngest population – its children. Representing about 1 percent of all short-term acute care hospitals, these hospitals provide almost 50 percent of the patient care to low-income children, including those covered by Medicaid and those who are uninsured.2,3 In addition, these hospitals are regional and national referral centers for critically ill children, often serving as the only source of care for many critical pediatric services.

Freestanding children’s hospitals provide care to a large percentage of children with medical complexity (CMC) and more than one-third of hospitalizations at freestanding children’s hospitals were for CMC compared to one-in-five at general hospitals.4

The CHGME Payment Program is designed to support freestanding children’s teaching hospitals by:

• Educating and training future pediatricians, pediatric sub-specialists, and other non-pediatric residents,

• Providing care for vulnerable and underserved children, and

• Conducting innovative and valuable pediatric research.

Funding children’s hospitals is a part of supporting HRSA’s strategic plan to: 1) improve access to quality health care and services; and 2) foster a health care workforce able to address current and emerging needs.

1 Children’s Hospital Graduate Medical Education Program highlights available at: https://bhw.hrsa.gov/funding/apply-grant/childrens-hospitals-graduate-medical-education.

2 Fast facts on US hospitals [Internet]. Chicago (IL): AHA; 2018 [cited 2018 Feb 7]. Available from:

https://www.aha.org/statistics/2018-01-09-fast-facts-us-hospitals-2018-pdf.

3 Colvin, Jeffrey D., et al. "Financial Loss for Inpatient Care of Medicaid-Insured Children." JAMA pediatrics 170.11 (2016):

1055-1062.

4 Leyenaar, JoAnna K. et al. “Epidemiology of Pediatric Hospitalizations at General Hospitals and Freestanding Children’s Hospitals in the United States.” Journal of hospital medicine 11.11 (2016): 743–749. PMC. Web. 7 Feb. 2018.

https://bhw.hrsa.gov/funding/apply-grant/childrens-hospitals-graduate-medical-education https://bhw.hrsa.gov/funding/apply-grant/childrens-hospitals-graduate-medical-education https://www.aha.org/statistics/2018-01-09-fast-facts-us-hospitals-2018-pdf

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The CHGME Payment Program statute allows the Secretary of HHS to establish a Quality Bonus System (QBS), whereby the Secretary distributes bonus payments to hospitals participating in the program that meet standards specified by the Secretary.

The goal of the QBS is to recognize and incentivize CHGME Payment Program awardees with high quality training to meet the pediatric workforce needs of the nation.

In fiscal year (FY) 2017, HRSA began engaging stakeholders in efforts to develop the CHGME QBS. In FY 2018, HRSA released a Federal Register Notice (FRN) seeking public comment on the proposed CHGME QBS and addressed comments received in a later released FRN. Target outcomes included highlighting children’s hospitals initiatives that have the greatest impact on patient access and quality and those that involve the most residents and/or involve the highest level of resident engagement.

HRSA awarded a QBS evaluation contract in FY 2019, to conduct an environmental scan of GME quality measures, develop quality measures for GME programs in the identified priority areas, and manage an organized stakeholder engagement process on the final QBS standards and measures. Recommendations from the QBS contract and data collected will help support HRSA’s plan to implement quality measures starting in FY 2022, should funds become available for this purpose. See Notice of Funding Opportunity (NOFO) Section V.3 Quality Bonus System for more information.

II. Award Information

1. Type of Application and Award

Types of applications sought: New and Competing Continuation.

HRSA will provide funding in the form of a formula-based payment program. The funds available for the CHGME Payment Program are distributed among participating eligible children’s hospitals. Hospitals that meet eligibility requirements in Section III.1 receive funds based on the annual appropriation.

The CHGME Payment Program makes payments throughout the year to distribute the Direct Medical Education (DME) and Indirect Medical Education (IME) funding. Each of the funding amounts is determined by a legislative formula, and a hospital receives its proportion of the total CHGME Payment Program funding based on the calculation of the formula. The formula was established by CHGME policy published in July 20, 2001 Federal Register notice. For DME, the CHGME Payment Program funding is proportional to the number of residents the hospital trains. Furthermore, the DME payment formula accounts for a hospital’s specific geographic variations in costs, and inflation. For IME, the CHGME formula takes into account the severity of illness of its inpatients, the number of available beds, and the number of residents the hospital trains.

