FORHP HRSA-24-002 (U2W) Medicare Rural Hospital Flexibility (FLEX) Program_FINAL.pdf

U.S. Department of Health and Human Services

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2024

Federal Office of Rural Health Policy

Hospital State Division

Medicare Rural Hospital Flexibility Program

Funding Opportunity Number: HRSA-24-002

Funding Opportunity Type(s): New, Competing Continuation

Assistance Listing Number: 93.241

Application Due Date: April 16, 2024

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

We will not approve deadline extensions for lack of registration.

Registration in all systems may take up to 1 month to complete.

Issuance Date: January 17, 2024

Laura Seifert, MPH

Public Health Analyst, Federal Office of Rural Health Policy

Call: 301-443-3343

Email: lseifert@hrsa.gov

See Section VII for a complete list of agency contacts.

Authority: 42 U.S.C. 1395i-4(g)(1)-(2) (§1820(g)(1)-(2) of the Social Security Act) mailto:lseifert@hrsa.gov

HRSA-24-002 Flex Program i

508 COMPLIANCE DISCLAIMER

Persons using assistive technology may not be able to fully access information in this file. For assistance, email or call one of the HRSA staff listed in Section VII Agency

Contacts.

SUMMARY

Funding Opportunity Title: Medicare Rural Hospital Flexibility Program

Funding Opportunity Number: HRSA-24-002

Assistance Listing Number: 93.241

Due Date for Applications: April 16, 2024

Purpose: The purpose of the Medicare Rural Hospital

Flexibility (Flex) Program is to enable states to support critical access hospitals (CAHs) in quality improvement, quality reporting, performance improvement and benchmarking; to assist facilities seeking designation as CAHs; and to establish or expand programs for the provision of rural emergency medical services (EMS).

Program Objective(s): The long-term objectives of the Flex Program are to enable CAHs, including CAH-owned clinics, and rural EMS agencies to:

• Show and improve quality of care;

• Stabilize finances and maintain services;

• Adjust to address changing community needs; and

• Ensure patient care is integrated throughout the rural health care delivery system.

Eligible Applicants: States are eligible to apply for funding under this notice, including states that are current Medicare

Rural Hospital Flexibility Program award recipients under HRSA-19-024 or states submitting a new application from a Governor designated entity.

HRSA will accept only one application from each state. The Governor designates the organization that may submit an application on behalf of each https://www.ruralhealthinfo.org/topics/critical-access-hospitals

HRSA-24-002 Flex Program ii state. See Section III.1 of this notice of funding opportunity (NOFO) for complete eligibility information.

Anticipated FY 2024 Total

Available Funding:

Approximately $30,000,000

We’re issuing this notice to ensure that, should funds become available for this purpose, we can process applications and award funds appropriately. You should note that we may cancel this program notice before award if funds are not appropriated.

Estimated Number and Type of

Award(s):

Approximately 45 competing continuation, new cooperative agreements

Estimated Annual Award

Amount:

Varies by state per year subject to the availability of appropriated funds

Cost Sharing or Matching

Required:

No

Period of Performance: September 1, 2024 through August 31, 2029

(5 years)

Agency Contacts: Business, administrative, or fiscal issues:

Bria Haley Grants Management Specialist Division of Grants Management Operations, OFAM

Email: bhaley@hrsa.gov

Program issues or technical assistance:

Laura Seifert

Public Health Analyst, Hospital State Division Federal Office of Rural Health Policy

Email: lseifert@hrsa.gov mailto:bhaley@hrsa.gov

HRSA-24-002 Flex Program iii

Application Guide

You (the applicant organization / agency) are responsible for reading and complying with the instructions included in this NOFO and in HRSA Application Guide (Application

Guide). Visit HRSA’s How to Prepare Your Application page for more information.

Technical Assistance

We have scheduled the following webinar:

Wednesday, January 31, 2024

2 – 3 p.m. ET

Weblink: https://hrsa-gov.zoomgov.com/j/1602225205?pwd=eDVwcWxHQWg1QzgxTWh2RGVvN2R3UT

Attendees without computer access or computer audio can use the following dial-in information:

Call-In Number: 1-833-568-8864

Meeting ID: 160 222 5205

Passcode: 45023337We will record the webinar. Please contact Laura Seifert

(lseifert@hrsa.gov) to access the recording.

http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://www.hrsa.gov/grants/apply-for-a-grant/prepare-your-application https://hrsa-gov.zoomgov.com/j/1602225205?pwd=eDVwcWxHQWg1QzgxTWh2RGVvN2R3UT09 https://hrsa-gov.zoomgov.com/j/1602225205?pwd=eDVwcWxHQWg1QzgxTWh2RGVvN2R3UT09 https://hrsa-gov.zoomgov.com/j/1602225205?pwd=eDVwcWxHQWg1QzgxTWh2RGVvN2R3UT09

