PKG00251320-instructions.pdf

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Bureau of Health Workforce Division of Medicine and Dentistry

Children’s Hospitals Graduate Medical Education (CHGME) Payment

Program

Funding Opportunity Number: HRSA-20-009 Funding Opportunity Types: New and Competing Continuation

Assistance Listings (CFDA) No. 93.255

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2020

Phase 1: Application Due Date in Grants.gov: July 23, 2019 Phase 2: Supplemental Information Due Date in EHBs:

August 7, 2019

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

Deadline extensions are not granted for lack of registration.

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

Issuance Date: May 24, 2019

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

Authority: Section 340E of the Public Health Service Act, as amended.

mailto:aflach-fulcher@hrsa.gov

HRSA-20-009 ii

EXECUTIVE SUMMARY

The Health Resources and Services Administration (HRSA) is accepting applications for fiscal year (FY) 2020 Children’s Hospitals Graduate Medical Education (CHGME) Payment Program. The purpose of this program is to fund freestanding children’s hospitals to support the training of pediatric and other residents in graduate medical education (GME) programs.

Funding Opportunity Title: Children’s Hospitals Graduate Medical Education Payment Program

Funding Opportunity Number: HRSA-20-009

Due Date for Applications: Grants.gov (Phase 1): July 23, 2019 at 11:59 P.M. Eastern Time;

HRSA Electronic Handbooks (EHBs) (Phase 2) supplemental information:

August 7, 2019 at 5:00 P.M. Eastern Time.

Anticipated Total Annual Available FY20 Funding:

$305,000,000

Estimated Number and Type of Award(s):

55-65 awards

Estimated Award Amount: Formula awards, varies

Cost Sharing/Match Required: No

Period of Performance: October 1, 2019 through September 30, 2020 (One year)

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

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

Application Guide

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

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

HRSA-20-009 iii

Submissions

The CHGME Payment Program requires two submissions during the federal FY: (1) an initial application to determine interim payments, and (2) a reconciliation application to finalize the number of full-time equivalent (FTE) resident counts and subsequently determine final payments. CHGME Payment Program awardees applying for the Quality Bonus System (QBS) payment must submit complete individual level documentation for all residents supported by the CHGME Payment Program in the FY 2020 Annual Performance Report (AY 2019-2020). See NOFO Section V.3 Quality_Bonus_System for more information.

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

Technical Assistance

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

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

https://bhw.hrsa.gov/fundingopportunities/

HRSA-20-009 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/MATCHING

3. OTHER

IV. APPLICATION AND SUBMISSION INFORMATION

1. ADDRESS TO REQUEST APPLICATION PACKAGE

2. CONTENT AND FORM OF APPLICATION SUBMISSION

i. Attachments

3. DUN AND BRADSTREET DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER AND

SYSTEM FOR AWARD MANAGEMENT (SAM)

4. SUBMISSION DATES AND TIMES

5. INTERGOVERNMENTAL REVIEW

6. FUNDING RESTRICTIONS

V. APPLICATION REVIEW INFORMATION

1. REVIEW CRITERIA

2. REVIEW AND SELECTION PROCESS

3. QUALITY BONUS SYSTEM (QBS) PAYMENT

3. ASSESSMENT OF RISK AND OTHER PRE-AWARD ACTIVITIES

4. ANTICIPATED ANNOUNCEMENT AND AWARD DATES

VI. AWARD ADMINISTRATION INFORMATION

1. AWARD NOTICES

2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

IX. TIPS FOR WRITING A STRONG APPLICATION

APPENDIX A

I. Program Funding Opportunity Description

1. Purpose

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

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

(HHS).

Program Goals To achieve this purpose in a timely and effective manner, the CHGME Payment Program provides support to freestanding children’s teaching hospitals by providing a payment established by a formula in accordance with Section 340E of the Public Health Service Act.

