cms-rht-26-001_final.pdf

Notice of Funding Opportunity

Application due November 5, 2025

Rural Health Transformation Program Opportunity number: CMS-RHT-26-001

Contents

Step 1: Review the Opportunity 4

Basic information 5

Summary 5

Funding details 6

Eligibility 7

Program description 10

Step 2: Get Ready to Apply 23

Get registered 24

Find the application package 24

Step 3: Build Your Application 25

Application checklist 26

Application contents and format 27

Step 4: Understand Review, Selection, and Award 46

Application review 47

Award notices 54

Step 5: Submit Your Application 55

Application submission and deadlines 56

Step 6: Learn What Happens After Award 58

Post-award requirements and administration 59

Contacts and Support 62

Before you begin 3

Appendix 64

Endnotes 124

Contents 2

Before you begin If you believe you are a good candidate for this funding opportunity, secure your SAM.gov and Grants.gov registrations now. If you are already registered, make sure your registrations are active and up-to-date.

SAM.gov registration (this can take several weeks)

You must have an active account with SAM.gov. This includes having a Unique

Entity Identifier (UEI).

See Step 2: Get Ready to Apply

Grants.gov registration (this can take several days)

You must have an active Grants.gov registration. Doing so requires a Login.gov registration as well.

See Step 2: Get Ready to Apply

Apply by the application due date

Applications are due by 11:59 p.m. Eastern Time on November 5, 2025.

To help you find what you need, this NOFO uses internal links. In Adobe

Reader, you can go back to where you were by pressing Alt + Left Arrow

(Windows) or Command + Left Arrow (Mac) on your keyboard.

Before you begin 3 https://sam.gov/ https://grants.gov/

1. Review 2. Get Ready 3. Build 4. Understand 5. Submit 6. Award Contacts

Step 1:

Review the Opportunity

In this step

Basic information 5

Summary 5

Funding details 6

Eligibility 7

Program description 10

Basic information Centers for Medicare & Medicaid Services (CMS)

Center for Medicaid and CHIP Services

Supporting rural communities to improve healthcare access, quality, and outcomes through system transformation.

Have questions?

See Contacts and

Support.

Key facts Opportunity name: Rural

Health Transformation

Program

Opportunity number:

CMS-RHT-26-001

Assistance listing:

93.798

NOFO version: Original

Key dates Informational program introduction applicant webinars: September 19 and 25, 2025

To register for the webinars, please visit the program website.

Optional letter of intent deadline:

September 30, 2025

Application submission deadline:

November 5, 2025

Expected award date:

December 31, 2025

Expected earliest start date: December 31, 2025

See other submissions for other time frames that may apply to this NOFO.

Summary The Rural Health Transformation (RHT) Program helps State governments to support rural communities across America in improving healthcare access, quality, and outcomes by transforming the healthcare delivery ecosystem.

The RHT Program focuses on promoting innovation, strategic partnerships, infrastructure development, and workforce investment.

States will help rural communities meet these strategic goals:

• Make rural America healthy again: Support rural health innovations and new access points to promote preventative health and address root causes of diseases. Projects will use evidence-based, outcomes-driven interventions to improve disease prevention, chronic disease management, behavioral health, and prenatal care.

• Sustainable access: Help rural providers become long-term access points for care by improving efficiency and sustainability. With RHT

Program support, rural facilities work together—or with high-quality regional systems—to share or coordinate operations, technology, primary and specialty care, and emergency services.

• Workforce development: Attract and retain a high-skilled health care workforce by strengthening recruitment and retention of healthcare providers in rural communities. Help rural providers practice at the top of their license and develop a broader set of providers to serve a rural community’s needs, such as community health workers, pharmacists, and individuals trained to help patients navigate the healthcare system.

• Innovative care: Spark the growth of innovative care models to improve health outcomes, coordinate care, and promote flexible care arrangements. Develop and implement payment mechanisms incentivizing providers or Accountable Care Organizations (ACOs) to

1. Review 2. Get Ready 3. Build 4. Understand 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 5 https://www.cms.gov/priorities/rural-health-transformation-rht-program/rural-health-transformation-rht-program?auHash=giZDOV_0UxTb7MzVnomtksGsTRf1kt3OMe5aKMIt1vc reduce health care costs, improve quality of care, and shift care to lower cost settings.

• Tech innovation: Foster use of innovative technologies that promote efficient care delivery, data security, and access to digital health tools by rural facilities, providers, and patients. Projects support access to remote care, improve data sharing, strengthen cybersecurity, and invest in emerging technologies.

Funding details Funding type: Cooperative agreement, which means that both you and CMS will have roles in the project. Throughout the life of your project, we will be there to help and work with you.

Announcement type: New

Expected total funding for the program: $50 billion over five budget periods

Expected total awards: Up to 50

This is a one-time application opportunity. We will provide funding in five budget periods of 10 months for the first budget period and 12 months for each subsequent budget period. These budget periods align with funding appropriated for this program from fiscal year 2026 through fiscal year 2030.