HRSA-24-002 Flex Program iv

Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

2. BACKGROUND

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AWARD

2. SUMMARY OF FUNDING

III. ELIGIBILITY INFORMATION

1. ELIGIBLE APPLICANTS

2. COST SHARING OR MATCHING

3. OTHER

IV. APPLICATION AND SUBMISSION INFORMATION

1. ADDRESS TO REQUEST APPLICATION PACKAGE

2. CONTENT AND FORM OF APPLICATION SUBMISSION

i. Project Abstract

ii. Project Narrative

iii. Budget

iv. Budget Narrative

v. Attachments

3. UNIQUE ENTITY IDENTIFIER (UEI) AND SYSTEM FOR AWARD MANAGEMENT (SAM)

4. SUBMISSION DATES AND TIMES

5. INTERGOVERNMENTAL REVIEW

6. FUNDING RESTRICTIONS

V. APPLICATION REVIEW INFORMATION

1. REVIEW CRITERIA

2. RESPONSE

3. EVALUATIVE MEASURES

2. REVIEW AND SELECTION PROCESS

3. ASSESSMENT OF RISK

VI. AWARD ADMINISTRATION INFORMATION

1. AWARD NOTICES

2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

3. REPORTING

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

APPENDIX A: PROJECTED FY24 STATE FLEX PROGRAM FUNDING LEVELS

APPENDIX B: GLOSSARY OF COMMON EVALUATION TERMS

APPENDIX C: HELPFUL RESOURCES

APPENDIX D: PAGE LIMIT WORKSHEET

HRSA-24-002 Flex Program 1

I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Medicare Rural

Hospital Flexibility (Flex) Program. The purpose of the Flex Program is to enable states to support critical access hospitals (CAHs) in quality improvement, quality reporting, performance improvement and benchmarking; to assist facilities seeking designation as

CAHs; and to establish or expand programs for the provision of rural emergency medical services (EMS).

The Flex Program aims to provide training and technical assistance to build capacity, support innovation, and promote sustainable improvement in the rural health care system. The overall goal of the Flex Program is to ensure that high quality health care services are available in rural communities and aligned with community needs. Health care services include appropriate preventative, ambulatory, pre-hospital, emergent, and inpatient care. High quality rural health care will deliver high value to patients and communities and result in healthier rural people.

The long-term objectives of the Flex Program are to enable CAHs, including CAH-owned clinics, and rural EMS agencies to:

• Show and improve quality of care;

• Stabilize finances and maintain services;

• Adjust to address changing community needs; and

• Ensure patient care is integrated throughout the rural health care delivery system.

State Flex funding for this period of performance will act as a resource and focal point to address needs and demonstrate outcomes in the following five program areas with priority for quality, financial and operational improvement in CAHs, and supporting rural hospitals converting to CAH status. We recognize that the healthcare landscape is changing rapidly, with focus being placed on value-based care and alternative payment models. We encourage states to develop projects supporting innovative models of care, as appropriate, and place them in the following program areas:

• Program Area 1: CAH Quality Improvement (required)

• Program Area 2: CAH Financial and Operational Improvement (required)

• Program Area 3: CAH Population Health Improvement (optional)

• Program Area 4: Rural EMS Improvement (optional)

• Program Area 5: CAH Designation (required if assistance is requested by rural hospitals)

For more details, see Program Requirements and Expectations.

https://www.ruralhealthinfo.org/topics/critical-access-hospitals

HRSA-24-002 Flex Program 2

2. Background

This program is authorized by 42 U.S.C. 1395i-4(g)(1)-(2) (§1820(g)(1)-(2) of the Social

Security Act). The Balanced Budget Act of 1997 (Public Law 105-33, codified in relevant part at 42 U.S.C. 1395i-4) created the CAH designation to improve access to hospital and other health services for rural residents. The Act also authorized state Flex programs to facilitate CAH designations and support CAHs and rural EMS.

There are 1,362 CAHs throughout the country that serve as first line health care providers to patient populations living in rural communities. The health care environment has changed drastically in recent years, affecting how hospitals operate financially, manage the quality of care, and participate in their communities, especially during the

COVID-19 pandemic. Over 150 rural hospitals have closed or converted since 2010, and the remaining rural hospitals are at a higher risk of closure. As the healthcare landscape continues to change, there is increased pressure on CAHs to become more efficient and effective in meeting the health needs of their communities to remain financially viable and continue to provide needed services. The Flex Program provides support to these hospitals and rural EMS agencies to improve quality of care as well as financial and operational processes, ensuring rural communities have access to high-quality, necessary healthcare.

Faced with a rapidly changing landscape moving toward quality improvement, value-based payment, and population health initiatives, for the upcoming period of performance the Flex Program will focus on activities that assist CAHs in demonstrating their value and preparing for the continuing changes in our health care system.

II. Award Information

1. Type of Application and Award

Application type(s): New, Competing Continuation

We will fund you via a cooperative agreement.

A cooperative agreement is like a grant in that we award money, but we are substantially involved with program activities.

Aside from monitoring and technical assistance (TA), we also get involved in these ways:

• Collaborating with award recipients to review and provide input on the work plan in alignment with HRSA priorities, state needs, and changes in the rural health care environment through such activities as identifying and prioritizing needs to be addressed using federal funds;

• Monitoring and supporting implementation of the work plan through progress report reviews;

https://www.govinfo.gov/content/pkg/PLAW-105publ33/pdf/PLAW-105publ33.pdf https://www.flexmonitoring.org/critical-access-hospital-locations-map https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/

HRSA-24-002 Flex Program 3

• Identifying opportunities to coordinate activities with other federally-funded projects;

• Providing guidance and assistance in identifying key changes in federal health care policies and the rural health care environment that impact State Flex

Programs (e.g., changes to national Medicare quality reporting program measures); and

• Collaborating with technical assistance providers that are developing tools and resources for State Flex Program use.