https://www.govinfo.gov/content/pkg/FR-2017-10-16/pdf/2017-22381.pdf https://www.govinfo.gov/content/pkg/FR-2018-06-26/pdf/2018-13592.pdf https://www.govinfo.gov/content/pkg/FR-2001-07-20/pdf/01-18166.pdf

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2. Summary of Funding

HRSA estimates approximately $332,000,000 to be available to fund 59-62 awardees;

this includes an estimated amount of up to $3 million for the CHGME QBS. The actual amount of CHGME Payment Program funding available, if any, will not be determined until the enactment of the final FY 2022 federal appropriation. This notice is a contingency action taken to ensure that applications can be processed and funds awarded in a timely manner should funds become available for the existing program under current law. The period of performance is October 1, 2021 through September 30, 2022 (one year).

In April 2014, the CHGME Payment Program was reauthorized to expand eligibility to “Newly Qualified Hospitals” that meet the eligibility requirements in Section III.1.b. The reauthorization permits the Secretary, “to make available up to 25 percent of the total amounts in excess of $245,000,000 …but not to exceed $7,000,000” 5 for the purpose of making CHGME Payment Program payments to these Newly Qualified Hospitals and for the QBS.

In FY 2021, Congress appropriated $350 million to the CHGME Payment Program. Of this amount, $4 million in payments are targeted to these newly qualified hospitals. If funding levels and mechanisms remain constant, it is estimated that up to approximately $3 million may be available in FY 2022 for the CHGME QBS. If the total amount available for the CHGME QBS in FY 2022 is less than $2 million, HRSA does not plan to implement the CHGME QBS in FY 2022 to minimize the administrative burden on the hospitals. In this case, the funds will be disbursed to all eligible hospitals (including those newly qualified) according to the CHGME Payment Program formula payment methodology.

All HRSA awards are subject to the Uniform Administrative Requirements, Cost Principles, and Audit Requirements at 45 CFR part 75.

III. Eligibility Information

1. Eligible Applicants

There are two categories of children’s hospitals that may be eligible for CHGME payments in FY 2022, depending on the funding appropriated to the program – “Currently Eligible Hospitals” and “Newly Qualified Hospitals.” Hospitals that are applying for the first time for the CHGME Payment Program may be hospitals that are

5 42 U.S.C. § 256e(h)(1).Children’s Hospital GME Support Reauthorization Act of 2013, P.L 113-98 . 42 USC 201 (2013).

https://www.govinfo.gov/content/pkg/BILLS-113s1557enr/pdf/BILLS-113s1557enr.pdfcongress.gov/113/plaws/publ98/PLAW- 113publ98.pdf https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=df3c54728d090168d3b2e780a6f6ca7c&ty=HTML&h=L&mc=true&n=pt45.1.75&r=PART

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new to the CHGME Payment Program but qualify under the “Currently Eligible Hospitals” requirements or are eligible as a “Newly Qualified Hospital.”

a. Currently Eligible Hospitals: Includes freestanding children’s hospitals that meet the original eligibility requirements for CHGME payments that were established prior to the Children’s Hospital GME Support Reauthorization Act of 2013. These freestanding children’s hospitals must meet the following criteria:

1) Have a Medicare payment agreement;

2) Are excluded from the Medicare Inpatient Prospective Payment System (IPPS) pursuant to section 1886(d)(1)(B)(iii)6 of the Social Security Act (SSA) and its accompanying regulations; and

3) Participate in an approved GME residency training program as defined in section 1886(h)(5)(A) of the SSA.

b. Newly Qualified Hospitals: As per the Children’s Hospital GME Support

Reauthorization Act of 2013, a freestanding hospital may be eligible for CHGME payments depending on the level of funding appropriated to the program if it meets the following criteria:

1) Has a Medicare payment agreement;

2) Is excluded from Medicare IPPS pursuant to section 1886(d)(1)(B) of the SSA and its accompanying regulations;

3) Its inpatients are predominantly individuals under 18 years of age;

4) Has an approved medical residency training program as defined in section

1886(h)(5)(A) of the SSA; and

5) Is not otherwise qualified to receive payments as a Currently Eligible Hospital as defined under this section or section 1886(h) of the SSA.

For those freestanding children’s hospitals that met the above requirements for Newly Qualified Hospitals as of April 7, 2014, and the Secretary had not previously determined an average number of FTE residents under section 1886(h)(4) of the SSA, the Secretary may establish such number of FTE residents for the purposes of calculating CHGME Payment Program payments.

