ET3-Medical Triage Line NOFO-OMB Cleared Final 2021.3.11_508.pdf

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U.S. Department of Health and Human Services

Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation

Emergency Triage, Treat, and Transport (ET3) Model Medical Triage Line

Notice of Funding Opportunity Type: New

Funding Opportunity Award Type: Cooperative Agreement

Notice of Funding Opportunity Number: CMS-2F2-21-001

Federal Assistance Listing Number: 93.381

Notice of Funding Opportunity Posting Date: March 12, 2021

Applicable Dates:

Letter of Intent to Apply Due Date: N/A

Electronic Application Due Date: May 11, 2021 3:00 pm Eastern Standard Time

Anticipated Issuance Notice(s) of Award: September 10, 2021

Anticipated Period of Performance: 2 years

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Table of Contents Executive Summary

A. Program Description A1. Purpose A2. Authority A3. Background A4. Program Requirements

A 4.1 Key Terms A 4.2 Eligible Applicants A 4.3 Period of Performance and Associated Funding Structure A 4.4 ET3 Medical Triage Line Functions A 4.5 Medical Triage Line Reporting Requirements A 4.6 Sustainability of the Medical Triage Line

A5. Technical Assistance and Information for Prospective Applicants

B. Federal Award Information B1. Total Funding B2. Award Amount B3. Anticipated Award Dates B4. Period of Performance B5. Number of Awards B6. Type of Award B7. Type of Competition

C. Eligibility Information C1. Eligible Applicants (select all that apply) C2. Cost Sharing or Matching C3. Letter of Intent C4. Ineligibility Criteria C5. Single Application Requirement C6. Continued Eligibility C7. EIN, DUNS, and SAM Regulations C8. Faith-Based Organizations C9. Other Eligibility Requirements

D. Application and Submission Information D1. Address to Request Application Package D2. Content and Form of Application Submission D3. Unique Entity Identifier and System for Award Management (SAM) D4. Submission Dates and Times D5. Intergovernmental Review D6. Cost Restrictions D7. Mandatory Disclosure

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E. Application Review Information E1. Criteria E2. Review and Selection Process E3. Federal Awardee Performance Integrity Information System (FAPIIS)

F. Federal Award Administration Information F1. Federal Award Notices F2. Administrative and National Policy Requirements F3. Terms and Conditions F4. Cooperative Agreement Terms and Conditions of Award F5. Reporting

G. CMS Contacts G1. Programmatic Questions G2. Administrative/Budget Questions H. Other Information

Appendix I. Guidance for Preparing a Budget Request and Narrative

Appendix II. Application and Submission Information

Appendix III. Business Assessment of Applicant Organization

Appendix IV. Accessibility Requirements

Appendix V. Review and Selection Process

Appendix VI. Application Check-Off List Required Contents

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Executive Summary The Emergency Triage, Treat, and Transport (ET3) model (the “model”) is a voluntary, five-year payment model that will provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare Fee-for-Service (FFS) beneficiaries following a 911 Call. ET3 consists of three interventions: the treatment in place and transport to an alternative destination interventions described in the Request for Applications, and the triage intervention described in this Notice of Funding Opportunity (NOFO). Together, these interventions make up a comprehensive model for potentially improving the quality of care and lowering costs to Medicare by reducing avoidable transports to hospital emergency departments (EDs) and avoidable inpatient admissions.

Through the ET3 model NOFO, Centers for Medicare & Medicaid Services (CMS) will fund recipients to establish or expand a Medical Triage Line. Eligible applicants are state and local governments, their Designees, or other entities that operate or have oversight over a Public Safety Answering Point (PSAP). A Medical Triage Line funded through the ET3 model will allow existing PSAPs to redirect Callers with non-emergency conditions to appropriate care alternatives.

HHS Awarding Agency Centers for Medicare & Medicaid Services (CMS)

CMS Awarding Center Center for Medicare and Medicaid Innovation

Notice of Funding Opportunity Title

Emergency Triage, Treat, and Transport (ET3) Model

Authorization Section 1115A of the Social Security Act (the Act)

Federal Assistance Listings Number

93.381

Funding Opportunity Type New

Funding Opportunity Number CMS-2F2-21-001

Type of Award Cooperative Agreement

Type of Competition Open to all Eligible Applicants

Letter of Intent N/A

Application Due Date and Time May 11, 2021 by 3:00 pm EST (Baltimore, MD)

Anticipated Issuance Notices of Award

September 10, 2021

Period of Performance Start Date September 10, 2021

Period of Performance End Date September 9, 2023

Anticipated Total Available Funding

$34,000,000

Maximum Award Amount Up to $1,175,000

Maximum Number of Awardees 40

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A. Program Description

A1. Purpose

CMS, through its Center for Medicare and Medicaid Innovation (Innovation Center), seeks applications for the triage intervention of the ET3 model. This intervention will test whether the establishment or expansion of Medical Triage Lines integrated with the PSAP can reduce inappropriate use of emergency ambulance services and increase efficiency in Emergency Medical Services (EMS) systems.