For each budget period, recipients will have until the end of the following fiscal year to spend awarded funding.

We will determine awardees by December 31, 2025. We will determine the four following award amounts by these dates:

• For funding appropriated for fiscal year 2027: October 31, 2026

• For funding appropriated for fiscal year 2028: October 31, 2027

• For funding appropriated for fiscal year 2029: October 31, 2028

• For funding appropriated for fiscal year 2030: October 31, 2029

Step 1: Review the Opportunity 6

Eligibility Eligible applicants In accordance with the authorizing statute, Section 71401 of Public Law 119-21, only the 50 U.S. States are eligible to receive an RHT Program award; the

District of Columbia and U.S. Territories are not eligible.

Local governments, hospitals, universities, nonprofits, federally recognized tribes, individuals, and any other entity besides one of the 50 States of the

United States are also ineligible to receive an RHT Program award.

All 50 U.S. States are eligible, even if they do not have a large rural population or any rural hospitals. We encourage every State to focus on how this funding could benefit its rural populations and consider applying.

Other eligibility requirements To apply for an RHT Program award, each State must submit an official application.

The primary recipient of each award must be a single State. Because each

State’s funding allotment is distinct, joint or consortium applications involving multiple States are not permitted.

The governor may designate a lead agency or office to develop and submit the application, like the State’s department of health, department of human services, or State Medicaid agency.

The application must come from a State government agency or office and include a letter of endorsement signed by the governor. See information on this letter in the Attachments.

Authorized Organizational Representatives To apply, you need to designate an authorized organizational representative

(AOR). This person is the State’s designated representative, with the authority to act on behalf of the State to handle grants and cooperative agreements.

This person must be an official with the authority to legally bind the State.

The AOR will sign all application forms. This signature means that the State will assume the obligations imposed by the terms and conditions of the award, including federal statutes and regulations and other terms and conditions of the award, if the State and CMS enter into a cooperative agreement.

Step 1: Review the Opportunity 7

The State’s responsibilities include oversight for using the award funds appropriately and carrying out the project as specified in your approved cooperative agreement.

Partners Only a State that submits an official application can be the primary recipient of each award under this opportunity. You may consult and involve numerous partners like universities, local health departments, community-based organizations, and provider associations in designing and implementing the planned activities proposed in your application and may sub-award or contract

RHT Program funds to such partners for various activities.

You must also consult certain stakeholders during the creation of your application, as described in application contents and format. However, these partners are not co-applicants. The prime awardee responsible to CMS will be the Governor-designated lead agency or office that submitted the application and was awarded funding.

Completeness and responsiveness criteria We will review your application to make sure it meets the requirements found in Eligibility, Application contents and format, and Application submission and deadlines.

We won’t consider an application that:

• Is from an organization that doesn’t meet all eligibility criteria.

• Is submitted after the deadline.

• Is not submitted through Grants.gov.

• Does not include all components required in the application checklist.

• Does not use the formatting requirements, including spacing, font size, etc.

We may allow you to correct minor errors if there is time before our decision deadline, but this is not guaranteed.

It is your responsibility to ensure the submission is complete and compliant.

Step 1: Review the Opportunity 8

Application limits A State may submit only one official completed application. We will not review multiple completed applications from the same State. States are expected to coordinate across relevant departments and stakeholders to develop a unified proposal. If more than one completed application is received from a State, the last submitted complete application prior to the submission deadline will be reviewed, and any earlier submissions will be disregarded.

Cost sharing This program has no cost-sharing requirement, meaning you do not need to contribute to the costs of this project.

Step 1: Review the Opportunity 9

Program description Purpose The RHT Program will provide funding to support States in enhancing existing activities and implementing activities articulated in the authorizing statute.[1]

Through a cooperative agreement award, funding under the RHT Program will be granted directly to States with approved applications, based on a single application opportunity, for investments that will transform the way care is delivered in rural communities. This funding will drive the following strategic goals, which are aligned with approved use of funds:

• Make rural America healthy again: Support rural health innovations and new access points to promote preventative health and address root causes of diseases. Projects will use evidence-based, outcomes-driven interventions to improve disease prevention, chronic disease management, behavioral health, and prenatal care.

• Sustainable access: Help rural providers become long-term access points for care by improving efficiency and sustainability. With RHT

Program support, rural facilities work together—or with high-quality regional systems—to share or coordinate operations, technology, primary and specialty care, and emergency services.

• Workforce development: Attract and retain a high-skilled health care workforce by strengthening recruitment and retention of healthcare providers in rural communities. Help rural providers practice at the top of their license and develop a broader set of providers to serve a rural community’s needs, such as community health workers, pharmacists, and individuals trained to help patients navigate the healthcare system.