Any public or private nonprofit and for-profit children's teaching hospital with an accredited residency training program (as defined below), that meets all of the above requirements for either category of eligibility may apply, though final eligibility for receiving funds as a “currently eligible hospital” or as a “newly qualified hospital” will depend on appropriated funding levels. Children’s hospitals applying for the CHGME Payment Program must train residents during the fiscal year for which they apply for funds.

6 The exclusion of children’s hospitals from IPPS set forth under section 1886(d)(1)(B)(iii) of the SSA states this exclusion exists for hospitals “whose inpatients are predominantly individuals under 18 years of age”.

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Residents may be included in a hospital’s resident FTE count for CHGME Payment Program purposes if the residency program (in which the resident is enrolled) meets one of the following criteria:

1. The program must lead toward board certification of its graduates by the

American Board of Medical Specialties (ABMS) and also be approved for education and training activities by one of the following accrediting bodies:

• Accreditation Council for Graduate Medical Education

• American Osteopathic Association

• Commission on Dental Accreditation of the American Dental Association

• Council of Podiatric Medicine Education of the American Podiatric Medical

Association

2. The program may count towards certification of the resident in a specialty or subspecialty listed in the current edition (at the time of the audit review) of the Directory of Graduate Medical Education Programs (published by the American Medical Association) or the Annual Report and Reference Handbook (published by the American Board of Medical Specialties).

2. Cost Sharing/Matching

Cost sharing or matching is not required for this program.

3. Other

Payments will be determined in compliance with all program mandates, rules, regulations, policies, and guidance.

Deadline HRSA will consider any application that fails to satisfy the deadline requirements referenced in Section IV.4 non-responsive and will not consider it for funding under this notice.

Multiple Applications: Multiple applications from an organization are not allowable.

If for any reason (including submitting to the wrong funding opportunity number or making corrections/updates), an application is submitted more than once prior to the application due date, HRSA will only accept your last validated electronic submission, under the correct funding opportunity number, prior to the Grants.gov application due date as the final and only acceptable application.

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Failure to include all required documents as part of the application will result in an application being considered incomplete or non-responsive. Applications received without the appropriate tables will be deemed non-responsive to the NOFO and will not be considered for funding under this notice.

Hospitals that are newly qualified to receive CHGME funds as “Newly Qualified Hospitals” under the Children’s Hospital GME Support Reauthorization Act of 2013, as of April 7, 2014, and that do not already have a CMS cap established and are not able to apply for a CMS cap as a new residency training program, will have a “CHGME cap” established. The “CHGME cap” will be established using the number of FTEs trained during the most recent Medicare cost report period completed on or before April 7, 2014. This value will be entered on sections 4, 5, and 6, of the HRSA 99-1, on lines 4.06, 5.06, and 6.06 as applicable. The “CHGME cap” reported by newly qualified hospitals will be verified by the CHGME auditors during the FY 2022 audit process.

Documentation Recommendations

Hospitals are responsible for the accuracy of application data submitted to HRSA and are subject to an audit. Hospitals are not required to submit documentation with their initial application to support resident counts reported on their CHGME Payment Program application. However, hospitals should be prepared to produce documentation in accordance with 42 CFR § 413.75(d) in any subsequent audit carried out by HHS or its delegate. The CHGME Payment Program has in place a Resident FTE Assessment (audit) process. Auditors conduct an assessment of the resident FTE counts each fiscal year between October and March. The results of these FTE assessments are the basis for the hospitals’ reconciliation applications. The audit methodology complies with the requirements under 42 CFR § 413.75(d) and parallels a similar GME audit process carried out by CMS to adjudicate the number of residents training in teaching hospitals with primarily adult patients. Children’s hospitals that do not report resident FTE counts to Medicare are not exempt from this policy. An official of the hospital must verify the information provided in the application used to support the number of resident FTEs for a particular cost-reporting period.

The audit is conducted to verify the FTE counts reported by the participating children’s hospitals are accurate and to identify the duplicate FTE residents claimed for CHGME payment during the same period of training time claimed for reimbursement from any other source of federal GME funding, to include GME programs within HRSA (e.g.