You must follow all relevant federal regulations and public policy requirements. Your other responsibilities will include:

• Developing and implementing a State Flex Program as described in this notice;

• Collaborating with HRSA on refining and implementing the work plan according to HRSA priorities, state needs, and changes in the rural health care environment;

• Negotiating with HRSA to update work plans at least annually, or more frequently as needed (e.g., in response to identified challenges or to establish new activities in response to environmental or national health care changes); and

• Ensuring program staff have appropriate training to carry out Flex Program activities.

2. Summary of Funding

We estimate approximately $30,000,000 will be available each year to fund 45 recipients. Projected funding amounts for current Flex Program recipients by state are based on FY 2023 amounts and are calculated based on the number of CAHs in a state, geographic remoteness of CAHs, and the risk of financial distress. Refer to

Appendix A for projected FY24 State Flex Program Funding Levels.

Applicants should propose a level of funding commensurate with current efforts in that state. This approach intends to minimize service disruptions, address the health needs of and ensure the continuity of care for residents of rural communities. New applicants to the Flex Program should propose a level of funding sufficient to support the state program’s operations and activities appropriate to the number of CAHs in the state.

The period of performance is September 1, 2024, through August 31, 2029 (5 years).

This program notice depends on the appropriation of funds. If funds are appropriated for this purpose, we will proceed with the application and award process.

Support beyond the first budget year will depend on:

• Appropriation

• Satisfactory progress in meeting the project’s objectives

HRSA-24-002 Flex Program 4

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

45 CFR part 75 - Uniform Administrative Requirements, Cost Principles, and Audit

Requirements for HHS Awards applies to all HRSA awards.

Authorizing legislation at 42 U.S.C. 1395i-4(g)(4)(B) (§1820(g)(4)(B) of the Social

Security Act) limits the use of funds for administrative expenses under the Flex

Program. You may not expend more than the lesser of: 15 percent of the amount of the cooperative agreement for administrative expenses; or your state’s federally negotiated indirect cost rate for administering the cooperative agreement (i.e., Indirect Cost Rate

Agreement (ICRA)). This limitation is a requirement of this federal award and, as required in 45 CFR § 75.351-353, the limitation includes subrecipients.

If you’ve never received a negotiated indirect cost rate, you may elect to charge a de minimis rate of 10 percent of modified total direct costs (MTDC)*. You may use this for the life of the award. If you choose this method, you must use it for all federal awards until you choose to negotiate for a rate. You may apply to do so at any time. See

Section 4.1.v. Budget Narrative in the Application Guide.

*Note: One exception is a governmental department or agency unit that receives more than $35 million in direct federal funding.

III. Eligibility Information

1. Eligible Applicants

States are eligible to apply for funding under this notice, including states that are current

Medicare Rural Hospital Flexibility Program award recipients under HRSA-19-024 or states submitting a new application from a Governor designated entity.

HRSA will accept only one application from each state. The Governor designates the organization that may submit an application on behalf of each state.

2. Cost Sharing or Matching

Cost sharing or matching is not required for this program.

3. Other

We may not consider an application for funding if it contains any of the following non-responsive criteria:

• Exceeds the funding ceiling amount

• Fails to satisfy the deadline requirements referenced in Section IV.4

Multiple Applications

We will only review your last validated application before the Grants.gov due date.

https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75#sg45.1.75_1344_675_1350.sg4 https://www.ssa.gov/OP_Home/ssact/title18/1820.htm

HRSA-24-002 Flex Program 5

IV. Application and Submission Information

1. Address to Request Application Package

We require you to apply online through Grants.gov. Use the SF-424 workspace application package associated with this notice of funding opportunity (NOFO). Follow these directions: How to Apply for Grants. If you choose to submit using an alternative online method, see Applicant System-to-System.

Note: Grants.gov calls the NOFO “Instructions.”

Select “Subscribe” and enter your email address for HRSA-24-002 to receive emails about changes, clarifications, or instances where we republish the NOFO. You will also be notified by email of documents we place in the RELATED DOCUMENTS tab that may affect the NOFO and your application. You’re responsible for reviewing all information that relates to this NOFO.

2. Content and Form of Application Submission

Application Format Requirements

Submit your information as the Application Guide and this program-specific NOFO state. Do so in English and budget figures expressed in U.S. dollars. There’s an

Application Completeness Checklist in the Application Guide to help you.

Application Page Limit

The total number of pages that count toward the page limit shall be no more than 50 pages when we print them. We will not review any pages that exceed the page limit.

Using the pages within the page limit, HRSA will determine eligibility using Section III.

Eligibility Information of the NOFO.

These items do not count toward the page limit:

• Standard OMB-approved forms you find in the NOFO’s workspace application package

• Abstract (standard form (SF) "Project_Abstract Summary”)

• Indirect Cost Rate Agreement

• Biographical sketches of key personnel

• Proof of non-profit status (if it applies)

If there are other items that do not count toward the page limit, we’ll make this clear in

Section IV.2.vi Attachments.

If you use an OMB-approved form that is not in the HRSA-24-002 workspace application package, it may count toward the page limit.