• Innovative care: Spark the growth of innovative care models to improve health outcomes, coordinate care, and promote flexible care arrangements. Develop and implement payment mechanisms incentivizing providers or Accountable Care Organizations (ACOs) to reduce health care costs, improve quality of care, and shift care to lower cost settings.

• Tech innovation: Foster use of innovative technologies that promote efficient care delivery, data security, and access to digital health tools by rural facilities, providers, and patients. Projects support access to remote care, improve data sharing, strengthen cybersecurity, and invest in emerging technologies.

Step 1: Review the Opportunity 10

Background As part of Public Law 119‑21, Congress established the $50 billion RHT

Program to help rural communities reimagine their health care delivery systems and improve health outcomes.

Congress authorized the Administrator of CMS to provide funding to States to invest in at least three uses of funds as described in the use of funds section and in statute.

This program addresses longstanding health-care challenges facing rural communities. Therefore, funding will be focused on promoting innovation, strategic partnerships, infrastructure development, and workforce investment to support rural population health care innovations and new access points to promote preventative health and address root causes of disease.

Program requirements and expectations Use of funds You may use funds awarded under this opportunity only for the permissible uses specified in the statute and described here. As a condition of approval, your application must reflect that you will use awarded funds to invest in at least three of these permissible uses that are described in Section 71401 of

Public Law 119-21:

A. Prevention and chronic disease: Promoting evidence-based, measurable interventions to improve prevention and chronic disease management.

B. Provider payments: Providing payments to health care providers for the provision of health care items or services, subject to restrictions described in the funding policies and limitations.

C. Consumer tech solutions: Promoting consumer-facing, technology-driven solutions for the prevention and management of chronic diseases.

D. Training and technical assistance: Providing training and technical assistance for the development and adoption of technology-enabled solutions that improve care delivery in rural hospitals, including remote monitoring, robotics, artificial intelligence, and other advanced technologies.

E. Workforce: Recruiting and retaining clinical workforce talent to rural areas, with commitments to serve rural communities for a minimum of 5 years.

Step 1: Review the Opportunity 11

F. IT advances: Providing technical assistance, software, and hardware for significant information technology advances designed to improve efficiency, enhance cybersecurity capability development, and improve patient health outcomes.

G. Appropriate care availability: Assisting rural communities to right size their health care delivery systems by identifying needed preventative, ambulatory, pre-hospital, emergency, acute inpatient care, outpatient care, and post-acute care service lines.

H. Behavioral health: Supporting access to opioid use disorder treatment services (as defined in section 1861(jjj)(1) of the Social Security Act), other substance use disorder treatment services, and mental health services.

I. Innovative care: Developing projects that support innovative models of care that include value-based care arrangements and alternative payment models, as appropriate.

Additional uses designed to promote sustainable access to high quality rural health care services, as determined by the Administrator:

J. Capital expenditures and infrastructure: Investing in existing rural health care facility buildings and infrastructure, including minor building alterations or renovations and equipment upgrades to ensure long-term overhead and upkeep costs are commensurate with patient volume, subject to restrictions in the funding policies and limitations.

K. Fostering collaboration: Initiating, fostering, and strengthening local and regional strategic partnerships between rural facilities and other health care providers to promote quality improvement, improve financial stability of rural facilities, and expand access to care.[2]

Collaborators and stakeholders You may collaborate and share ideas with other States, however, each State must apply separately for its own funding. Your initiatives could include multistate collaborations, such as regional networks or complementary workforce initiatives.

You may consult and involve partners like universities, local health departments, and provider associations when designing and implementing the activities in your project.

You may subaward or subcontract RHT Program funds to such partners for various activities, but you must make your process and criteria for selecting such subawardees and subcontractors clear to CMS. Note that the terms and

Step 1: Review the Opportunity 12 conditions of federal awards generally flow down to subawards and subrecipients, as specified in 2 CFR 200.101(b)(1).

See the governor’s endorsement section for stakeholders you need to consult when writing your application.

Funds distribution The RHT Program will provide approximately $50 billion to approved States over five budget periods. $10 billion of funding becomes available each budget period, beginning in fiscal year 2026 and ending in fiscal year 2030.

The money will be distributed as follows:

• Baseline funding: We will distribute $25 billion equally among all approved States, up to a maximum of 50 approved States. Baseline funding will be half of the total funding available each budget period.

◦ Baseline funding per approved State = half of the total funding available each budget period / # of approved States

• Workload funding: We will distribute the other $25 billion based on the content and quality of your application and rural factors. Workload funding will be half of the total funding available each budget period.

The initial Workload funding amounts will be calculated based on the information you provide CMS in the RHT Program application and government data sets.