The ET3 Model aims to:

• Provide person-centered care, such that beneficiaries receive the appropriate level of care delivered safely at the right time and place while having greater control of their health care through the availability of more options.

• Encourage appropriate utilization of services to meet health care needs effectively.

• Increase efficiency in the EMS system to allow for more rapid response to time-sensitive conditions.

This NOFO is open to state and local governments, their Designees, or other entities that operate or have authority over a PSAP and are located in geographic regions where ambulance suppliers and providers have been selected to participate in the ET3 model. Model Participants were selected through a separate Request for Applications process. A list of Model Participants and the regions where the model will be implemented can be found on the ET3 website (CMS link to ET3 initiatives). An applicant to this NOFO must propose to operate the Medical Triage Line in a Geographic Region that includes at least one ZIP code of a Participant’s Model Region.

CMS will award, through a competitive process, cooperative agreements to up to 40 Recipients.

The triage intervention of the model will be tested for a two-year period, pending availability of funds. Funding for the second year will be issued via a non-competing continuation award. The parameters for the triage intervention of the model are described throughout this NOFO.

A2. Authority

Section 1115A of the Social Security Act (the Act) authorizes the Secretary of the Department of Health and Human Services to test innovative payment and service delivery models expected to reduce Medicare, Medicaid, or CHIP expenditures while preserving or enhancing the quality of care.

Under section 1115A(d)(1) of the Act, the Secretary of Health and Human Services may waive such requirements of Titles XI and XVIII and of sections 1902(a)(1), 1902(a)(13), and 1903(m)(2)(A)(iii), and 1934 (other than subsections (b)(1)(A) and (c)(5) of such section) as may be necessary solely for purposes of carrying out section 1115A with respect to testing models described in section 1115A(b). For this model and consistent with this standard, the Secretary may consider issuing waivers of certain fraud and abuse provisions in sections 1128A, 1128B, and 1877 of the Act. Waivers are not being issued in this document; waivers, if any, would be set forth in separately issued documentation. Thus, notwithstanding any other provision of this NOFO, all Recipients, sub-recipients, and all other relevant individuals or entities must comply with all applicable laws and regulations, except as explicitly provided in any such separately documented waiver issued pursuant to section 1115A(d)(1) specifically for the ET3 model. Any https://innovation.cms.gov/initiatives/et3/

2021-03-10 Page 6 of 78 such waiver would apply solely to the ET3 model and could differ in scope or design from waivers granted for other programs or models.

CMS provides no opinion on the legality of any contractual or financial arrangement that an applicant proposes, implements, or documents. The receipt by CMS of any such information in the course of the Application process or otherwise shall not be construed as a waiver or modification of any applicable laws, rules, or regulations, and will not preclude CMS, HHS, a law enforcement agency, or any other federal agency from enforcing any and all applicable laws, rules, and regulations.

A3. Background

The ET3 model will support the implementation of a Medical Triage Line integrated into a PSAP in an eligible region. Evidence suggests medical triage programs integrated with PSAPs are becoming more widely adopted. While most studies of telephone-based interventions focus on medical advice lines rather than on secondary triage as part of 911 medical dispatch, large-scale application of 911 prioritization systems is beginning to create a robust evidence base to support their accuracy in categorizing medical emergencies over the phone. A study in Texas aimed at examining an ED diversion collaboration to divert lower acuity patients from EDs to more appropriate levels of care determined that 6% of all EMS calls were diverted to a Medical Triage Line rather than initiation of an ambulance.1 Numbers published by The Regional Emergency Medical Services Authority (REMSA) suggest that their medical triage program had roughly a 2.5% to 3% dispatcher transfer rate from 911 to the triage nurse.2 Among these and other programs, findings suggest accuracy in medical dispatcher evaluation of low-acuity cases and that there is potential for avoidable transports to hospital EDs. Through the ET3 model, the Innovation Center intends to allocate cooperative agreement funding to implement Medical Triage Lines integrated with 911 dispatch systems to reduce inappropriate use of emergency ambulance services and potentially increase efficiencies in EMS systems.

Separately from this NOFO, the Innovation Center has selected ambulance suppliers and providers based on criteria in the Request for Applications that would provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare FFS beneficiaries following a 911 Call. Medicare regulations have historically only allowed payment for emergency ground ambulance services when individuals are transported to hospitals, critical access hospitals, skilled nursing facilities, and dialysis centers. This creates an incentive to bring beneficiaries to high-acuity, high-cost settings (e.g., EDs), even when a lower-acuity, lower-cost setting may more appropriately meet an individual’s needs. The ET3 model payment arrangements implemented through model participation agreements may change these misaligned incentives and have the potential to improve the quality of care and lower costs to Medicare by reducing avoidable transports to the hospital ED and potentially reducing avoidable inpatient admissions. The model structure consists of three interventions: triage, treat, and transport, as seen in Figure 1.

