FY23 MIPPA Nataive Americans Application Form.pdf

VIII. Attachment: Application for FY23 Tribal MIPPA Funding

Due Date: July 27, 2023, 11:59 p.m., ET

To: Yi-Hsin Yan, Grants Management Specialist

Administration for Community Living, Office of Grants Management

MIPPA.Grants@acl.hhs.gov

From: ____________________________________________________

Grantee/Organization Name

State

Grant No.: 23__ __ __ __OATA (Please send separate email for each application)

(Number) (State Code)_______________________________________________ (FY 2023-2026 Title VI Part A/B Grant No. is on the Notice of Award below the “Date”, e.g., 2301AKOATA. DO NOT ENTER “HHS-2023-ACL-MITR-2301”.)

RE: Application for FY 2023 MIPPA Funding in response to Funding Opportunity Number:

HHS-2023-ACL-MITR-2301

We are requesting FY 2023 funding under the Medicare Improvements for Patients and Providers Act (MIPPA) for Beneficiary Outreach and Assistance in the amount of at least $2,000. These funds will be used to coordinate at least one community announcement and one community outreach event to inform and assist eligible Native American, Alaska Native and Native Hawaiian elders about the benefits available to them through Medicare Part D, the Low-Income subsidy, the Medicare Savings Program, or Medicare prevention benefits and screenings. Where possible, we will maximize resources by collaborating with local providers, the Indian Health Service, Tribal Health Services and others involved with these programs.

We will submit a narrative report to ACL within 90 days following the event(s). This narrative report will include a brief description of the event(s), date(s), location(s), and number of participants, and will be submitted via e-mail to MIPPA.Grants@acl.hhs.gov. Include the word “FY23 MIPPA Report: State, Name of Tribe, and [Your MIPPA Grant Number]” on the subject line. We will also submit a final Federal Financial Report (FFR) in PMS within 120 days after the project period end date. These funds will not be used for lobbying.

Print/Type Name of Tribal Chair (or designee) Date

Signature of Tribal Chair (or designee)

(1)____________________________________(2)____________________________________

(3)____________________________________(4)____________________________________

Print/Type ALL E-mail Address(es) to Receive the Notice of Award (NoA) for This Funding mailto:MIPPA.Grants@acl.hhs.gov mailto:MIPPA.Grants@acl.hhs.gov