The total points score is determined by two sets of factors (see Table 1, and the appendix for detailed definitions and points scoring methodology):

1. Rural facility and population score factors

2. Technical score factors

1. Review 2. Get Ready 3. Build 4. Understand 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 13 https://www.ecfr.gov/current/title-2/part-200/section-200.101#p-200.101(b)(1)

CMS will re-calculate each approved State’s technical score and corresponding Workload funding amount for each subsequent budget period based on the information and data the approved State provides in the required annual reporting each year. In particular, CMS will focus on assessing progress towards the goals and commitments that an approved State makes as documented in its cooperative agreement. The definition and factors for calculating the technical score will remain the same as described in this

NOFO. A State’s rural facility and population score will not be recalculated every budget period and will only be calculated once, based on data available during your initial application process in calendar year Q4 2025.

Workload funding factors The workload funding factor types are described here. Refer to the appendix for detailed definitions and points scoring methodology.

• Data-driven metrics: Points awarded based on the value of your metrics compared to other States.

• Initiative-based: Points are awarded based on a qualitative assessment of the programmatic initiatives you outlined in your application and subsequent follow-through. States should decide what types of initiatives they use funding on and do not have to use funding on all initiative-based factors.

• State policy actions: Points are awarded based on current State policy, based on third-party resources accessed by CMS and validated by you attesting to your current policy stance in your application, proposed policy action that you commit to by accepting the award, and subsequent follow-through toward meeting your policy action commitments. We believe these State policy actions, which don’t use funding and are optional to pursue, will be complimentary to and greatly enhance the impact of initiative-based investments and their benefits to health care in rural communities. The State policy components of factors B. 2 and B. 4 will not count towards a State’s overall score until the budget period beginning after October 31, 2026. States will also have until December 31, 2028 to follow through on meeting their policy commitments for these two factors only.

Step 1: Review the Opportunity 14

Table 1: Rural facility and population score and technical score factors

Rural facility and population score factors Factor type

A. 1. Absolute size of rural population in a State Data-driven

A. 2. Proportion of Rural Health Facilities in the State Data-driven

A. 3. Uncompensated care in a State Data-driven

A. 4. % of State population located in rural areas Data-driven

A. 5. Metrics that define a State as being frontier Data-driven

A. 6. Area of a State in total square miles Data-driven

A. 7. % of hospitals in a State that receive Medicaid DSH payments Data-driven

Technical score factors Factor type

B. 1. Population health clinical infrastructure Initiative-based

B. 2. Health and lifestyle Initiative-based and State policy actions

B. 3. SNAP waivers State policy actions

B. 4. Nutrition Continuing Medical Education State policy actions

C. 1. Rural provider strategic partnerships Initiative-based

C. 2. EMS Initiative-based

C. 3. Certificate of Need State policy actions

D. 1. Talent recruitment Initiative-based

D. 2. Licensure compacts State policy actions

D. 3. Scope of practice State policy actions

E. 1. Medicaid provider payment incentives Initiative-based

E. 2. Individuals dually eligible for Medicare and Medicaid Initiative-based and Data-driven

E. 3. Short-term, limited-duration insurance State policy actions

F. 1. Remote care services Initiative-based and State policy actions

F. 2. Data infrastructure Initiative-based and Data-driven

F. 3. Consumer-facing tech Initiative-based

Step 1: Review the Opportunity 15

Funding redistribution In accordance with 42 U.S.C. 1397ee(h)(1)(B), in either of the following scenarios, unexpended or unobligated funds will be redistributed:

• Unexpended: A State does not spend all funds CMS awarded to it by the end of the subsequent fiscal year with respect to each budget period start date. Spending can include expenses paid out on initiatives run at the State level, or funding paid out as subawards, subgrants, or subcontracts to other organizations and entities to execute initiatives, with strong State oversight. Funding earmarked but not paid out for future spending, expenses, or subawards/subgrants/subcontracts are not considered spent.

• Unobligated: CMS does not award the full $10 billion available in a given budget period.

If such additional funds become available, we will redistribute them in the nearest following fiscal year possible according to the same structure outlined previously. Any funding that is unexpended or unobligated as of

October 1, 2032, shall be returned to the Treasury of the United States.

Cooperative agreement terms Cooperative agreements require substantial CMS project involvement after an award is made. There are specific roles for both you and CMS as described here. We may be in contact at least once a month, and more frequently when appropriate.

Your responsibilities

• Comply with the terms and conditions of the award.

• Collaborate with CMS staff to implement and monitor the project.

• Submit the performance measures agreed upon in your cooperative agreement, Notice of Award, and subsequent revisions to work plan as approved by us.

• Submit all required performance assessments, evaluations, and financial reports included in the terms and conditions. See the reporting section.

• Attend monthly calls with the CMS project or grants management specialist to discuss your project’s progress and challenges. The meetings will include key personnel and the State project officer or project director.

• Participate in any virtual meetings.

Step 1: Review the Opportunity 16

CMS responsibilities

• Monitor the project’s performance and progress according to the processes outlined in Post-Award Requirements and Administration.

• Collaborate with you and provide substantial project planning and implementation input.

• Provide substantial input in evaluation activities.

• Make recommendations for continuing the project.

• Maintain up-to-date website content to keep you informed.