THCGME Program), CMS and the Department of Defense. If a FTE residents’ time is submitted to the CHGME program and other federal GME programs for the purposes of receiving payment, the children’s hospitals cannot also claim that same time for payment from the CHGME Payment Program. It is the responsibility of the children’s hospital to resolve any overlaps (i.e., two or more hospitals claim a resident for the same or an overlapping period of time) before a disputed FTE resident will be included in the final FTE resident count used for calculation of CHGME Payment Program funding.

https://www.ecfr.gov/cgi-bin/text-idx?SID=89de6e35acde8f65824bed9d603d15bc&mc=true&node=se42.2.413_175&rgn=div8 https://www.ecfr.gov/cgi-bin/text-idx?SID=89de6e35acde8f65824bed9d603d15bc&mc=true&node=se42.2.413_175&rgn=div8

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HRSA requires applicants to coordinate closely with affiliated teaching hospitals and teaching health centers in order to avoid over-reporting of CHGME supported FTE residents. The audit contractor will review the institutional agreement (also known as an affiliation agreement, memorandum of understanding, inter-institutional agreement, letter of commitment, letter of affiliation, letter of agreement, or written agreement) between the children’s hospital and the sponsoring institution/residency program if the children’s hospital is not the sponsoring institution or a major participating institution.

The institutional agreement should identify the name(s) of the sponsoring institution(s), the residency program in which the residents are enrolled, the children’s hospital, the residency program or department at the children’s hospital where the residents will be rotating, the number of resident FTEs allowed (e.g. 1 FTE per month), effective and expiration dates of the agreement, and financial arrangements. Agreements may vary slightly by specialty due to varying ACGME residency review committee requirements for institutional agreements.

IV. Application and Submission Information

Initial Application Process Overview

Phase I:

Step 1: Confirmation of current registration with the System for Award Management (SAM.gov) Step 2: Registration & Finding the CHGME NOFO on Grants.gov Step 3: Completion of the SF424 (R&R) short form in Grants.gov

Phase II:

Step 1: Registration in HRSA Electronic Handbooks (EHBs) Step 2: Access, completion and submission of CHGME application in HRSA EHBs

1. Address to Request Application Package

HRSA requires you to apply electronically. HRSA instructs you to register with SAM.gov and begin the application through Grants.gov using the SF-424 Research and Related (R&R) workspace application package associated with this NOFO following the directions provided at https://www.grants.gov/applicants/apply-for-grants.html.

Neither a project abstract, a project narrative, nor budget information is required for this funding opportunity. In conjunction with the application requirements and instructions in Section 5 of HRSA’s SF-424 R&R Two-Tier Application Guide, please note the following:

https://www.sam.gov/SAM/ https://www.grants.gov/ https://www.grants.gov/ https://grants.hrsa.gov/2010/WebEPSExternal/Interface/common/accesscontrol/login.aspx?TgtURL=grants.hrsa.gov/webexternal/home.asp&RefURL=https://www.bing.com/search?q=HRSA+EHB&form=IENTHT&mkt=en-us&httpsmsn=1&msnews=1&refig=fbfe4624e30c4699f41383a00b3cafdf&sp=-1&pq=hrsa+ehb&sc=8-8&qs=n&sk=&cvid=fbfe4624e30c4699f41383a00b3cafdf https://www.grants.gov/applicants/apply-for-grants.html https://www.grants.gov/applicants/apply-for-grants.html

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Phase 1. Grants.gov application: Required information must be complete and successfully validated under the correct funding opportunity number by 11:59 P.M.

Eastern Time on July 15, 2021.

The following should be included as part of the Grants.gov submission:

a) SF-424 R&R cover page

b) Project/Performance Site Location(s) form; and

c) Disclosure of Lobbying Activities (SF-LLL), if applicable.

Phase 2. HRSA EHBs: Registration and CHGME applications must be completed and successfully submitted by 5:00 P.M. Eastern Time on August 30, 2021 by your organization’s designated Authorizing Official designated to the CHGME Payment Program. Please note that you can only begin Phase 2 in the HRSA EHBs after Phase 1 in Grants.gov has been completed by the application due date and HRSA has assigned the application a tracking number. CHGME application includes submitting supplemental information, which is completing data forms HRSA 99, HRSA 99-1(1 through 4), HRSA 99-2, and HRSA 99-5 as well as the required Attachments.