Program Objective Support the education and training of future pediatricians, pediatric sub-specialists, and other non-pediatric residents in freestanding children’s teaching hospitals, including the training of residents in pediatric dentistry and pediatric psychology.

2. Background

This program is authorized by Section 340E of the Public Health Service Act, as most recently amended by the Dr. Benjy Frances Brooks Children's Hospital GME Support Reauthorization Act of 2018 (P.L. 115-241). In 1999, Congress addressed the difference of explicit GME funding between freestanding children’s teaching hospitals and other teaching hospitals by passing the Healthcare Research and Quality Act, which established the CHGME Payment Program. There have been several amendments to the program’s statutory authority, including in April 2014 where the eligibility of the program was expanded to include certain hospitals (see Section III.

Eligibility Information) and most recently in September 2018, when the CHGME Payment Program was reauthorized for a period of five years.

The CHGME Payment Program supports HRSA’s mission to improve health outcomes and address health disparities through access to quality services, a skilled health workforce, and innovative, high-value programs. HRSA improves the health of underserved and vulnerable populations by strengthening the health workforce and connecting skilled professionals to communities in need. HRSA oversees several grant programs that support the placement of providers, provide financial support to students in health professions programs, provide continuing education to current health professionals, and foster the development of curricula that promote quality health care.

The nearly 60 freestanding children’s teaching hospitals across the country train about 48 percent of all pediatric residents and 53 percent of pediatric specialists training in the United States (U.S.) annually, and provide valuable training for physicians in many other specialties.1 These are the physicians who care for America’s youngest population – its children. Representing about 1 percent of all short-term acute care hospitals, these hospitals provide almost 50 percent of the patient care to low-income children, including those covered by Medicaid and those who are uninsured.2,3 In addition, these hospitals are regional and national referral centers for critically ill children, often serving as the only source of care for many critical pediatric services. Freestanding children’s hospitals provide care to a large percentage of children with medical complexity (CMC) and more than one-third of hospitalizations at freestanding children’s hospitals were for CMC compared to one-in-five at general hospitals.4 This program provides the funding needed to support children’s hospitals in providing residency training.5

The CHGME Payment Program is designed to support the three-pronged social missions of freestanding children’s teaching hospitals that comply with the social mission of medical education:6

Educate and train future pediatricians, pediatric sub-specialists, and other non-pediatric residents, Provide care for vulnerable and underserved children, and

Conduct innovative and valuable pediatric research.

Funding children’s hospitals is an important part of supporting HRSA’s strategic plan to:

1) improve access to quality health care and services; and 2) foster a health care workforce able to address current and emerging needs.

1 Children’s Hospital Graduate Medical Education Program highlights available at:

https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/childrens-hospital-highlights.pdf.

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

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

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

170.11 (2016): 1055-1062.

4 Leyenaar, JoAnna K. et al. “Epidemiology of Pediatric Hospitalizations at General Hospitals and Freestanding

Children’s Hospitals in the United States.” Journal of hospital medicine 11.11 (2016): 743–749. PMC. Web. 7 Feb.

2018.

5 Supporting Children’s Hospitals and Children Health: The Role of the Federal “CHGME” Program. Prepared by

The Lewin Group for the National Association of Children’s Hospitals, September 5, 2006.

6 Financing Graduate Medical Education to meet the need of Children and the future of the Pediatrician Workforce.

Pediatrics, Volume 121, Number 4, April 2008.

https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/childrens-hospital-highlights.pdf https://www.aha.org/statistics/2018-01-09-fast-facts-us-hospitals-2018-pdf

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

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

In fiscal year (FY) 2017, HRSA began engaging stakeholders in efforts to develop the CHGME QBS. In FY 2018, HRSA released a Federal Register Notice (FRN) seeking public comment on the proposed CHGME QBS (available online at https://www.gpo.gov/fdsys/pkg/FR-2017-10-16/pdf/2017-22381.pdf) and addressed comments received in a later released FRN (https://www.govinfo.gov/content/pkg/FR- 2018-06-26/pdf/2018-13592.pdf). HRSA requested comments on the proposed timeline, eligibility, standards, documentation, QBS measures, potential data sources, and payment structure for FY 2020 and beyond. HRSA received seventeen (17) responses, which were overall supportive of implementing a QBS for the CHGME Payment Program. However, some respondents expressed concern with the proposed patient and graduate outcomes proposed to determine the quality of training programs.