Applications must be complete and validated by Grants.gov under HRSA-24-002 before the deadline.

https://www.grants.gov/ https://www.grants.gov/applicants/grant-applications/how-to-apply-for-grants https://www.grants.gov/system-to-system/applicant-system-to-system/

HRSA-24-002 Flex Program 6

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

• When you submit your application, you certify that you and your principals1 (for example, program director, principal investigator) can participate in receiving award funds to carry out a proposed project. That is, no federal department or agency has debarred, suspended, proposed for debarment, claimed you ineligible, or you have voluntarily excluded yourself from participating.

• If you fail to make mandatory disclosures, we may take an action like those in 45 CFR § 75.371. This includes suspending or debarring you.2

• If you cannot certify this, you must include an explanation in Attachment #9:

Other Relevant Documents.

(See Section 4.1 viii “Certifications” of the Application Guide)

Program Requirements and Expectations

• State Flex Programs must have key personnel conducting activities central to this program, including a project director with adequate time to oversee the program’s administrative, fiscal, and business operations for the entirety of the project. Flex work may be supported by one person or split across multiple staff members.

• State Flex Programs must address the required program areas of (1) CAH

Quality Improvement and (2) CAH Financial & Operational Improvement.

Program Area (5) CAH Designation is required only if hospitals in the recipient’s state seek help in conversion to CAH status. For detailed examples of potential

Flex interventions and activities, refer to the Flex Program Funding Guidance. In order to maximize the impact of Flex Program funding, we encourage state Flex

Programs to prioritize the highest need CAHs in your state.

• As applicable, other provider types such as CAH-owned rural health clinics, rural

EMS organizations, and Rural Emergency Hospitals may be invited to participate in Flex related activities. Assistance provided to other types of rural hospitals, for example hospitals interested in converting to Rural Emergency Hospitals, must be clearly justified and secondary to CAH assistance.

• State Flex Programs must support analysis and distribution of both current data and new data (if proposed) to help CAHs improve their performance, continue to report on program outcomes, track trends, and identify areas of growth and best practices.

• HRSA expects State Flex Programs to consider ways to develop statewide data collection methods to address identified gaps in data related to CAHs and rural

EMS, including opportunities to leverage relationships with stakeholders and share resources for data collection.

1 See def initions at eCFR :: 2 CFR 180.995 -- Principal. and eCFR :: 2 CFR 376.995 -- Principal (HHS supplement to government-wide def inition at 2 CFR 180.995).

2 See also 2 CFR parts 180 and 376, 31 U.S.C. § 3354, and 45 CFR § 75.113.

https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#se45.1.75_1371 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#se45.1.75_1371 https://www.ruralcenter.org/resources/flex-program-funding-guidance#fy24-structure https://www.ecfr.gov/current/title-2/subtitle-A/chapter-I/part-180/subpart-I/section-180.995 https://www.ecfr.gov/current/title-2/subtitle-B/chapter-III/part-376/subpart-I/section-376.995 https://www.ecfr.gov/current/title-2/subtitle-B/chapter-III/part-376/subpart-I/section-376.995 https://www.ecfr.gov/current/title-2/subtitle-A/chapter-I/part-180 https://www.ecfr.gov/current/title-2/subtitle-B/chapter-III/part-376 https://uscode.house.gov/view.xhtml?req=granuleid%3AUSC-prelim-title31-chapter33&edition=prelim https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-B/section-75.113

HRSA-24-002 Flex Program 7

• HRSA expects State Flex Programs to use the data they collect to evaluate how their programs are performing overall and implement a plan for continuous improvement in the program. See Appendix B for a list of definitions for common program evaluation terms.

• To meet the goals of the Medicare Beneficiary Quality Improvement Project

(MBQIP), HRSA expects State Flex Programs to encourage all CAHs to participate in MBQIP reporting. We highly encourage CAHs to report as many measures as possible. For CAHs that are unable to report on one or more measures, State Flex Programs will provide that information on a regular basis to

FORHP along with a reason why the CAH(s) cannot report a measure(s).

• State Flex Programs must consult with their state hospital associations, rural hospitals, and rural community members to identify community needs and appropriate projects. We also encourage states to work with Quality Innovation

Network-Quality Improvement Organizations (QIN-QIOs), Health Information

Exchanges (HIEs), Hospital Improvement Innovation Networks (HIINs), CDC-funded Healthcare Associated Infections and Antibiotic Resistance prevention programs, State Rural Health Associations, and others concerned with the future of rural health care.

• We encourage these external partnerships to implement projects that ensure the consistent and systematic fair, just, and impartial treatment3 of all patients by addressing social determinants of health (SDOH)4 to improve the quality of healthcare provided.

• New applicants (e.g., states that do not currently have a State Flex Program) are required to develop, or be in the process of developing, a state rural health care plan as part of this application. NOTE: This does NOT apply to current Flex

Program recipients.

• To ensure program maintenance and integrity, State Flex Programs must attend the annual Flex Program meeting and one other regional or national meeting each year related to the administration of the Flex award.

• To ensure Flex Program staff have adequate training, new staff directly responsible for executing the Flex Program award activities must attend a Flex

Program Workshop within one year of their start date.