• Review and approve all key personnel.

• Maintain regular communication with you through at least monthly conference calls along with technical assistance and consultation.

• Review and provide feedback on all required performance assessment reports.

• Review and approve all required submitted data.

• Provide a structured approach to sharing, integrating, and actively applying improvement concepts, tactics, and lessons learned amongst approved award recipients.

• Evaluate changes to proposed activities in your workplan in extenuating circumstances. We will evaluate your State’s rural health transformation plan amendments as needed to approve use of funding for alternative activities not originally agreed upon in your application and annual reporting. The intent is not to change a State’s allocated funding amount, but to accommodate funding of alternative activities not originally envisioned in rare and extenuating circumstances with existing allocated funding. Extenuating circumstances may include:

◦ Drastic changes in the State health care delivery system that would make your original activities not reasonably practicable to implement or not beneficial.

◦ Catastrophic events that are not foreseeable when you apply.

Substantial CMS project involvement relates to programmatic involvement, not administrative oversight.

Statutory authority Public Law 119-21, Section 71401

Step 1: Review the Opportunity 17

Funding policies and limitations Changes in HHS regulations Awards will be subject to any applicable provisions of 2 CFR Part 200 and 2

CFR Part 300. As of October 1, 2025, HHS will adopt 2 CFR Part 200, with some modifications included in 2 CFR Part 300. These regulations can be found at 89 FR 80055 and replace those in 45 CFR Part 75.

Limitations We do not allow the following costs:

• Pre-award costs.

• Meeting matching requirements for any other federal funds or local entities.

• Services, equipment, or supports that are the legal responsibility of another party under federal, State, or tribal law, such as vocational rehabilitation or education services.

• Services, equipment, or supports that are the legal responsibility of another party under any civil rights law, such as modifying a workplace or providing accommodations that are obligations under law.

• Goods or services not allocable to the project.

• Supplanting existing State, local, tribal, or private funding of infrastructure or services, such as staff salaries.

• Construction or building expansion, purchasing or significant retrofitting of buildings, cosmetic upgrades, or any other cost that materially increases the value of the capital or useful life as a direct cost.

• The cost of independent research and development, including their proportionate share of indirect costs. See 2 CFR 300.477.

• Funds related to any activity designed to influence the enactment of legislation, appropriations, regulation, administrative action, or executive order.

• Purchase of covered telecommunications and video surveillance equipment (See 2 CFR 200.216) as well as financial assistance to households for installation and monthly broadband internet costs.

• Meals, unless in limited circumstances such as:

◦ Subjects and patients under study.

◦ Where specifically approved as part of the project or program activity, such as in programs providing children’s services.

1. Review 2. Get Ready 3. Build 4. Understand 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 18 https://www.ecfr.gov/current/title-2/part-200 https://www.federalregister.gov/documents/2024/10/02/2024-21984/health-and-human-services-adoption-of-the-uniform-administrative-requirements-cost-principles-and https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75 https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-C/section-200.216

◦ As part of a per diem or subsistence allowance provided in conjunction with allowable travel.

• Activities prohibited under 2 CFR 200.450 and the HHS Grants Policy

Statement, including but not limited to:

◦ Paying the salary or expenses of any grant recipient, or agent acting for such recipient, related to any activity designed to influence the enactment of legislation, appropriations, regulation, administrative action, or executive order proposed or pending before the Congress or any State government, State legislature, or local legislature or legislative body.

◦ Lobbying, but awardees can lobby at their own expense if they can segregate federal funds from other financial resources used for lobbying.

For guidance on some types of costs that we restrict or do not allow, see 2

CFR Part 200 Subpart E - General Provisions for Selected Items of Cost.

Program-specific limitations Unallowable costs

• New construction is unallowable. Supplanting funding for in-process or planned construction projects or directing funding towards new construction builds is unallowable. Renovations or alterations, as described in category J of the program requirements and expectations use of funds section, are allowed if they are clearly linked to program goals.

◦ Category J funding cannot exceed 20% of the total funding CMS awards States in a given budget period.

• To replace payment for clinical services that could be reimbursed by insurance. We will not accept payments to clinical services if they duplicate billable services and/or attempt to change payment amounts of existing fee schedules. If you plan to fund direct health care services, you must justify why they are not already reimbursable, how the payment will fill a gap in care coverage (such as uncompensated care or services not covered by insurance), and/or how they transform the current care delivery model.

◦ Funding for provider payments, as described in category B of the program requirements and expectations use of funds section, cannot exceed 15% of the total funding CMS awards States in a given budget period.

1. Review 2. Get Ready 3. Build 4. Understand 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 19 https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-E/subject-group-ECFRed1f39f9b3d4e72/section-200.450 https://www.ecfr.gov/current/title-2/part-200/subject-group-ECFRed1f39f9b3d4e72 https://www.ecfr.gov/current/title-2/part-200/subject-group-ECFRed1f39f9b3d4e72

◦ Funding cannot be used for initiatives that fund certain cosmetic and experimental procedures that fall within the definition of a specified sex-trait modification procedure at 45 CFR 156.400 because that is beyond the scope of this program.