1 Murphy, E. R., Petrovich, J.. (2017). 9-1-1 Triage: Implications of an Emergency Diversion Collaboration Effort. Perspectives on Social Work, 13(1), 23-29 2 Smith, L. R., Amico, P., Hoerger, T., Jacobs, S., Payne, J., & Renaud, J. (August 2017). Evaluation of the Health Care Innovation Awards: Community resource planning, prevention, and monitoring: Third annual report addendum. RTI International.

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Figure 1: Overview of ET3 Model

A4. Program Requirements

A 4.1 Key Terms

The following key terms will be used throughout this NOFO:

911 Call: A three-digit or seven-digit telephone number used by a Public Safety Answering Point (PSAP) to facilitate the reporting of an emergency requiring response.

911 Telecommunicator: A call taker/dispatcher at a PSAP qualified to answer incoming 911 Calls and/or to provide the appropriate emergency response.

Caller: Any individual that initiates a 911 Call to the Recipient’s PSAP.

Community Resource: An entity that is included on the Recipient’s Resource List as an appropriate alternative source of care to sending the Caller to the ED.

Designee: An entity that operates a PSAP through a valid agreement with, or other authorization from, a state or local government.

Functional Medical Triage Line: A Medical Triage Line that is accepting transfers from 911 Telecommunicators and has the capacity to provide all Triage Core Functions.

Geographic Region: The geographic area and population served by the Medical Triage Line under the ET3 model.

Implementation Plan: A written plan for implementing the Medical Triage Line that addresses each element set forth in section D2.d.II of this NOFO, and updated in accordance with section F5. of this NOFO.

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Medical Triage Line: A telephone triage service staffed by Triage Line Staff that receives transfers from 911 Telecommunicators and utilizes protocols with the purpose of identifying which Callers may not need ambulance transport and instead may be navigated towards more appropriate sources of care, including alternative Community Resources, Caller’s usual source of care, or the provision of self-care instruction while focusing on triage appropriateness and safety.

Model Participant: An entity that is a Medicare-enrolled ambulance provider or supplier that has entered into a participation agreement with CMS to participate in the ET3 model.

Model Region: The counties or equivalent entities where a Model Participant offers Medicare-covered ground ambulance transport, transport to an alternative destination and, if applicable, treatment in place to ET3 model beneficiaries during the model performance period.

Optional Functions: The optional activities of the Medical Triage Line that help the Caller coordinate and access the care that is recommended by the Triage Line Staff, as appropriate.

Public Safety Answering Point (PSAP): An entity responsible for receiving 911 Calls, as either a primary or secondary PSAP, and processing those 911 Calls according to a specific operational policy.

Recipient: An entity that operates or has authority over a PSAP that has been awarded funding through a cooperative agreement with the Innovation Center to test the ET3 Medical Triage Line intervention.

Resource List: A list of Community Resources that may be recommended by the Triage Line Staff to Callers referred to a Medical Triage Line as a component of the Recipient’s Medical Triage Line intervention.

Support Staff: Optional staff of the Recipient that are not Triage Line Staff and who do not provide clinical guidance to Callers. These staff members may support non-clinical Medical Triage Line activities as set forth in a CMS-approved Implementation Plan.

Triage Core Functions: Activities required to be performed by the Triage Line Staff in the operation of the Medical Triage Line, as described in sections A4.4.1 and A4.4.2.

Triage Line Staff: A healthcare professional, who is a registered nurse or holds an equivalent or more advanced clinical licensure (e.g., clinical nurse specialist, certified nurse practitioner, physician’s assistant, or physician (MD or DO)), and carries out the Triage Core Functions of the Medical Triage Line and, if applicable, Optional Functions.

Warm Handoff: The process by which a 911 Telecommunicator, the Triage Line Staff or Support Staff, or a Community Resource, with the Caller on the line, verbally relays to another entity (e.g., the Caller’s usual source of care, a Community Resource, or Triage Line Staff) Caller information, which may include the Caller’s chief complaint, symptoms, and past history, such that the Caller does not need to repeat their information and concerns.

A 4.2 Eligible Applicants

Entities described in section C1 may apply to receive funding for the development or expansion of a Medical Triage Line. This Medical Triage Line will identify Callers that may not require ambulance dispatch and discuss Caller concerns to determine if these low-acuity Callers should

2021-03-10 Page 9 of 78 be routed to more appropriate care, such as an urgent care center, Caller’s usual source of care, or a behavioral health center. By triaging these Callers, this intervention of the ET3 model is expected to contribute to the overall model goals to provide the right care at the right time and place, while reducing healthcare utilization and costs associated with avoidable ED visits and hospitalizations. By allowing beneficiaries with lower-acuity needs the opportunity to access care in more appropriate settings through the medical triage process, the ET3 model could also free up EMS time and resources to focus on high-acuity cases.

An entity must meet all of the following criteria in order to be eligible to apply to this NOFO:

• Is a state or local government entity or its Designee, or another entity that operates or has authority over a PSAP. A Designee or another entity must be one of the types of eligible entities described in section C1. If the applicant is a Designee, the applicant must describe the existing agreement or authorization between the applicant and the state or local government entity that authorizes applicant to implement a Medical Triage Line in the proposed Geographic Region. If the applicant is any other type of entity, the applicant must demonstrate in its application that it has the authority to operate or control a PSAP and implement a Medical Triage Line in its proposed Geographic Region.