Based on the comments received, HRSA decided to focus the QBS on specific CHGME Payment Program metrics and goals.

In FY 2019, HRSA also released a FRN seeking public comment and OMB approval on the proposed QBS Initiative Response Form (Final FRN available online at https://www.govinfo.gov/content/pkg/FR-2019-02-07/pdf/2019-01434.pdf). This form was approved and will be used for the first phase of the CHGME QBS in FY 2019.

In FY 2019, HRSA is implementing the first phase of the CHGME QBS during the reconciliation process, which occurs in late May 2019. Target outcomes include highlighting children’s hospitals initiatives that have the greatest impact on patient access and quality and those that involve the most residents and/or involve the highest level of resident engagement.

The FY 2020 CHGME NOFO continues the QBS by continuing to collect baseline information to establish QBS standards in the future. HRSA is planning to award a QBS evaluation contract prior to the end of FY 2019, to conduct an environmental scan of GME quality measures, develop quality measures for GME programs in the identified priority areas, and manage an organized stakeholder engagement process on potential QBS standards and measures. Recommendations from the QBS contract and data collected in the FY 2019 and FY 2020 QBS years will help support HRSA’s plan to implement a full Pay-for-Performance QBS starting in FY 2021, should funds become available for this purpose. See Notice of Funding Opportunity (NOFO) Section V.3 Quality_Bonus_System for more information.

https://www.gpo.gov/fdsys/pkg/FR-2017-10-16/pdf/2017-22381.pdf https://www.govinfo.gov/content/pkg/FR-2018-06-26/pdf/2018-13592.pdf https://www.govinfo.gov/content/pkg/FR-2018-06-26/pdf/2018-13592.pdf https://www.govinfo.gov/content/pkg/FR-2019-02-07/pdf/2019-01434.pdf

II. Award Information

1. Type of Application and Award

Type of applications sought: New and Competing Continuation.

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

Traditionally, the CHGME Payment Program has made payments throughout the year to distribute the Direct Medical Education (DME) and Indirect Medical Education (IME) funding. Each of the funding amounts is determined by a formula, and a hospital receives its proportion of the total CHGME Payment Program funding based on the calculation of the formula. For DME, the CHGME Payment Program funding is proportional to the number of residents the hospital trains. Furthermore, the DME payment formula accounts for a hospital’s specific geographic variations in costs, and inflation. For IME, the CHGME formula takes into account the severity of illness of its inpatients, the number of available beds, and the number of residents the hospital trains.

2. Summary of Funding

HRSA expects approximately $305,000,000 to be available to fund 55-65 awardees;

this includes the estimated $3 million for the CHGME QBS. The actual amount of CHGME Payment Program funding available, if any, will not be determined until enactment of the final FY 2020 federal appropriation. The FY 2020 President’s Budget proposes to provide GME support for children’s hospital as part of a broader GME reform effort supported with mandatory funds. Legislative action is needed for this proposal to be enacted. This notice is a contingency action taken to ensure that applications can be processed and funds awarded in a timely manner should funds become available for the existing program under current law. The period of performance is October 1, 2019 through September 30, 2020 (one year).

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

In FY 2019, Congress appropriated $325 million to the CHGME Payment Program. Of this amount, up to $4 million in payments are targeted to newly qualified hospitals. If funding levels and mechanisms remain constant, it is estimated that approximately $3 million may be available in FY 2020 for the CHGME QBS. If the total amount available for the CHGME QBS in FY 2020 is less than $2 million, HRSA does not plan to implement the CHGME QBS in FY 2020 to minimize the administrative burden on the hospitals. In this case, the funds will be disbursed to all eligible hospitals (including those newly qualified) according to the CHGME Payment Program formula payment methodology.