• No more than 5% of total funding CMS awards to a State in a given budget period can support funding the replacement of an EMR system if a previous HITECH certified EMR system is already in place as of

September 1, 2025.

• Funding towards initiatives similar to the “Rural Tech Catalyst Fund

Initiative” (as described in the appendix) cannot exceed the lesser of (1)

10% of total funding awarded to a State in a given budget period or (2)

$20M of total funding awarded to a State in a given budget period, and funding is subject to all restrictions and requirements described in the example initiative.

• Clinician salaries or wage supports for facilities that subject clinicians to non-compete contractual limitations.

• None of the funding shall be used by the State for an expenditure that is attributable to an intergovernmental transfer, certified public expenditure, or any other expenditure to finance the non-Federal share of expenditures required under any provision of law.

• SSA Section 2105(c), paragraphs (1), (7), and (9) apply as funding limitations. These limitations are related to general limitations, limitations on payment for abortions, and citizenship documentation requirements for payments made with respect to an individual.

Noncompliance If we determine that you are not using award funds in a manner consistent with the description you provided in your approved application (a “violation of agreement”), we may withhold, reduce, or recover your award payments.

Violations of agreement include, but are not limited to:

• Using funds in a manner inconsistent with activities described in a State’s application, on activities explicitly limited in the Limitations and Program-specific limitations sections, and/or on activities we have not approved.

• Failure to finalize State policy actions proposed in your application by the end of calendar year 2027. States will have until the end of calendar year

2028 to enact the relevant policies for factors B. 2 and B. 4.

• Not investing funds in a way that broadly affects your State’s rural areas and residents in a positive manner.

1. Review 2. Get Ready 3. Build 4. Understand 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 20 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-156/subpart-E/section-156.400 https://www.ssa.gov/OP_Home/ssact/title21/2105.htm

• Failure to submit required reporting requirements as described in the

Reporting section.

• Failure to follow through on other actions in your approved application.

• Violating the terms and conditions of the award.

• Improperly managing or using award funds, including fraud, waste, abuse, and criminal activity.

You must remedy noncompliance within 90 days after we notify you of a violation. Remediation may include submitting a remediation plan. If you do not remedy your noncompliance, we may recover past payments and withhold further payments of both workload and baseline funding. If we withhold or recover funding, we will do so as follows:

• For violations that affect your technical score: Proportional to the incremental award funds granted based on the technical score points you were previously awarded.

• For violations that do not directly affect your technical score: Assessed on a case-by-case basis. All prior and future payments become eligible for withholding and/or recovery.

As required by Public Law 119-21, any amounts withheld or recovered shall be returned to the Treasury of the United States.

General policies Support beyond the first budget year will depend on:

• Appropriation of funds;

• Satisfactory progress in meeting your project’s objectives; and

• A decision that continued funding is in the government’s best interest.

Indirect costs Indirect costs are those shared across multiple projects and not easily separated. Costs included in the indirect cost pool must not be charged as direct costs.

To charge indirect costs you can select one of two methods:

Method 1 — Approved rate. If you currently have an indirect cost rate approved by your Cognizant Federal Agency, you may use that rate.

Method 2 — De minimis rate. If you do not have a negotiated indirect cost rate, you may elect to charge a de minimis rate (see 2 CFR 200.414(f)).

1. Review 2. Get Ready 3. Build 4. Understand 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 21 https://www.ecfr.gov/current/title-2/part-200/section-200.1#p-200.1(Cognizant%20agency%20for%20indirect%20costs) https://www.ecfr.gov/current/title-2/section-200.414

However, according to Section 71401 of Public Law 119-21, not more than 10% of the amount allotted to a State for a budget period may be used by the State for administrative expenses.

This 10% limit applies to administrative costs for your entire budget, including indirect and direct costs.

Salary rate limitation The salary rate limitation in the current appropriations act applies to this program. As of January 2025, the salary rate limitation is $225,700.

Program income If you earn any money from your award-supported project activities (known as program income), you must use it for the purposes and under the conditions of the award. Find more about program income at 2 CFR 200.307.

Post-award requirements

Before you apply, make sure you understand the requirements that come with an award.

See Step 6: Learn What Happens After Award for information on regulations that apply, reporting, and more.

1. Review 2. Get Ready 3. Build 4. Understand 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 22 https://www.ecfr.gov/current/title-2/section-200.307

Step 2:

Get Ready to Apply

In this step

Get registered 24

Find the application package 24

Get registered SAM.gov You must have an active account with SAM.gov to apply. SAM.gov registration can take several weeks. Begin that process today.

To register:

• Go to SAM.gov Entity Registration and select Get Started. From the same page, you can also select the Entity Registration Checklist for the information you will need to register.