• Has the authority to implement a Medical Triage Line in its Geographic Region

• Proposes to implement or expand a Medical Triage Line in a Geographic Region that includes at least one ZIP code in a Model Participant’s Model Region

• Operates or has authority over the PSAP that receives 911 Calls in a Geographic Region that includes at least one ZIP code in a Model Participant’s Model Region as well as the authority to implement the triage intervention of the ET3 model integrated with the PSAP. A full list of Model Participants is available on the ET3 model website (CMS link to ET3 initiatives).

A 4.3 Period of Performance and Associated Funding Structure

Each Recipient will have the opportunity to implement or expand upon an existing Medical Triage Line during two distinct stages: Pre-Implementation (Year 1); and Implementation and Operation (Year 2). To receive funding for Year 2, applicants must submit a non-competing continuation application and meet established performance measurement requirements. Additional instructions will be included in the terms and conditions of award.

Table A lays out examples of required activities each Recipient may undertake during each stage as well as associated funding types.

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Table A. Required Recipient Activities and Associated Funding by Stage

Stage Required Recipient Activity Funding Pre- Implementation (Year 1)

• Establish or evaluate current infrastructure such as physical space, hardware, and software systems, and equipment

• Establish or expand capacity for the Medical Triage Line

• Review or develop and test triage protocols and revise as necessary

• Complete ongoing training for personnel

• Establish systems and processes for submitting quarterly and annual reports, including all required qualitative and quantitative data to CMS as required in Section F5.

• Develop or update a staffing plan and recruit, hire and train personnel

• Implement a Functional Medical Triage Line

• Develop coordination and relationships with payers and other funding sources to contribute to the development, maintenance, and sustainability of the Medical Triage Line

• Operate the Medical Triage Line in accordance with the award terms and conditions

• Report required data to the Innovation Center in accordance with award terms and conditions, 42 CFR 403.1110, and any other applicable laws, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security regulations

• Annual Implementation Funding

Implementation and Operation (Year 2)

• Operate the Medical Triage Line in accordance with the award terms and conditions

• Test triage protocols and revise as necessary

• Report required data to the Innovation Center in accordance with award terms and conditions, 42 CFR 403.1110, and any other applicable laws, such as the HIPAA privacy and security regulations

• Annual Implementation Funding

• Milestone Funding (Note:

Milestone Funding will be restricted, is not guaranteed and will be based on Recipient’s performance and reporting requirements during Year 1)

Award amounts will vary based on the needs demonstrated and population served by each applicant in its responses to this NOFO. For example, the amount of funding awarded to support a Recipient during the Pre-Implementation stage would take into account whether the Recipient

2021-03-10 Page 11 of 78 proposed to establish a new Medical Triage Line or expand upon an existing line; as well as the size of the Geographic Region in which the Recipient proposes to implement the Medical Triage Line. Milestone Funding will be available during Year 2, subject to availability of funds, based on Recipient’s demonstrated performance in establishing or maintaining a functioning Medical Triage Line, and timely reporting of required data to CMS. Further detail regarding required data is provided in section A4.5 and reporting requirements are further detailed in section F5.

A 4.4 ET3 Medical Triage Line Functions

A 4.4.1 General Requirements Each Recipient must use NOFO funding to establish or expand upon an existing Medical Triage Line that is integrated with the PSAP in the Recipient’s Geographic Region. The Medical Triage Line must meet the requirements detailed throughout this NOFO including the implementation of Triage Core Functions with the Recipient’s existing PSAP. Recipients may choose to directly connect eligible Callers to an external Medical Triage Line via Warm Handoff, as long as external partners/receiving entities meet the requirements of this NOFO and applicable state and local regulations and requirements. This may include transferring the Caller to another PSAP, another emergency medical dispatch center, or another service provided by a Caller’s insurer or usual source of care. NOFO funding may not be used to operate or support an existing non-emergency publicly available line, such as 311 or 211, and may not be used to operate or support separate non-emergency telephone access.

A Recipient may choose to operate the Medical Triage Line either 24 hours a day, seven days a week (“24/7”) or during a subset of hours. If the proposed Medical Triage Line will not operate 24/7, the applicant must propose a specific schedule and explain how the proposed schedule will ensure access to the Medical Triage Line during times when low-acuity calls have the highest volume. Additionally, each Recipient must implement Medical Triage Line protocols that are compliant with state, local, and federal requirements and clinical best practices, and are subject to internal quality improvement processes to ensure that quality and safety practices are implemented and tracked.

As defined above, Triage Line Staff must be healthcare professionals, defined as a registered nurse or an individual who holds an equivalent or more advanced clinical licensure (e.g., clinical nurse specialist, certified nurse practitioner, physician’s assistant, or physician (MD or DO)) and carries out the Triage Core Functions and, if applicable, Optional Functions of the Medical Triage Line. Applicants who propose to staff the Medical Triage Line with Triage Line Staff who have training and experience specific to emergency medical care will receive preference. It is the responsibility of the Recipient to ensure that all Triage Line Staff are licensed in good standing within the Geographic Region, are not suspended or debarred from participation in any federal health programs, and are not currently under state or federal investigation related to their health care practice.