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

III. Eligibility Information

1. Eligible Applicants

There are two categories of children’s hospitals that may be eligible for CHGME payments in FY 2020, depending on the funding appropriated to the program – “Currently Eligible Hospitals” and “Newly Qualified Hospitals”. Hospitals that are applying for the first time for the CHGME Payment Program may be hospitals that are eligible as a “Newly Qualified Hospital” or hospitals that are new to the CHGME Payment Program but qualify under the “Currently Eligible Hospitals” requirements.

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

1) Have a Medicare payment agreement;

2) Are excluded from the Medicare Inpatient Prospective Payment System (IPPS) pursuant to section 1886(d)(1)(B)(iii)7 of the Social Security Act (SSA) and its accompanying regulations; and

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

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

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

1) Has a Medicare payment agreement;

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

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

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

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

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

https://www.ecfr.gov/cgi-bin/text-idx?SID=ad608f0f0aaf8112d03deadbfb3b0a83&mc=true&tpl=/ecfrbrowse/Title45/45cfr75_main_02.tpl

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

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

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

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

1. The program must be approved by one of the following accrediting bodies:

Accreditation Council for Graduate Medical Education (ACGME)

The American Osteopathic Association

Commission on Dental Accreditation of the American Dental Association

Council of Podiatric Medicine Education of the American Podiatric Medical Association

Leads toward board certification by the American Board of Medical Specialties (ABMS)

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

2. Cost Sharing/Matching

Cost sharing or matching is not required for this program.

3. Other

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

Deadline Any application that fails to satisfy the deadline requirements referenced in Section IV.4 will be considered non-responsive and will not be considered for funding under this notice.

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

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

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

Hospitals that are newly qualified to receive CHGME funds as “Newly Qualified Hospitals” under the Children’s Hospital GME Support Reauthorization Act of 2013, as of April 7, 2014, and that do not already have a CMS cap established and are not able to apply for a CMS cap as a new residency training program, will have a “CHGME cap” established. The “CHGME cap” will be established using the number of FTEs trained during the most recent Medicare cost report period completed on or before April 7, 2014. This value will be entered on sections 4, 5, and 6, of the HRSA 99-1, on lines 4.06, 5.06, and 6.06 as applicable. The “CHGME cap” reported by newly qualified hospitals will be verified by the CHGME auditors during the FY 2020 audit process.

Documentation Recommendations

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

IV. Application and Submission Information

Initial Application Process Overview

Phase I:

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

Phase II:

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

1. Address to Request Application Package

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

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

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

Eastern Time on July 23, 2019.

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

a) SF-424 R&R cover page

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

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

Phase 2. HRSA EHBs: Registration and CHGME applications must be complete and successfully submitted by your organization’s Authorizing Official by 5:00 P.M. Eastern Time on August 7, 2019. Please note that you can only begin Phase 2 in the HRSA EHBs after Phase 1 in Grants.gov has been completed by the applicable due date and HRSA has assigned the application a tracking number. CHGME application includes submitting supplemental information, which is completing data forms HRSA 99, HRSA 99-1(1 through 4), HRSA 99-2, and HRSA 99-5 as well as the required Attachments.

Only applicants who successfully have an application validated in Grants.Gov (Phase 1) by the July 23, 2019 due date may submit the additional information and CHGME Payment Program data forms in the HRSA EHBs (Phase 2).

The NOFO is also known as “Instructions” on Grants.gov. You must provide your email address when reviewing or preparing the workspace application package in order to receive notifications including modifications and/or republications of the NOFO on Grants.gov before its closing date. Responding to an earlier version of a modified notice may result in a less competitive or ineligible application. Please note you are ultimately responsible for reviewing the For Applicants page for all information relevant to desired opportunities.