• You must agree to the financial assistance general certifications and representations specifically. Those for contracts are different.

When you register, you will also receive your required Unique Entity Identifier

(UEI).

Once you register:

• You will have to maintain your registration throughout the life of any award.

• If your organization has multiple UEIs, use the one associated with your physical location.

Grants.gov You must also have an active account with Grants.gov. You can see step-by-step instructions at the Grants.gov Quick Start Guide for Applicants.

Need Help? See Contacts and Support.

Find the application package The application package has all the forms you need to apply. You can find it at this NOFO’s Grants.gov opportunity page.

We recommend that you select the Subscribe button from the View Grant

Opportunity page for this NOFO to get updates.

If you can’t use Grants.gov to download application materials or have other technical difficulties, including issues with application submission, contact

Grants.gov for assistance.

1. Review 2. Get Ready 3. Build 4. Understand 5. Submit 6. Award Contacts

Step 2: Get Ready to Apply 24 https://sam.gov/content/entity-registration https://www.hhs.gov/sites/default/files/financial-assistance-general-certification-representations.pdf https://www.hhs.gov/sites/default/files/financial-assistance-general-certification-representations.pdf http://grants.gov/applicants/applicant-registration https://www.grants.gov/quick-start-guide/applicants https://www.grants.gov/support https://www.grants.gov/support

Step 3:

Build Your Application

In this step

Application checklist 26

Application contents and format 27

Application checklist Make sure that you have everything you need to apply:

Narratives Component How to upload Page limit

Project summary Use the Project Abstract Summary

Form.

1 page

Project narrative Use the Project Narrative Attachment form.

60 pages

Budget narrative Use the Budget Narrative Attachment form.

20 pages

Attachments Insert each in a single Attachments form.

Component Page limit

Governor’s endorsement 4 pages

Indirect cost rate agreement None

Business assessment of applicant organization 12 pages

Program duplication assessment 5 pages

Other supporting documentation 35 pages

Other required forms Complete each required form in Grants.gov.

Component Page limit

SF-424: Application for Federal Assistance None

SF-424A: Budget Information for Non-Construction Programs None

Project/Performance Site Location None

Disclosure of Lobbying Activities (SF-LLL) None

Step 3: Build Your Application 26

Application contents and format We will provide instructions on how to build your application, including document formats in the following sections. See completeness and responsiveness criteria to understand what may disqualify your application from consideration.

Your organization’s authorized organizational representative (AOR) must certify and submit your application.

See requirements for Intergovernmental review, if any.

Project summary Limit to one page. May be single spaced. Follow other formatting requirements for the project narrative.

Write a one-page summary of your proposed project including its purpose and outcomes. Do not include any proprietary or confidential information. We will use this document for information sharing and public information requests if you get an award. Include:

• The name of your organization.

• The names of any subrecipients or sub-awardee organizations, if applicable.

• Project goals.

• Total budget amount.

• A description of how you will use funds.

Project narrative The project narrative is the most important part of your application and should clearly describe your proposed project. You must address the proposed goals, measurable objectives, and milestones, following the instructions in this section.

The project narrative should be as specific as possible given space. We encourage you to use tables, bullet points, and headings to improve readability. For example, to convey your plan in a snapshot, you could include a table summarizing your key goals, activities, and timelines.

Step 3: Build Your Application 27

Define any acronyms or State-specific program names. Remember that reviewers may not be familiar with your specific landscape, so provide any needed explanations.

Avoid overly technical jargon. Keep your narrative clear and focused on what you will do and why it will make a difference for rural health in your State.

Required format for project narrative

Page limit: 60

Endnotes are not included in the page limit.

File name: Project narrative

File format: PDF

Font size: 12-point font, preferably Times New Roman, Arial, or fonts of similar size

Footnotes and text in graphics may be 10-point.

Spacing for main content: Double-spaced

Spacing for project abstract, tables, and footnotes: Single-spaced

Margins: 1-inch

Page size: 8.5 x 11

Include consecutive page numbers throughout.

Use the following headings and format in your project narrative.

Rural health needs and target population Describe the current rural health landscape in your State and the specific challenges that the RHT Program plan seeks to address. Describe the specific criteria or data that your State uses to identify rural areas in this application.

Provide data on:

• Rural demographics, such as: population size and density, income levels, employment sectors, unemployment rates, education attainment, health insurance coverage.

• Health outcomes, such as: rates of chronic conditions, child and maternal health outcomes.

• Healthcare access, such as: average distance to the nearest hospital or primary care clinic, availability of healthcare providers, availability of public transportation, health care facility numbers and distribution.

Step 3: Build Your Application 28

• Rural facility financial health, such as: number of rural hospital closures, utilization levels and patient volumes of existing rural health facilities.

Identify the target populations and geographic areas in your State that will benefit from the program. For example:

• “Rural residents in 20 high-need counties, including substantial tribal populations.”