The Recipient must inform Callers they have the right to refuse or deny care or referrals made by Triage Line Staff and be transferred back to 911. Instances of refusal of Triage Line Staff’s recommendations as well as requests to transfer back to 911 should be documented by the Recipient in order to meet reporting requirements outlined in Section A4.5.

Recipients may not use the Medical Triage Line to limit coverage for or access to medically necessary ambulance services including transport to an ED. Each Recipient will be responsible

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Cooperative agreement funding awarded through this NOFO is available only to support eligible functions of the Medical Triage Line and is not available to duplicate or supplant existing funding, or to support other services that are provided after or as a result of the Medical Triage Line encounter. For example, ET3 model funding cannot be used for the following:

• To support the costs of services provided by a Community Resource or usual source of care, including to defray patient cost-sharing;

• Transportation; or

• Salaries and fringe benefits for Community Resource personnel.

A 4.4.2 Triage Core Functions (Required) Triage Line Staff must carry out the following required Triage Core Functions:

• Assess Caller concerns based on predetermined protocols;

• Provide care recommendations to Callers based on protocol-driven assessment;

• Return Callers to 911 via Warm Handoff upon Caller request or based on predetermined protocols;

• Provide Callers with contact information for relevant Community Resources when appropriate; and

• Recommend that Callers contact their regular source of care when appropriate.

If proposed for inclusion as part of the Implementation Plan, Support Staff may only carry out non-clinical activities, such as:

• Conduct a Warm Handoff to transfer a Caller from a 911 Telecommunicator to Triage Line Staff

• Collect Caller demographic information

A 4.4.3 Community Resources (Required) Each Recipient must have a Resource List comprised of Community Resources. The Recipient must inform Callers that they are making recommendations for them and that they have the right to choose the care they receive. The Resource List must be reviewed by the Recipient and updated on at least a semi-annual basis. The Recipient must identify at least one Community Resource that is a clinic that accepts sliding fee scale payments and include such a clinic on its Resource list. The Resource List must reflect Community Resources that currently have capacity and capability to meet Caller needs as identified by the Recipient. A Recipient’s determination as to which individuals or entities are included on the Community Resource List may not take into account or be conditioned upon: (1) whether the individual or entity is serving, or agreed to serve, as a supplemental funding source to Recipient; or (2) the volume or value of referrals between the Recipient and the individual or entity. Recipient shall make the Resource List available to CMS or its contractors upon request or during an audit.

Triage Line Staff will recommend Community Resources from their Resource List that Callers may contact for appropriate care as alternatives to sending the Caller to the ED. Examples of Community Resources include, but are not limited to:

• Urgent care centers

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• Primary care clinics

• Behavioral health centers

• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics

• External 211 resource lines or centers

• Substance abuse services

• State and/or local public health agencies

• Civil legal aid organizations

• Foodbanks

• Transportation and paratransit services, taxis, and rideshare

• Homeless and other temporary shelters

• Home health and/or visiting nurse programs

• Early intervention services

• Dentists, podiatrists, optometrists, and other medical professionals

A 4.4.4 Service Coordination (Optional) Applicant may elect to provide services that help the Caller coordinate and access the care that is recommended by the Triage Line Staff, as appropriate. In these cases, the applicant may earn additional points on their application. Optional Functions will allow the applicant to propose services that meet the applicant community’s comprehensive needs for urgent information or support. For any services related to Optional Functions that may or may not be covered by insurance and may require out-of-pocket payments, Triage Line Staff is responsible for informing the Caller that they may be responsible for those costs. Triage Line Staff must perform Optional Functions in accordance with the award terms and conditions and protocols that are compliant with state, local, and federal requirements.

Optional Functions may include, but are not limited to:

• Providing a Warm Handoff to Caller’s usual source of care, which may include, but is not limited to, a primary care provider or an Accountable Care Organization (ACO) provider or supplier.

• Providing a Warm Handoff to a Community Resource, such as an FQHC or homeless shelter.

• Assisting the Caller with scheduling an appointment with their usual source of care or a Community Resource.

• Coordinating transportation on behalf of the Caller to a Community Resource or to their usual source of care.

A 4.4.5 Interoperability Plan (Optional) Applicants may earn additional points on their application for the inclusion of an interoperability plan that details an ability to share patient data among key stakeholders. Many health systems are now accepting financial responsibility for managing patients’ care at a population level. These systems often lose the ability to track patients’ care following a 911 Call, and it is beneficial to the patient to connect them back to their primary care providers and/or care management system.

Additionally, Callers can benefit from knowing when health care resources referred from the Medical Triage Line are in-network and therefore not subject to additional out-of-network cost-sharing.