2. Content and Form of Application Submission

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

See Section 9.5 of the SF-424 R&R Two-Tier Application Guide for the Application Completeness Checklist.

Applications must be complete and validated by Grants.gov under the correct funding opportunity number prior to the Phase 1 deadline, and supplemental information must be submitted in the EHBs prior to the Phase 2 deadline, to be considered under this notice.

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

1) The prospective recipient certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.

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

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

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

https://www.grants.gov/web/grants/applicants.html https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf

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

a) HRSA 99: Demographic and Contact Information Form

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

Form

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

Teaching of Residents Form

d) HRSA 99-5: Application Checklist

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

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

i. Attachments

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

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

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

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

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

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

3. Dun and Bradstreet Data Universal Numbering System (DUNS) Number and System for Award Management (SAM)

You must obtain a valid DUNS number, also known as the Unique Entity Identifier, for your organization/agency and provide that number in your application. You must also register with the System for Award Management (SAM) and continue to maintain active SAM registration with current information at all times during which you have an active federal award or an application or plan under consideration by an agency (unless the applicant is an individual or federal agency that is exempted from those requirements under 2 CFR 25.110(b) or (c), or has an exception approved by the agency under 2 CFR 25.110(d)).

HRSA may not make an award to an applicant until the applicant has complied with all applicable DUNS and SAM requirements and, if an applicant has not fully complied with the requirements by the time HRSA is ready to make an award, HRSA may determine that the applicant is not qualified to receive an award and use that determination as the basis for making an award to another applicant.

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

The Grants.gov registration process requires information in three separate systems:

Dun and Bradstreet (http://www.dnb.com/duns-number.html)

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

Grants.gov (http://www.grants.gov/)

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

UPDATED SAM.GOV ALERT: For your SAM.gov registration, you must submit a notarized letter appointing the authorized Entity Administrator. The review process changed for the Federal Assistance community on June 11, 2018. Read the updated FAQs to learn more about this and the current login process for SAM.gov.

4. Submission Dates and Times

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

Grants.gov (Phase 1): July 23, 2019 at 11:59 P.M. Eastern Time.

HRSA EHBs (Phase 2): August 7, 2019 at 5:00 P.M. Eastern Time.

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

5. Intergovernmental Review

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

http://www.dnb.com/duns-number.html) https://www.sam.gov/ http://www.grants.gov/ https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf https://www.gsa.gov/about-us/organization/federal-acquisition-service/office-of-systems-management/integrated-award-environment-iae/sam-update https://www.gsa.gov/about-us/organization/federal-acquisition-service/office-of-systems-management/integrated-award-environment-iae/sam-update

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

6. Funding Restrictions

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

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

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

The General Provisions in Division B of the Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019, (P.L. 115-245) apply to this program. Please see Section 5.1.iv of HRSA’s SF-424 R&R Two-Tier Application Guide for additional information.

Note that these or other restrictions may apply in FY 2020, as required by law.

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

V. Application Review Information

1. Review Criteria

This is a formula-based payment program that does not require submission of a project narrative for review by a review committee. HRSA is responsible for the review of each application for eligibility, completeness and accuracy (including the data reported on all tables), and compliance with the requirements outlined in this NOFO. Application review is conducted at HRSA by HRSA staff, and Fiscal Intermediaries conduct an independent assessment of FTE resident count. Section 340E(e)(3) of the Public Health Service Act states, in part, “[t]he Secretary shall determine any changes to the number of residents reported by a hospital in the application of the hospital for the current fiscal year to determine the final amount payable to the hospital for the current fiscal year for both direct expense and indirect expense amounts.” The assessment of the FTE resident count by Fiscal Intermediaries occurs within a six-month period from the start of the federal FY to the spring of the same federal FY, to allow for reconciliation of payments within the appropriation year for which payments are made. CHGME Fiscal Intermediaries carry out the FTE assessment of residents each fiscal year, and each of the children’s hospitals participating in the program is subject to this https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf assessment. The final amount determined through the reconciliation process is subject to administrative and judicial review under section 1878 of the SSA.