Only applicants who successfully have an application validated in Grants.Gov (Phase 1) by the July 15, 2021 due date may submit the additional information CHGME Payment Program data forms in the HRSA EHBs (Phase 2).

The NOFO is also known as “Instructions” on Grants.gov. You must select “Subscribe” and provide your email address for each NOFO you are reviewing or preparing in the workspace application package in order to receive notifications including modifications, clarifications, and/or republications of the NOFO on Grants.gov. You will also receive notifications of documents placed in the RELATED DOCUMENTS tab on Grants.gov that may affect the NOFO and your application. You are ultimately responsible for reviewing the For Applicants page for all information relevant to this NOFO.

2. Content and Form of Application Submission

Unless indicated otherwise in this NOFO, you must submit the information outlined in the SF-424 R&R Two-Tier Application Guide in addition to the program specific information below. You should not attach any supporting documentation that contains personal identifying information with the application including rotation schedules, IRIS data, etc. You are responsible for reading and complying with the instructions included in HRSA’s SF-424 R&R Two-Tier Application Guide except where instructed in the NOFO to do otherwise. You must submit the application in the English language and must be in the terms of U.S. dollars (45 CFR § 75.111(a)).

See Section 9.5 of the SF-424 R&R Two-Tier Application Guide for the Application Completeness Checklist. Applications must be complete and validated by Grants.gov under the correct funding opportunity number prior to the Phase 1 deadline, and supplemental information must be submitted in the EHBs prior to the Phase 2 deadline, to be considered under this notice.

https://www.grants.gov/web/grants/home.html https://grants.hrsa.gov/2010/WebEPSExternal/Interface/common/accesscontrol/login.aspx?TgtURL=grants.hrsa.gov/webexternal/home.asp&RefURL=https://www.bing.com/search?q=HRSA+EHB&form=IENTHT&mkt=en-us&httpsmsn=1&msnews=1&refig=fbfe4624e30c4699f41383a00b3cafdf&sp=-1&pq=hrsa+ehb&sc=8-8&qs=n&sk=&cvid=fbfe4624e30c4699f41383a00b3cafdf https://www.grants.gov/web/grants/applicants.html https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75&ap45.1.75_1521.ix#se45.1.75_1111

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Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

1) You certify, on behalf of the applicant organization, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.

2) Failure to make required disclosures can result in any of the remedies described in 45 CFR § 75.371, including suspension or debarment. (See also 2 CFR parts 180 and 376, and 31 U.S.C. 3321).

3) Where you are unable to attest to any of the statements in this certification, an explanation shall be included as Attachment #5.

See Section 5.1 viii of HRSA’s SF-424 R&R Two-Tier Application Guide for additional information on all certifications.

Program-Specific Forms

The CHGME application includes four (4) forms that are available electronically in the EHBs:

a) HRSA 99: Demographic and Contact Information Form

b) HRSA 99-1: Determination of Weighted and Unweighted Resident FTE Count

Form

c) HRSA 99-2: Determination of Indirect Medical Education Data Related to the

Teaching of Residents Form

d) HRSA 99-5: Application Checklist

Copies of these forms are included in the NOFO for your reference (Appendix A).

Do not include these tables as part of the Grants.gov application submission since you will be entering the data online in the HRSA EHBs by accessing the CHGME web application as part of Phase 2.

i. Attachments

Please provide the following items to complete the content of the application. Each attachment must be clearly labeled, and is to be submitted during Phase 2 of the application directly in the EHBs:

Attachment 1 – If the hospital files a full Medicare Cost Report with CMS, attach Worksheet E-3 part IV or Worksheet E-4 of the Medicare Cost Reports for each of the Medicare Cost Report periods (where applicable).

Attachment 2 – Medicare Affiliation agreements when the hospital utilizes such agreements to increase/decrease its 1996 FTE resident cap, including a letter indicating that the affiliation agreements were filed with CMS prior to July 1 of that affiliation agreement’s academic year.

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Attachment 3 – Documents providing support of additions or reductions to resident FTE cap, if applicable.

Attachment 4 – Evidence of non-profit status, if applicable.

Attachment 5 – Delinquency on federal debt explanation and/or Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification explanation, if applicable.