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To foster interoperability between the PSAP, Medical Triage Line, and other care management systems, the applicant may elect to build upon their Medical Triage Line or implement a method of information sharing between the PSAP, Triage Line Staff, Community Resources, Caller’s usual source of care (such as an ACO provider or supplier), Caller’s insurance companies, and/or other stakeholders outlined in the application submitted in response to this NOFO.

Applicants who propose an interoperability plan with the capability of identifying a Caller’s usual source of care and/or insurance provider, as well as a plan to triage that Caller back to their usual source of care in appropriate situations, will receive preference.

The following is a non-exhaustive list of potential capabilities of the interoperability plan:

• Identify means by which the Medical Triage Line would collect the Caller’s insurance information

• Determine which Community Resources accept the Caller’s insurance

• Reconnect the Caller with their usual source of care

• Notify Caller’s usual source of care of the triage interaction and recommendation

• Search for past medical history, medications, allergies, etc.

• Perform electronic notifications to provide relevant clinical data to Caller’s usual source of care, insurer or other health information exchange network.

Funding awarded under this NOFO may be used to strengthen an existing data-sharing system or implement a new one, including purchasing hardware and/or software for such systems, for the applicant to achieve its proposed data-sharing goals under this model.

This plan should demonstrate an understanding of state and federal privacy laws and ensure compliance with all applicable standards, including HIPAA privacy and security regulations and 42 CFR Part 2. The plan should clearly identify when and how consent and authorization will be obtained, including written consent when required.

A 4.5 Medical Triage Line Reporting Requirements

Applicants are required to determine a process by which they can collect data in order to provide the data detailed in Section F5 to CMS on a quarterly and annual basis. Each applicant must demonstrate its capacity to submit the data points listed below; however, CMS reserves the right to modify the data requirements, to be finalized in the Terms and Conditions of award:

• Total number of 911 Calls received via Recipient’s PSAP by fire, police, medical, as applicable

• Total number of Recipient’s 911 Calls routed to Medical Triage Line

• Number of 911 Calls with medical prioritization based upon applicable dispatch protocols

• Number of 911 Calls protocol-eligible to be transferred to Medical Triage Line

• Number of 911 Calls protocol-eligible to be transferred to Medical Triage Line but received during Medical Triage Line off hours

• Number of Callers consenting to be transferred to Medical Triage Line

• Number of 911 Calls answered by Triage Line Staff

• Total number of 911 Calls routed to the Recipient’s Medical Triage Line that were dropped or disconnected

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• Average wait time between when the 911 Telecommunicator transfers the 911 Call to the Medical Triage Line and Triage Line Staff answers the call

• Total number of Medical Triage Line calls routed back to 911 due to Caller request

• Total number of Medical Triage Line calls routed back to 911 due to medical necessity or

Recipient’s protocols

• Total number of Medical Triage Line calls where Caller is provided recommendations from the Resource List, broken down by resource type

• Total number of Medical Triage Line calls that end in Caller hanging up prior to recommendation, transfer, or Warm Handoff

• Aggregate numbers for Medical Triage Line Caller insurance type to include Medicare, Medicaid, Private Insurer, or Not Insured

• Descriptive data on Medical Triage Line Callers (gender, age, zip code, chief complaint)

• Count of individuals given Optional Functions (if applicable), broken down by service

• Any other data required by CMS

A 4.6 Sustainability of the Medical Triage Line

Applicants are required to present a sustainability plan outlining how Medical Triage Line services will be sustained after the period of performance has ended. This may include securing other funding sources, identifying Community Resources, payers, and others in the Geographic Region that can share in ongoing investment of the Medical Triage Line, or seek local or state support to sustain these services. Applicants should present a demonstrated plan to engage external funders, though confirmed funding is not required.

CMS encourages applicants to identify supplemental funding sources to support the Medical Triage Line implementation and/or ongoing operation. Coordination with other funding sources will contribute to the sustainability of the Medical Triage Line after CMS funding has expired.

Lack of external funding shall not disqualify an applicant from consideration for an ET3 model award. However, applicants that can demonstrate the presence of confirmed funding or a clear plan to obtain external funding will receive higher preference. An applicant that demonstrates existing or planned coordination with one or more other funding sources is eligible to receive more application points than those who do not plan to seek out additional funding sources.

Supplemental funding must comply with all applicable laws and regulations, including the fraud and abuse laws, and may not be conditioned on the volume or value of referrals or other business generated, directly or indirectly, by the ET3 model.

A5. Technical Assistance and Information for Prospective Applicants

Prior to the application deadline, CMS will host multiple forums to provide details about the ET3 model and to answer questions from potential applicants. Information about the forums will be posted on the Innovation Center website.

CMS expects to award three support contracts: one for evaluation, one for implementation and assisting CMS in monitoring, and one for a learning system. The Recipient is required to comply with requests from these contractors to support CMS monitoring and evaluation efforts, which includes but is not limited to requests for on-site and desk audits and site visits. If CMS or CMS’s contractors identify problems through monitoring or otherwise, CMS may request that https://innovation.cms.gov/

2021-03-10 Page 16 of 78 the Recipient implement a corrective action plan. Recipient must also comply with requests from contractors to participate in the learning system as described in section F5.a.iii.