• “All rural hospitals, rural health clinics, and community health centers in rural areas statewide.”

This section sets the context and the case for change. It should establish the need for transformation and help reviewers understand the specific rural health problems your plan will tackle, such as access gaps, quality issues, or unsustainable financing.

Rural health transformation plan:

Goals and strategies This section should include a detailed Rural Health Transformation Plan as required by statute in 42 U.S.C. 1397ee(h)(2)(A)(i). Present your vision, goals, and strategies for transforming rural health in a structured manner. We recommend organizing this section by the objectives or related groupings. For example, you might combine discussion of access and outcomes or technology and data.

Address each element required by statute:

• Improving access: What specific actions will you take to improve rural residents’ access to hospitals, primary care, specialty care, behavioral health care, and other services, or to health care items?

◦ Examples of actions: Establishing telehealth specialty consult programs, keeping emergency departments open, expanding maternal health services.

• Improving outcomes: What health care outcomes of rural residents will you target? How will you achieve improvements in these outcomes?

◦ Examples of outcomes: Reduction of risk factors associated with increased mortality risk for certain conditions, better chronic disease control.

◦ Examples of methods: Care coordination, community health worker programs.

• Technology use: How will you use new and emerging technologies that emphasize prevention and chronic disease management? How will you

Step 3: Build Your Application 29 evaluate the suitability of new technologies for rural providers and patients? How will you plan for long term sustainability of adopted technologies?

◦ Examples of emerging technology: Telehealth expansion, remote monitoring for chronic disease, AI diagnostic tools in rural clinics.

• Partnerships: How will you foster local and regional strategic partnerships between health care providers and other key stakeholders that promote measurable quality improvement, increase financial stability, maximize economies of scale, and share best practices in rural health care delivery? Describe any networks, consortiums, or affiliations you will create or strengthen among rural providers, federally qualified health centers, and other health care providers, as applicable. Describe their governance structure(s) and how it will reflect the communities they plan to serve. What will those partnerships do? How will they be structured? What improvements will those partnerships promote?

◦ Examples of partner activities: Information sharing, joint training, group purchasing.

• Workforce: How will you recruit and train more clinicians for rural areas?

◦ Examples of methods: New incentive programs, expanded scopes of practice, additional or expanded training programs, telehealth support to extend the reach of specialists.

• Data-driven solutions: How will you harness data and technology to furnish high-quality health care services as close to a rural patient’s home as possible?

◦ Examples of technology and data: Building a rural health data dashboard, connecting rural providers to an electronic health information exchange (HIE), using data to drive quality improvement.

• Financial solvency strategies: What reforms or innovations will you make to ensure the financial stability of rural hospitals and other rural providers? If rural hospitals in the State are at risk of financial insolvency, how will the plan stabilize them?

◦ Examples of solvency strategies: Transitioning hospitals to new payment models, modifying facility service offerings, right-sizing facilities with low utilization, modifying the number and types of facilities, reducing rural facility bypass, diversifying revenue streams, or changing State policies, such as updating Medicaid payment policies.

Step 3: Build Your Application 30

• Cause identification: Why are standalone rural hospitals at risk of service reduction or closure, and how will your plan address those causes?

◦ Examples of causes: Low volume, low quality, bypass of rural providers, payer mix, competition.

You must also address these other required components of the Rural Health

Transformation Plan:

• Program key performance objectives: Paint a cohesive and comprehensive picture of what your overall program will achieve by the end of the funding period of the cooperative agreement (FY 2031). Include specific and measurable objectives with both baseline data and targets, where possible. Your evaluation outcomes metrics for each initiative, as described in the metrics and evaluation plan, should be consistent with and complementary to the overall program performance objectives.

◦ Examples of objectives: “Increase the ratio of rural primary care providers to rural population by X,” “reduce 30-day readmissions in rural hospitals by Y%,” “ensure that 95% of rural residents have access to broadband-enabled telehealth,” “reduce risk factors related to chronic disease by Z%”

• Strategic goals alignment: Where relevant, discuss how these elements align with the five strategic goals described in the purpose section.

• Legislative or regulatory action: Explicitly mention any commitments you are making to change legislation or regulations. See the technical factors in the program description, with further explanation in the appendix.

Describe:

◦ Your current policy for each State policy related to the “State policy actions” technical score factors.

◦ What legislative or regulatory actions related to the technical score factors you are committed to pursuing.

◦ Your timeline for pursuing legislative or regulatory action.

◦ How the specific legislative or regulatory action will improve access, quality, and/or cost of care in rural communities.

◦ Remember, you will receive technical score credit for commitments made in your application. If you do not finalize legislative or regulatory actions by the end of calendar year 2027 (December 31, 2027), we will recover payments we made to you based on technical score credit received from these commitments (see Table 4). States will have until December 31, 2028 to follow through on meeting their policy commitments for technical score factors B. 2 and B. 4.

Step 3: Build Your Application 31

• Other required information: Information…