3. Dun and Bradstreet Data Universal Numbering System (DUNS) Number Transition to the Unique Entity Identifier (UEI) and System for Award Management (SAM)

You must obtain a valid DUNS number, also known as the Unique Entity Identifier, for your organization/agency and provide that number in your application. In April 2022, the *DUNS number will be replaced by the UEI, a “new, non- proprietary identifier” requested in, and assigned by, the System for Award Management (SAM.gov). For more details, visit the following: Planned UEI Updates in Grant Application Forms and General Service Administration’s UEI Update page.

You must also register with SAM and continue to maintain active SAM registration with current information at all times during which you have an active federal award or an application or plan under consideration by an agency (unless the applicant is an individual or federal agency that is exempted from those requirements under 2 CFR 25.110(b) or (c), or has an exception approved by the agency under 2 CFR 25.110(d).

SAM is an official website of the U.S. government. There is no cost to use SAM. You can use this site for FREE to:

• Register to do business with the U.S. government

• Update or renew your entity registration

• Check status of an entity registration

• Search for entity registration and exclusion records

If you are chosen as a recipient, HRSA would not make an award until you have complied with all applicable DUNS (or UEI) and SAM requirements and, if you have not fully complied with the requirements by the time HRSA is ready to make an award, you may be deemed not qualified to receive an award and HRSA will use that determination as the basis for making an award to another applicant.

If you have already completed Grants.gov registration for HRSA or another federal agency, confirm that it is still active and that the Authorized Organization Representative (AOR) has been approved.

https://www.grants.gov/web/grants/forms/planned-uei-updates.html https://www.grants.gov/web/grants/forms/planned-uei-updates.html https://www.gsa.gov/entityid https://www.ecfr.gov/cgi-bin/text-idx?node=pt2.1.25&rgn=div5#se2.1.25_1110 https://www.ecfr.gov/cgi-bin/text-idx?node=pt2.1.25&rgn=div5#se2.1.25_1110 https://www.ecfr.gov/cgi-bin/text-idx?node=pt2.1.25&rgn=div5#se2.1.25_1110

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Currently, the Grants.gov registration process requires information in three separate systems:

• Dun and Bradstreet (https://www.dnb.com/duns-number/lookup.html)

• System for Award Management (SAM) (https://www.sam.gov/SAM/)

• Grants.gov (http://www.grants.gov/)

For further details, see Section 3.1 of HRSA’s SF-424 R&R Two-Tier Application Guide.

SAM.GOV ALERT: Please note that as of May 24, 2021 SAM interfaces will change, please see the SAM.gov Alert for additional information. If you are a point of contact for your agency's system account that accesses SAM Entity Management data, please review and take the necessary actions as reflected in SAM Interfaces Are Changing.

If you fail to allow ample time to complete registration with SAM.gov or Grants.gov, you will not be eligible for a deadline extension or waiver of the electronic submission requirement.

4. Submission Dates and Times

Application Due Date The due dates for applications under this NOFO are as follows:

• Grants.gov (Phase 1): July 15, 2021 at 11:59 p.m. ET.

• HRSA EHBs (Phase 2): August 30, 2021 at 5:00 p.m. ET.

See Section 9.2.5 – Summary of e-mails from Grants.gov of HRSA’s SF-424 R&R Two- Tier Application Guide for additional information.

5. Intergovernmental Review

The CHGME Payment Program is not subject to the provisions of Executive Order 12372, as implemented by 45 CFR 100.

See Section 5.1 ii of HRSA’s SF-424 R&R Two-Tier Application Guide for additional information.

6. Funding Restrictions

It is anticipated that funds awarded under this payment program will be for direct and indirect graduate medical expenses for a period of performance of one (1) year.

Funding is dependent on the availability of funds and the amount of funding will be determined based on congressionally appropriated dollars.

Funds under this notice may not be used for purposes specified in HRSA’s SF-424 R&R Two-Tier Application Guide under “Funding Restrictions.”

https://www.dnb.com/duns-number/lookup.html https://www.sam.gov/SAM/ http://www.grants.gov/ https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf http://sam.gov/ https://sam.gov/SAM/pages/public/generalInfo/samNews.jsf https://sam.gov/SAM/transcript/SAM_Interface_Changes.pdf https://sam.gov/SAM/transcript/SAM_Interface_Changes.pdf https://www.grants.gov/ https://grants.hrsa.gov/2010/WebEPSExternal/Interface/common/accesscontrol/login.aspx?TgtURL=grants.hrsa.gov/webexternal/home.asp&RefURL=https://www.bing.com/search?q=hrsa+ehb&src=IE-SearchBox&FORM=IENAE2 https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf

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The General Provisions in Division H of the Consolidated Appropriations Act, 2021 (P.L.