3 As def ined by Executive Order 13985: https://www.federalregister.gov/documents/2021/01/25/2021- 01753/advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government 4 Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality -of -life outcomes and risks. https://health.gov/healthypeople/priority-areas/social-determinants-health https://www.federalregister.gov/documents/2021/01/25/2021-01753/advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government https://www.federalregister.gov/documents/2021/01/25/2021-01753/advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government https://www.federalregister.gov/documents/2021/01/25/2021-01753/advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government

HRSA-24-002 Flex Program 8

• State Flex Programs must participate in information sharing and program improvement activities coordinated by designated Flex Program technical assistance providers.

• State Flex Programs must participate in the national evaluation of the Flex

Program.

Program-Specific Instructions Include application requirements and instructions from Section 4 of the Application

Guide (budget, budget narrative, staffing plan and personnel requirements, assurances, certifications, and abstract). Also include the following:

i. Project Abstract

Use the Standard OMB-approved Project Abstract Summary Form that you’ll find in the workspace application package. Do not upload the abstract as an attachment or it may count toward the page limit. For information you must include in the Project Abstract

Summary Form, see Section 4.1.ix of the Application Guide.

NARRATIVE GUIDANCE

The following table provides a crosswalk between the narrative language and where each section falls within the review criteria. Make sure you’ve addressed everything. We may consider any forms or attachments you reference in a narrative section during the merit review.

Narrative Section Review Criteria

Introduction Criterion 1: NEED

Organizational Information Criterion 5: RESOURCES/CAPABILITIES

Need Criterion 1: NEED

Approach Criterion 2: RESPONSE

Work Plan Criterion 2: RESPONSE

Criterion 4: IMPACT

Resolution of Challenges Criterion 2: RESPONSE

Evaluation and Technical Support

Capacity

Criterion 3: EVALUATIVE MEASURES

Criterion 5: RESOURCES/CAPABILITIES

Budget Narrative Criterion 6: SUPPORT REQUESTED

HRSA-24-002 Flex Program 9

ii. Project Narrative

This section must describe all aspects of the proposed project. Make it brief and clear.

All applicants must address the program areas of (1) CAH Quality Improvement and (2)

CAH Financial & Operational Improvement, as these are priority areas for addressing need. The program areas of (3) CAH Population Health Improvement and (4) Rural

EMS Improvement are optional. Program Area (5) CAH Designation is required only if hospitals in the applicant’s state seek help in conversion to CAH status. State Flex

Programs considering work in an optional program area (3 or 4) must demonstrate that existing needs of CAHs and rural hospitals in the required program areas have been or will be addressed and additional resources are available to work in the optional areas.

Provide the following information in the following order. Please use the section headers.

This ensures reviewers can understand your proposed project.

▪ Introduction -- Corresponds to Section V’s Review Criterion #1: Need

Briefly describe the purpose of the proposed project, the vision of your State Flex

Program, and your goals for the five-year period of performance. Indicate which of the program areas noted above that you will be working in.

▪ Organizational Information -- Corresponds to Section V’s Review Criterion #5:

Resources/Capabilities o Briefly describe your mission, structure, and scope of current activities.

Explain how these elements all contribute to the organization’s ability to carry out the program requirements and meet program expectations.

Include a project organizational chart in Attachment #7 and explain (as applicable) how the State Flex Program fits within the larger organization.

o Include a staffing plan and job descriptions for key personnel such as organization staff or contractors as Attachment 2. HRSA recommends dedicating staff with adequate time to meet program goals, at least 1.0 full time equivalent, either one full time person or multiple part time people. Key personnel may include a Project Director, State Flex

Coordinator, or others who contribute to the Flex Program in a substantive manner.

o Describe relationships, contracts and subawards that contribute to the ability of the State Flex Program to meet program requirements and expectations.

o Describe how you will ensure coordination between staff, contractors, and subrecipients, as applicable.

o Describe how you will monitor subawards and/or contracts, if applicable.

HRSA-24-002 Flex Program 10 o Discuss how you’ll follow the approved plan, account for federal funds, and record all costs to avoid audit findings.

o NEW APPLICANTS: Include your state rural health care plan that meets the requirements of section 1820(b)(1)(A) of the Social Security Act as

Attachment 8. Describe your consultation process with your state hospital association, rural hospitals located in your state, and the State

Office of Rural Health. If your state rural health care plan is not completed at the time of submitting this application, describe your plans to complete the plan by the date of award. Include an assurance that your state has designated (consistent with its rural health care plan), or is in the process of designating, rural nonprofit or public hospitals or facilities located in your state as CAHs. (NOTE: this does NOT apply to current Flex Program recipients).

▪ Need -- Corresponds to Section V’s Review Criterion #1: Need

This section will help reviewers understand whom you will serve with the proposed project.

o Describe the needs of CAHs, rural EMS agencies, and rural communities in the state. Outline the high-level needs for all CAHs in your state in the areas of quality, financial, operational, and population health. Discuss rural EMS agencies, and other stakeholders, as applicable. (Note: This needs assessment is separate from the CAH and EMS assessment activities identified within the Flex program areas.)

o Utilize the most relevant and recent data available including:

▪ Quality data (MBQIP reports, annual state quality reports from the

Flex Monitoring Team (FMT))

▪ Financial data (Critical Access Hospital Measurement &

Performance Assessment System (CAHMPAS) from the FMT or other relevant sources that collect more timely financial data from hospitals)

▪ Population health data (Population health toolkit from the National

Rural Health Resource Center, CAHMPAS, or the Rural Health

Mapping Tool from NORC)