2. Review and Selection Process

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

3. Quality Bonus System (QBS) Payment

The FY 2020 CHGME NOFO includes the estimated $3 million that may be available for the CHGME QBS, which supports HRSA’s efforts to improve the quality of the data collected about our programs, which will in turn assist in measuring and demonstrating long-term programmatic impacts and effectiveness. The FY 2020 CHGME QBS will incentivize complete individual level reporting for all residents supported by the CHGME Payment Program. In order to qualify for the QBS payment: 1) CHGME awardees must complete individual level documentation for all residents supported by the CHGME Payment Program in the FY 2020 Annual Performance Report (AY 2019-2020); and 2) CHGME awardees must not have a Not Reported rate more than a 10% in any individual level demographic or National Provider Identifier (NPI) field. CHGME will extract data from the FY 2020 Annual Performance Report related to the hospital’s initiatives, resident curriculum, and direct resident involvement in the following areas:

a. Integrated care models (e.g., integrated behavioral and mental health, care coordination across providers and settings);

b. Telehealth and/or Health Information Technology (e.g., electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration);

c. Population health;

d. Social determinants of health; and

e. Additional initiatives to improve access and quality of care to rural/underserved communities.

QBS Quality Area Term Definitions

Integrated care models - a graduated spectrum of health services wherein a facility delivers primary care services and coordinates with behavioral health care, oral health care, and/or public health strategies and interventions.

Telehealth - the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration.

Population Health - the health outcomes of a group of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group. Note that population health is not just the overall health of a population but also includes the distribution of health outcomes within a population.

Social Determinants of Health – the circumstances in which people are born, grow up, live, work, and age, as well as the systems put place to deal with illness.

See CHGME Annual Performance Report (AY 2017–2018) Instruction Manual for further information about the required performance measures collected.

HRSA recognizes quality improvement, patient safety, and provider/resident wellness initiatives as transformation areas included in the ACGME Common Program Requirements, therefore are integral to every ACGME accredited residency program.8 The vast majority of CHGME awardees have ACGME accredited residency programs and will therefore be expected by ACGME to address these requirements. Collection of this information would therefore be duplicative, and as such, the CHGME QBS will not focus on these areas in FY 2020.

Additional submission instructions will be included in the reconciliation application.

Payment Structure: QBS payments in FY 2020 are targeted to be disbursed at the end of the fiscal year to ensure CHGME follows legislative mandates. CHGME hospitals that submit the required documentation outlined above will receive a portion of the available funds for the CHGME QBS payment. Amounts will be distributed according to a three tiered payment structure that recognizes the different annual payment levels received by CHGME hospitals. Hospitals that meet the QBS standards will be evenly divided into three tiers based on their combined direct and indirect fiscal year payment amounts, as calculated per the established CHGME Payment Program formulas:

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

8 Accreditation Council for Graduate Medical Education Common Program Requirements, available at:

https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf https://bhw.hrsa.gov/sites/default/files/bhw/grants/chgme-apr-2017-2018-reporting-manual.pdf https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf

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

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

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

3. Assessment of Risk and Other Pre-Award Activities

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

HRSA reviews applications for other considerations that include past performance, as applicable, cost analysis of the project/program budget, assessment of your management systems, ensuring continued applicant eligibility, and compliance with any public policy requirements, including those requiring just-in-time submissions. HRSA may ask you to submit additional programmatic or administrative information or to undertake certain activities in anticipation of an award. However, even at this point in the process, such requests do not guarantee that HRSA will make an award. Following review of all applicable information, the HRSA’s approving and business management officials will determine whether HRSA can make an award, if special conditions are required, and what level of funding is appropriate.

Award decisions are discretionary and are not subject to appeal to any HRSA or HHS official or board.