116-260) apply to this program. Consolidated Appropriations Act, 2021 (P.L. 116-260) Please see Section 5.1.iv of HRSA’s SF-424 R&R Two-Tier Application Guide for additional information. Note that these or other restrictions will apply in following fiscal years, as required by law.

You are required to have the necessary policies, procedures and financial controls in place to ensure that your organization complies with all legal requirements and restrictions applicable to the receipt of federal funding, including statutory restrictions on use of funds for lobbying, executive salaries, gun control, abortion, etc. Like those for all other applicable award requirements, the effectiveness of these policies, procedures and controls is subject to audit.

V. Application Review Information

1. Review Criteria

This formula-based payment program does not require submission of a project narrative for review by a review committee. HRSA is responsible for the review of each application for eligibility, completeness and accuracy (including the data reported on all tables), and compliance with the requirements outlined in this NOFO. Application review is conducted at HRSA by HRSA staff, and Fiscal Intermediaries (FI) conduct an independent assessment of FTE resident count. Section 340E(e)(3) of the Public Health Service Act states, in part, “[t]he Secretary shall determine any changes to the number of residents reported by a hospital in the application of the hospital for the current fiscal year to determine the final amount payable to the hospital for the current fiscal year for both direct expense and indirect expense amounts.” The assessment of the FTE resident count by FIs occurs within a six-month period from the start of the federal fiscal year to the spring of the same federal fiscal year, to allow for reconciliation of payments within the appropriation year for which payments are made.

CHGME FIs carry out the FTE assessment of residents each fiscal year, and each of the children’s hospitals participating in the program is subject to this assessment. The final amount determined through the reconciliation process is subject to administrative and judicial review under section 1878 of the SSA.

2. Review and Selection Process

The funds appropriated for the CHGME Payment Program are distributed among participating institutions as a formula-based payment program. Program data reported on HRSA forms are used to determine funding and administer the program. All required tables must be submitted electronically in the HRSA EHBs with the Phase 2 submission. Applications received without the appropriate tables will be deemed non-responsive to the NOFO and will not be considered for funding under this notice.

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3. Quality Bonus System (QBS) Payment

The FY 2022 CHGME NOFO includes up to an estimated $3 million that may be available for the CHGME QBS, which focus on quality measurement and improvement and further recognizes hospitals for quality improvement and GME transformation efforts and engagement in broader initiatives involving high priority focus areas, which supports HRSA’s efforts to improve the quality of the data collected about our programs, which will in turn assist in measuring and demonstrating long-term programmatic impacts and effectiveness.

In order to qualify for the QBS payment,

1) CHGME awardees must complete individual level documentation for all residents supported by the CHGME Payment Program in the FY 2022 Annual Performance Report (AY 2021-2022); and

2) CHGME awardees must report at 90% or greater response rate, excluding the “Not Reported” response option, in any individual level demographic including ethnicity, race, rural background and disadvantaged background, and training level data including training in telehealth and interprofessional teams in the FY 2022 Annual Performance Report (AY 2021-2022); and

3) Awardees must report provide 50% or greater complete post-residency employment data in the FY 2022 Annual Performance Report (AY 2021- 2022)

See CHGME Annual Performance Report (AY 2019–2020) Instruction Manual for further information about the required performance measures collected.

Payment Structure: QBS payments in FY 2022 are targeted to be disbursed at the end of the fiscal year to ensure CHGME follows legislative mandates. CHGME hospitals that submit the required documentation outlined above will receive a portion of the available funds for the CHGME QBS payment. Amounts will be distributed according to a three tiered payment structure that recognizes the different annual payment levels received by CHGME hospitals. A QBS base payment rate will be determined from the total amount available and the number of hospitals that qualify for the CHGME QBS in a fiscal year. Hospitals that meet the QBS standards will be divided into three tiers based on their combined direct and indirect fiscal year payment amounts, as calculated per the established CHGME Payment Program formulas:

Tier 1: Hospitals that qualify for the quality bonus payment that are in the lowest third of calculated CHGME annual payments among hospitals that qualify for the quality bonus payment of calculated CHGME annual payments will receive the QBS base payment.