▪ Emergency Medical Services data (National Emergency Medical

Services Information System) o Clearly answer the following questions in your needs assessment:

▪ What is the environment for CAHs in your state, including current status and trends? Include the total number of CAHs in your state https://www.flexmonitoring.org/publication/mbqip-quality-measures-national-annual-report-2021 https://cahmpas.flexmonitoring.org/ https://cahmpas.flexmonitoring.org/ https://www.ruralcenter.org/resources/toolkits/population-health https://ruralhealthmap.norc.org/ https://ruralhealthmap.norc.org/ https://nemsis.org/ https://nemsis.org/

HRSA-24-002 Flex Program 11 and note any newly certified CAHs or CAHs that closed or converted to a different facility type within the past five years.

▪ Which CAHs in your state are vulnerable (financially or otherwise) and most in need of state Flex Program assistance?

▪ What are the challenges that limit the ability of CAHs to provide high quality care to communities or that make financial stability difficult for CAHs?

▪ What resources are available to help CAHs succeed?

▪ What stakeholders are engaged in supporting CAH efforts and how are they doing so? What additional stakeholders could be engaged?

▪ What are the gaps in data related to CAHs in your state?

o If you plan to include work in the two optional program areas (program area 3: population health or program area 4: rural EMS improvement), answer the following questions, as applicable:

▪ What is the environment for engaging in population health work in your state?

▪ What are the population health needs challenging rural communities in your state?

▪ What stakeholders are engaged in supporting community needs in your state? What additional stakeholders could be sought out?

▪ What data is available to show the unique needs of rural communities in your state?

▪ What are the gaps in services related to CAHs and minority populations in your state?

▪ What is the environment for rural EMS in your state, including current status and trends? Include total number of rural EMS agencies in your state and estimate the number that may participate in Flex projects.

▪ What are the challenges in your state that affect quality of care and financial stability of rural EMS agencies?

▪ Which rural EMS agencies are vulnerable (financially or otherwise) and most in need of state Flex Program assistance?

▪ What resources are available to help rural EMS agencies succeed?

HRSA-24-002 Flex Program 12

▪ What stakeholders are engaged in supporting rural EMS agencies and how are they doing so? What other stakeholders could be engaged?

▪ What data is available on rural EMS in your state? What are the gaps in data related to rural EMS?

o Discuss any relevant barriers in the service area that the project hopes to overcome.

▪ Approach -- Corresponds to Section V’s Review Criterion #2: Response o Tell us how you’ll address the identified needs of CAHs, rural EMS agencies, and rural communities in the state, and meet the program requirements and expectations described in this NOFO.

o Describe how proposed projects and interventions will achieve Flex

Program goals.

▪ Explain the conceptual framework that supports the specific projects selected in each program area and how they will achieve the identified objectives and associated outcomes.

▪ Specific improvement projects can be for one to five years, and you should assess project outcomes at the end of each budget year as well as over the course of the five-year period of performance.

o Describe how your projects will drive change at the hospital, EMS agency, and community level and lead to the desired improvement.

o Describe your process for prioritizing CAHs and how training, technical assistance, and other support will be targeted to CAHs with high needs and capacity. To efficiently use Flex funding and maximize program impact, we encourage State Flex Programs to consider funding cohorts of CAHs with similar challenges.

o Explain your process for engaging key stakeholders in your project.

Describe your plan for CAH site visits, including planned annual number, content, participants, duration, and frequency. Discuss how you will engage non-reporting CAHs in MBQIP. Discuss any significant collaborative activities between the State Flex Program and other organizations—note that work completed under a contract or subaward paid with funds under this notice is not a collaborative activity, instead it is a Flex-funded activity.

o Discuss initiatives planned to improve the effectiveness of the State Flex

Program and how you have incorporated the Core Competencies for

State Flex Program Excellence, as applicable. Please do not report https://www.ruralcenter.org/resources/conducting-cah-site-visit-recommended-steps https://www.ruralcenter.org/programs/tasc/core-competencies https://www.ruralcenter.org/programs/tasc/core-competencies

HRSA-24-002 Flex Program 13 scores from the Core Competencies Self-Assessment because that is a tool designed for internal organizational self-improvement.

▪ Work Plan -- Corresponds to Section V’s Review Criteria #2: Response and #4:

Impact o Include the work plan as Attachment 1. Refer to the Flex Program

Funding Guidance section of the Technical Assistance & Services

Center website (TASC) for more information on the structure of the work plan.

o Describe how you’ll achieve each of the program goals during the period of performance. You find these in the Approach section.

o Organize the work plan by the program areas listed in the introduction.

Only list the program areas that will be part of your State Flex Program for this period of performance.

o Include a minimum of one clearly defined outcome in each program area with a clear, time-based target.

o Some projects may span all five years of the program while others may not.

▪ State Flex Programs are encouraged to implement strategic projects that can build over the course of the five-year period of performance.

▪ For the first year of the period of performance, the work plan should include concise descriptions of activities and projects planned in each program area, expected outputs (process measures) for each, a timeline with key milestones to track progress, and who is responsible for completing each project.

Identify multi-year projects as appropriate.