The evaluation contractor will collect and analyze data necessary to evaluate each award as part of the evaluation of the ET3 model. To the extent possible, CMS will identify factors that are driving the identified impact and any improvements in care quality and savings to the Medicare program, and use qualitative and quantitative data to inform our findings.

The implementation and monitoring contractor will support program operations including:

providing technical assistance to Recipients; facilitating reporting requirements; managing program data; assisting in the monitoring of program implementation and general model compliance; as well as supporting programmatic operations. During the period of performance, CMS may request modification to a Recipient’s Implementation Plan or associated documents to ensure continued program integrity and to streamline program operations with contractor functions. CMS will provide details to Recipient for contractor-related work after awards are made.

The learning system contractor will create and facilitate peer-to-peer exchange for Recipients.

The system developed by this contractor will allow Model Participants and Recipients to share their experiences and learning, assist CMS in tracking their progress to identify areas for improvement, and assist with identifying and sharing promising practices.

The implementation and monitoring, evaluation, and learning system contractors will assist CMS in coordinating site visits and interviews to observe program implementation, facilitating continuous quality improvement, and evaluating the qualitative impacts of the model.

B. Federal Award Information

B1. Total Funding

CMS will award up to $34 million, subject to the availability of funds, across up to 40 Recipients to cover a total funding period of two years. Individual awards will not exceed $1,175,000 (see B.2, Award Amount for additional information). Cooperative agreements will be awarded with consideration to: (1) overall cost effectiveness of the applicant’s implementation proposal, (2) overall quality of the proposal and the ability to meet project goals, and (3) ability to demonstrate a sustainability plan. The amount of funding for each cooperative agreement award will depend on the individual Recipient’s need as demonstrated in its application submitted in response to this

NOFO.

B2. Award Amount

The period of performance is divided into two periods: Pre-Implementation (Year 1); and Implementation and Operation (Year 2). Award amounts will vary based on the pre-implementation, implementation, and operational needs demonstrated by applicants in their application submitted in response to this NOFO as well as the scope and design of the proposed intervention, availability of other funding, and variations in healthcare costs in the Recipient’s Geographic Region.

Total Funding Available: The total funding available will be up to $34 million across up to 40 Recipients. Individual awards will not exceed $1,175,000.

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Funding During the Pre-Implementation Stage: The total funding available during the Pre- Implementation Stage (Year 1) will be up to $700,000 per Recipient.

Funding During the Implementation and Operation Stage: Funding during the Implementation and Operation Stage (Year 2) will be up to $475,000 per Recipient, inclusive of potential Milestone Funding. During Year 2, a Recipient has the opportunity to access Milestone Funding, which will be awarded as one-time funding, in an amount equivalent to up to 25% of the total award. Milestone Funding will be restricted and is not guaranteed.

The total award amount is the total funding awarded for the full two-year period of performance, inclusive of Pre-Implementation Funding, Implementation and Operation Funding, and Milestone Funding. For example, if the total award amount for two years totaled $1,000,000, total Milestone Funding would be $250,000 and total Pre-Implementation and Implementation and Operation Funding would be $750,000. A Recipient will only be able to draw down Milestone Funding if it demonstrates satisfactory establishment of a Functional Medical Triage Line at the time of its Non-Competing Continuation application and completes all required reporting in Year 1, further detailed in section F5. Reporting. Milestone Funding will be restricted and is not guaranteed.

B3. Anticipated Award Dates

Anticipated award issuance date for these awards will be September 10, 2021. The Pre- Implementation stage will start on September 10, 2021.

B4. Period of Performance

The project and budget period for each cooperative agreement awarded will be two years from the date of award. The estimated project period is September 10, 2021 – September 9, 2023.

The project period will consist of two 1-year budget periods.

Year one 12-month Pre-Implementation stage (budget period 1):

September 10, 2021 to September 9, 2022

Year two 12-month Implementation and Operation stage (budget period 2):

September 10, 2022 to September 9, 2023

B5. Number of Awards

The maximum number of awards will be 40 awards.

B6. Type of Award

The type of award issued under this NOFO will be a cooperative agreement. The difference between grants and cooperative agreements is the degree of federal programmatic involvement rather than the type of administrative requirements imposed. A cooperative agreement is distinguished from a grant in that it provides for substantial involvement between the federal awarding agency and the non-federal entity in carrying out the activity contemplated by the federal award. Therefore, statutes, regulations, policies, that are applicable to grants also apply to cooperative agreements, unless the award itself provides otherwise. References throughout this NOFO to grants also apply to cooperative agreements unless this NOFO states otherwise. Please refer to section F4. Cooperative Agreement Terms and Conditions of Award for more information about cooperative agreements.