Effective January 1, 2016, HRSA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS). You may review and comment on any information about your organization that a federal awarding agency previously entered. HRSA will consider any of your comments, in addition to other information in FAPIIS in making a judgment about your organization’s integrity, business ethics, and record of performance under federal awards when completing the review of risk posed by applicants as described in 45 CFR § 200.205 Federal Awarding Agency Review of Risk Posed by Applicants.

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

4. Anticipated Announcement and Award Dates https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75 https://www.fapiis.gov/fapiis/index.action https://www.fapiis.gov/fapiis/index.action https://www.fapiis.gov/ http://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75 http://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75

HRSA anticipates issuing/announcing Notice of Awards (NOAs), subject to availability of funds, in November 2019. For “Newly Qualified Hospitals,” the reauthorization permits the Secretary, “to make available up to 25 percent of the total amounts in excess of $245,000,000” but “not to exceed $7,000,000.” “Newly Qualified Hospitals” will not receive their payment, if any, until after the annual appropriation has been made, and only if the annual appropriation is funded at $245,000,000 or more for FY 2020.

VI. Award Administration Information

1. Award Notices

HRSA intends to issue the Notice of Award (NOA), subject to availability of funds, in November 2019. “Newly Qualified Hospitals” will not receive an NOA until after November. See Section 6.4 of HRSA’s SF-424 R&R Two-Tier Application Guide for additional information.

2. Administrative and National Policy Requirements

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

Requirements under Subawards and Contracts under Grants

The terms and conditions in the NOA apply directly to the recipient of HRSA funds.

The recipient is accountable for the performance of the project, program, or activity;

the appropriate expenditure of funds under the award by all parties; and all other obligations of the recipient, as cited in the NOA. In general, the requirements that apply to the recipient, including public policy requirements, also apply to subrecipients and contractors under grants, unless the NOA specifies an exception. See 45 CFR §

75.101 Applicability for more details.

3. Reporting

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

a. Audit Requirements HHS, or any other authorized federal agency, may conduct an audit to determine whether the applicant has complied with all governing laws and regulations in its application for funding. All information submitted to HRSA by an applicant or participating hospital during or after the award of funds is subject to review in an audit.

In addition, a Resident FTE Assessment will be conducted between October and May of each fiscal year. A CHGME Fiscal Intermediary is assigned to https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf https://www.hrsa.gov/grants/apply/applicationguide/sf424rr2guidev2.pdf https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75 each children’s hospital currently receiving CHGME Payment Program funding. The CHGME FI conducts an assessment of resident FTE counts reported by the children’s hospital in its initial application (HRSA 99-1) for CHGME Payment Program funding to determine any changes to those resident FTE counts prior to the CHGME Payment Program reconciliation application cycle. The CHGME Fiscal Intermediary follows a detailed protocol based on CMS rules and regulations designed to ensure that each resident FTE claimed by the children’s hospital is documented in accordance with 42 CFR 413.75(d). Resident counts are based on the number of residents training at the hospital complex and certain non-hospital/non-provider settings/sites throughout the hospital’s fiscal year. Residents are counted as FTEs based on the total time necessary to fill a full-time residency slot for the year. Eligible hospitals are subject to the terms of the Full-Time Equivalent Assessment Process Guidance and Assessments, which is available electronically via the CHGME Payment Program web site at:

https://bhw.hrsa.gov/grants/medicine/chgme.

b. Progress Reports

For this program, Government Performance and Results Act performance data tables are submitted as part of the reconciliation application, using the HRSA 99-4 form.

c. Performance Reports The CHGME Payment Program mandates an annual submission of a Performance Report. Recipients must submit a Performance Report to HRSA via the EHBs on an annual basis, as required by Public Law 109-307, as an addendum to the hospital's application for CHGME funding. All HRSA recipients are required to collect and report performance data so that HRSA can meet its obligations under the Government Performance and Results Modernization Act of 2010, and recipients of CHGME funding must also specifically submit the information required under Section 340E(b)(3)(B) of the Public Health Service (PHS) Act.