▪ Resolution of Challenges -- Corresponds to Section V’s Review Criterion #2:

Response

Discuss challenges that you are likely to encounter in designing and carrying out the activities in the work plan. Explain approaches that you’ll use to resolve them.

▪ Evaluation and Technical Support Capacity -- Corresponds to Section V’s Review

Criteria #3: Evaluative Measures and #5: Resources/Capabilities o Describe the systems and processes that you’ll use to track performance outcomes. Describe how you’ll collect and manage data (for example, assigned skilled staff, data management software) in a way that allows for accurate and timely reporting of those outcomes.

https://www.ruralcenter.org/programs/tasc/flex-program/funding-guidance https://www.ruralcenter.org/programs/tasc/flex-program/funding-guidance

HRSA-24-002 Flex Program 14 o Describe your plan to evaluate how the program performs overall and how that will contribute to continuous quality improvement. Identify the data you will collect and analyze to assess your progress toward achieving your outcomes. The evaluation should monitor ongoing processes and the progress towards the project’s goals and objectives.

Describe barriers and your plan to address them.

iii. Budget

The Application Guide directions may differ from those on Grants.gov.

Follow the instructions in Section 4.1.iv Budget of the Application Guide and any specific instructions listed in this section. Your budget should show a well-organized plan.

Reminder: The total project or program costs are all allowable (direct and indirect) costs used for the HRSA activity or project. This includes costs charged to the award and non-federal funds used to satisfy a matching or cost-sharing requirement (which may include MOE, if applicable).

Program Income

You must use any program income you generate from awarded funds for approved project-related activities. Use program income under the addition alternative (45 CFR §

75.307(e)(2)). Find post-award requirements for program income at 45 CFR § 75.307.

Specific Instructions

The Flex Program requires the following:

• Please review the multi-year award information and include the 5th year budget as Attachment 5.

• If indirect costs are included in the budget, attach a copy of the indirect cost rate agreement as Attachment 6.

• As noted in Section 4.1.iv of HRSA’s SF-424 Application Guide the costs of advisory councils are unallowable unless authorized by the HHS awarding agency. For State Flex Programs, HRSA will authorize reasonable costs, e.g., travel and meeting expenses, for stakeholder groups convened to provide input to the State Flex Program on improving program operations and meeting state needs. These groups may be called Flex advisory councils, committees, or other names.

As required by the Consolidated Appropriations Act, 2023 (P.L. 117-328), Division H, §

202, “None of the funds appropriated in this title shall be used to pay the salary of an individual, through a grant or other extramural mechanism, at a rate in excess of

Executive Level II.” Effective January 2024, the salary rate limitation is $221,900. As required by law, salary rate limitations may apply in future years and will be updated.

https://www.hrsa.gov/sites/default/files/hrsa/grants/sf424-application-guide.pdf https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-D/subject-group-ECFR911e5e1a30bfbcb/section-75.307 https://www.hrsa.gov/sites/default/files/hrsa/grants/sf424-application-guide.pdf https://www.congress.gov/bill/117th-congress/house-bill/2617/text

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iv. Budget Narrative

See Section 4.1.v. of the Application Guide.

In addition, the Flex Program requires the following:

• As noted in Section 4.1.v of HRSA’s SF-424 Application Guide, for any contractual costs or subawards, include a clear explanation as to the purpose of each contract/subaward, how the costs were estimated, and the specific deliverables.

• Do not provide line-item details on proposed contracts, rather you should provide the basis for your cost estimate for the contract.

• You are responsible for ensuring that your organization or institution has in place an established and adequate procurement system with fully developed written procedures for awarding and monitoring all contracts/subawards.

• Recipients must notify potential subrecipients that entities receiving subawards must be registered in SAM and provide the recipient with their UEI number (see 2

CFR part 25).

• For consultant services, list the total costs for all consultant services. In the budget narrative, identify each consultant, the services he/she will perform, total number of days, travel costs, and total estimated costs.

• For subawards to entities that will help carry out the work of the award, describe how you will monitor their work to ensure the funds are being properly used.

v. Attachments

Provide the following attachments in the order we list them.

Most attachments count toward the application page limit. Indirect cost rate agreement and proof of non-profit status (if it applies) are the only exceptions. They will not count toward the page limit.

Clearly label each attachment. Upload attachments into the application. Reviewers will not open any attachments you link to.

Attachment 1: Work Plan

Attach the project’s work plan. Make sure it includes everything that Section IV.2.ii.

Project Narrative details in a concise, tabular format. Include process and outcome measures for your program areas that are part of the state Flex Program.

Attachment 2: Staffing Plan and Job Descriptions for Key Personnel (see Section

4.1. of the Application Guide)

Attach a staffing plan that includes a rationale for each award-funded position. Include position descriptions and keep each description to one page as much as possible.

HRSA-24-002 Flex Program 16

Include the role, responsibilities, and qualifications of proposed project staff. Describe your organization’s timekeeping process. This ensures that you’ll comply with federal standards related to recording personnel costs.

Attachment 3: Biographical Sketches of Key Personnel (Does not count towards the page limit)

Include biographical sketches for people who will hold the key positions you describe in

Attachment 2. Keep it to two pages or less per person. Do not include addresses or

SSNs. If you include someone you have not hired yet, include a letter of commitment from that person with the biographical sketch. Key personnel for the state Flex Program are Project Director, state Flex Coordinator, and other individuals who contribute to the execution of the program in a substantive, measurable way, whether or not they receive salaries or compensation under the award.