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B7. Type of Competition

Open to All Eligible Applicants

C. Eligibility Information

C1. Eligible Applicants (select all that apply)

☒ City or township governments ☒ County governments ☒ Faith-based organizations ☒ For profit organizations other than small businesses ☐ Foreign and international organizations ☐ Independent school districts ☐ Individuals ☒ Native American tribal organizations (other than federally recognized tribal governments) ☒ Native American tribal governments (Federally recognized) ☒ Nonprofits having a 501(c)(3) status with the IRS, other than institutions of higher education ☒ Nonprofits that do not have a 501(c)(3) status with the IRS, other than institutions of higher education ☐ Private institutions of higher education ☐ Public and State controlled institutions of higher education ☐ Public housing authorities/Indian housing authorities ☒ Small businesses ☒ Special district governments ☒ State governments ☐ Unrestricted ☐ Other An entity must meet all of the following criteria in order to be eligible to apply to this NOFO:

• Is a state or local government entity or Designee, or another entity that operates or has authority over a PSAP. A Designee or other entity must be one of the eligible entities indicated above. If the applicant is a Designee, the applicant must describe the existing agreement or authorization between the applicant and the state or local government entity that authorizes applicant to implement a Medical Triage Line in the proposed Geographic Region. If the applicant is any other type of entity, the applicant must demonstrate in its application that it has the authority to operate or control a PSAP and implement a Medical Triage Line in the proposed Geographic Region.

• Has the authority to implement a Medical Triage Line in its Geographic Region

• Proposes to implement or expand a Medical Triage Line in a Geographic Region that includes at least one ZIP code in a Model Participant’s Model Region.

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• Operates or has authority over the PSAP that receives 911 Calls in a Geographic Region that includes at least one ZIP code in a Model Participant’s Model Region as well as the authority to implement the triage intervention of the ET3 model integrated with the PSAP. A full list of Model Participants is available on the ET3 model website.

C2. Cost Sharing or Matching

Cost sharing or matching is not required. Recipients are encouraged to coordinate agreements with other funding sources during the course of the period of performance; and are required to include coordination with other payers as part of Recipient’s sustainability plans, if applicable.

C3. Letter of Intent

N/A

Letters of intent will not be collected or considered for this funding opportunity.

C4. Ineligibility Criteria

CMS will consider the following criteria as potential reasons for applicant disqualification for award.

• Lack of Model Participant in applicant’s proposed Geographic Region. There must be an overlap of at least one ZIP code in a Model Participant’s Model Region and the applicant’s proposed Geographic Region, based on Model Participants selected for the model. A full list of Model Participants is located on ET3 model website.

• Incomplete application. A non-exhaustive list of circumstances that constitute an incomplete application includes:

o Failure to specify a proposed Geographic Region for Medical Triage Line implementation or expansion;

o Failure to meet application requirements;

o Failure to address all required sections of the project narrative;

o Omission of a Budget Narrative or Project Narrative;

• Insufficient supporting detail provided in the application. CMS will not review applications that merely restate the text within the NOFO. Applicants should detail their proposed approach to achieving program goals and milestones, as well as their proposed approach to ensuring safe triage protocols and procedure. Reviewers will note evidence of how effectively the applicant includes these elements in their application.

• Inability or unwillingness to collect and share monitoring and evaluation data with CMS or its contractors.

• Late submission of an application (refer to Section D4.)

C5. Single Application Requirement

Only one application may be submitted per applicant. Any exceptions or special instructions will be noted below.

C6. Continued Eligibility

Recipients must meet reporting and certification deadlines (as outlined in section F) to be eligible throughout the initial 12-month budget period and to remain eligible for a non-competing continuation award for subsequent budget periods in multi-year projects. In addition, Recipients

2021-03-10 Page 20 of 78 would need to demonstrate strong performance during the previous funding cycle(s) before additional year funding is awarded; or, in the case of awards where all funding is issued in the first year, to ensure continued access to funding. At any time in the award cycle, Recipients could receive decreased funding or their award could be terminated if they fail to perform the requirements of the award.

C7. EIN, DUNS, and SAM Regulations

In order to apply, all applicants are required to have a valid Employer Identification Number (EIN), otherwise known as a Taxpayer Identification Number (TIN); a Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number; and be registered in the System for Award Management (SAM) database (https://beta.sam.gov/) to be able to submit an application at grants.gov. See Appendix II. Application and Submission Information for descriptions of EIN, DUNS, and SAM.

C8. Faith-Based Organizations

Faith-Based Organizations are eligible to apply.

C9. Other Eligibility Requirements

Not Applicable

D. Application and Submission Information

D1. Address to Request Application Package

Open to All Eligible Applicants

Application materials will be available on the https://www.grants.gov. Please note that CMS requires applications for all Notice of Funding Opportunities to be submitted electronically through the https://www.grants.gov. Applicants will be able to download a copy of the application packet, complete it off-line, and then upload and submit the application via the https://www.grants.gov. Refer to Appendix II. Application and Submission Information for additional requirements.

D2. Content and Form of Application Submission

a. Application format

Applications determined to be ineligible, incomplete, and/or nonresponsive based on the initial screening may be eliminated from further review. However, in accordance with HHS Grants Policy, the CMS, Office of Acquisition and Grants Management (OAGM), Grants Management Officer in his/her sole discretion, may continue the review process for an ineligible application if it is in the best interests of the government to meet the objectives of the program.