Tier 2: Hospitals that qualify for the quality bonus payment that are in the middle third of calculated CHGME annual payments among hospitals that qualify for the quality bonus payment will receive two times the QBS base payment.

https://grants4.hrsa.gov/WebBPMHExternal/Interface/ProgramManualhtmL.aspx?FormCode=1&IsPM=True&EHBActivityCode=T23

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Tier 3: Hospitals that qualify for the quality bonus payment that are in the highest third of calculated CHGME annual payments among hospitals that qualify for the quality bonus payment will receive three times the QBS base payment.

The QBS base payment rate would be determined from the total amount available and the number of hospitals that qualify for the CHGME QBS in a fiscal year.

4. Assessment of Risk

HRSA may elect not to fund applicants with management or financial instability that directly relates to the organization’s ability to implement statutory, regulatory or other requirements (45 CFR § 75.205).

HRSA reviews applications for other considerations that include past performance, as applicable, cost analysis of the project/program budget, assessment of your management systems, ensuring continued applicant eligibility, and compliance with any public policy requirements, including those requiring just-in-time submissions.

HRSA may ask you to submit additional programmatic or administrative information or to undertake certain activities in anticipation of an award. However, even at this point in the process, such requests do not guarantee that HRSA will make an award.

Following review of all applicable information, the HRSA’s approving and business management officials will determine whether HRSA can make an award, if special conditions are required, and what level of funding is appropriate. Award decisions are discretionary and are not subject to appeal to any HRSA or HHS official or board.

HRSA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS). You may review and comment on any information about your organization that a federal awarding agency previously entered. HRSA will consider any of your comments, in addition to other information in FAPIIS in making a judgment about your organization’s integrity, business ethics, and record of performance under federal awards when completing the review of risk posed by applicants as described in 45 CFR § 200.205 Federal Awarding Agency Review of Risk Posed by Applicants.

HRSA will report to FAPIIS a determination that an applicant is not qualified (45 CFR § 75.212).

VI. Award Administration Information

1. Award Notices

HRSA intends to issue the Notice of Award (NOA) to “Currently Eligible Hospitals”, subject to the availability of funds through the enactment of an annual appropriation or a continuing resolution in November 2021. The NoA to “Newly Qualified Hospitals” is to be https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#se45.1.75_1205 https://www.fapiis.gov/fapiis/index.action https://www.fapiis.gov/ https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75#se45.1.75_1205 http://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#se45.1.75_1212 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75

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issued once an annual appropriation is passed. See Section 6.4 of HRSA’s SF-424 R&R Two-Tier Application Guide for additional information.

For “Newly Qualified Hospitals,” the reauthorization permits the Secretary, “to make available up to 25 percent of the total amounts in excess of $245,000,000” but “not to exceed $7,000,000.” “Newly Qualified Hospitals” will not receive an award, if any, until after an annual appropriation has been passed, and only if the annual appropriation is funded at $245,000,000 or more for FY 2022.

2. Administrative and National Policy Requirements

See Section 2.2 of HRSA’s SF-424 R&R Two-Tier Application Guide.

If you are successful and receive a Notice of Award NOA, in accepting the award, you agree that the award and any activities thereunder are subject to all provisions of 45 CFR part 75, currently in effect or implemented during the period of the award, other Department regulations and policies in effect at the time of the award, and applicable statutory provisions.”

Requirements of Subawards

The terms and conditions in the NOA apply directly to the recipient of HRSA funds. The recipient is accountable for the performance of the project, program, or activity; the appropriate expenditure of funds under the award by all parties; and all other obligations of the recipient, as cited in the NOA. In general, the requirements that apply to the recipient, including public policy requirements, also apply to subrecipients and contractors under grants, unless the NOA specifies an exception, and it is the recipient’s responsibility to monitor the compliance of all funded subrecipients. See 45 CFR § 75.101 (Applicability) for more details.

3. Reporting

Please note that the OMB revisions to Guidance for Grants and Agreements termination provisions located at 2 CFR § 200.340 - Termination applies to all federal awards effective August 13, 2020.”

Award recipients must comply with Section 7 of HRSA’s SF-424 R&R Two-Tier Application Guide and the following reporting and review activities:

a. Audit Requirements HHS, or any other authorized federal agency, may conduct an audit to determine whether the applicant has complied with all governing laws and regulations in its application for funding.