Attachment 4: Letters of Agreement, Memoranda of Understanding (as required to document eligibility)

Provide any documents that describe working relationships between your organization and other entities and programs you cite in the proposal. Documents that confirm actual or pending contracts or agreements should clearly describe the roles of the contractors and any deliverable. Make sure you sign and date any letters of agreement.

Attachment 5: For Multi-Year Budgets—5th Year Budget

After using columns (1) through (4) of the SF-424A Section B for a 5-year period of performance, you need to submit the budget for the 5th year as an attachment. SF-424A

Section B does not count in the page limit; however, any related budget narrative does count. See Section 4.1.iv of the Application Guide.

Attachment 6: Indirect Cost Rate Agreement (Does not count towards the page limit)

Provide the current federally negotiated indirect cost rate agreement used to substantiate indirect costs in the proposed budget.

Attachment 7: Project Organizational Chart

Provide a one-page figure that shows the program’s organizational structure. Include subrecipients and contractors that are integral to the success of the program.

Attachment 8: State Rural Health Care Plan (NEW APPLICANTS ONLY)

Describe your consultation process with your state hospital association, rural hospitals located in your state, and the State Office of Rural Health. If your state rural health care plan is not completed at the time of submitting this application, describe your plans to complete the plan by the date of award. (NOTE: this does NOT apply to current Flex

Program recipients).

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Attachments 9–15: Other Relevant Documents (no more than 15)

Include any other documents that are relevant to the application. This may include tables or charts that give more details about the proposal (for example, Gantt or PERT charts, or flow charts.), or letters of support, which are not required for eligibility but you may have already developed for your program. Letters must show a commitment to the project/program (in-kind services, dollars, staff, space, equipment, etc.). These documents do count toward the page limit.

3. Unique Entity Identifier (UEI) and System for Award Management (SAM)

A UEI is required to apply for this funding. You must register in the SAM.gov to receive your UEI.

You cannot use a DUNS number to apply. For more details, visit the following webpage:

General Service Administration’s UEI Update.

After you register with SAM, maintain it. Keep your information updated when you have:

an active federal award, application, or plan that an agency is considering.5

When you register, you must submit a notarized letter naming the authorized Entity

Administrator.

We will not make an award until you comply with all relevant SAM requirements. If you have not met the requirements by the time we’re ready to make an award, we will deem you unqualified and award another applicant.

If you already registered on Grants.gov, confirm that the registration is active and that the Authorized Organization Representative (AOR) has been approved.

To register in Grants.gov, submit information in two systems:

• System for Award Management (SAM) (SAM Knowledge Base)

• Grants.gov

Effective March 3, 2023, individuals assigned a SAM.gov Entity Administrator role must be an employee, officer, or board member, and cannot be a non-employee. This change is to ensure entities are in control of who has permission to control roles within their entity.

Here’s what this means:

• Entity Administrators assigning roles to non-employees will only be able to assign a

Data Entry role or lower.

5 Unless 2 CFR § 25.110(b) or (c) exempts you f rom those requirements or the agency approved an exemption for you under 2 CFR § 25.110(d)).

https://www.gsa.gov/entityid https://sam.gov/content/home https://www.fsd.gov/gsafsd_sp?id=gsa_kb_view2&kb_id=f66d8e6cdb76d4100d73f81d0f9619c6 https://www.grants.gov/ https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.fsd.gov%2Fgsafsd_sp%3Fid%3Dkb_article_view%26sysparm_article%3DKB0017347&data=05%7C01%7CDDixon%40hrsa.gov%7C80dfe1e3c58a4e26cd0008db143e65c3%7C14b77578977342d58507251ca2dc2b06%7C0%7C0%7C638126030447564740%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=nnDr7%2B8Bn1g9416eowK4Vwfx%2BO2%2BuUP1Nlu9KkvZoa4%3D&reserved=0

HRSA-24-002 Flex Program 18

• Any entities assigning Entity Administrator roles using an Entity Administrator Role

Request Letter (formerly called “notarized letter”) will no longer be able to assign the

Entity Administrator role to a non-employee.

• Entity Administrator roles assigned to non-employees will be converted to Data Entry roles. With a Data Entry role, non-employees can still create and manage entity registration data entry but cannot manage roles.

If you are an entity using a non-employee or if you are a non-employee working with an entity to manage registrations, please read (and share) more about this change on the

BUY.GSA.gov blog to know what to expect.

For more details, see Section 3.1 of the Application Guide.

Note: Allow enough time to register with SAM and Grants.gov. We do not grant application extensions or waivers if you fail to register in time.

4. Submission Dates and Times

Application Due Date

Your application is due on April 16, 2024 at 11:59 p.m. ET. We suggest you submit your application to Grants.gov at least 3 calendar days before the deadline to allow for any unexpected events. See the Application Guide’s Section 8.2.5 – Summary of emails from Grants.gov.

5. Intergovernmental Review

The Medicare Rural Hospital Flexibility Program does not need to follow the terms of

Executive Order 12372 in 45 CFR part 100.

See Section 4.1 ii of the Application Guide for more information.

6. Funding Restrictions

The General Provisions in Division H of the Consolidated Appropriations Act, 2023 (P.L.

117-328) apply to this…