State Flexibility Grant 2-5-18.pdf

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services

Center for Consumer Information and Insurance Oversight

The State Flexibility to Stabilize the Market Grant Program Grants to Support States in Providing Added Flexibility to Strengthen the Private Health

Insurance Market through Implementation of Market Reforms under Part A of Title XXVII of the Public Health Service Act

Notice of Funding Opportunity

Invitation to Apply for 2018

Funding Opportunity Number: PR-PRP-18-001

CFDA: 93.413

Funding Opportunity Posting Date: February 5, 2018

Applicable Dates:

Mandatory Letter of Intent to Apply Due Date February 26, 2018

Electronic Application Due Date: April 5, 2018 (3:00 p.m. EST)

Anticipated Issuance Notices of Award: June 5, 2018

Anticipated Period of Performance: June 6, 2018 – June 5, 2020

Table of Contents

EXECUTIVE SUMMARY

A. PROGRAM DESCRIPTION

A1. Purpose A2. Authority A3. Background A4. Program Requirements A5. Technical Assistance and Information for Prospective Applicants

B. FEDERAL AWARD INFORMATION

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

C. ELIGIBILITY INFORMATION

C1. Eligible Applicants C2. Cost Sharing or Matching C3. Letter of Intent C4. Ineligibility Criteria C5. Single Application Requirements C6. Continued Eligibility C7. EIN, DUNS, and SAM Regulations C8. Foreign and International Organizations C9. Faith-Based Organizations

D. APPLICATION AND SUBMISSION INFORMATION

D1. Address to Request Application Package D2. Content and Form of Application Submission D3. Unique Entity Identifier and System for Award Management (SAM)—Required D4. Submission Dates and Times D5. Intergovernmental Review D6. Cost Restrictions D7. Mandatory Disclosure D8. Other Submission Requirements

E. APPLICATION REVIEW INFORMATION

E1. Criteria E2. Review and Selection Process E3. Federal Awardee Performance and Integrity Information Systems (FAPIIS) ..26

F. FEDERAL AWARD ADMINISTRATION INFORMATION

F1. Federal Award Notices F2. Administrative and National Policy Requirements F3. Terms and Conditions F4. Reporting

G. CMS CONTACTS

G1. Programmatic Contact G2. Grants Management Specialist/Business Administration Contact

APPENDICES

APPENDIX I: Guidance for Preparing a Budget Request and Narrative APPENDIX II: Application and Submission Information APPENDIX III: Business Assessment of Applicant Organization (Questions) APPENDIX IV: 504 Compliance, Accessibility Provisions APPENDIX V: Review and Selection Process APPENDIX VI: Workload Funds - Example APPENDIX VII: List and Summary of Provisions under Part A of Title XXVII of the PHS Act for which Grant Funding is Available APPENDIX VIII: Definitions APPENDIX IX: Application Check-off List

Executive Summary

The State Flexibility to Stabilize the Market Grant Program will provide a funding source to enhance and support the role of States in the implementation and planning for several of the Federal market reforms and consumer protections under Part A of Title XXVII of the Public Health Service Act (PHS Act). The State Flexibility to Stabilize the Market Grant Program will provide States with the opportunity to ensure their laws, regulations, and procedures are in line with the Federal requirements, and enhance the States’ ability to effectively regulate their respective health insurance markets through innovative measures that support the pre-selected market reforms and consumer protections under Part A of Title XXVII of the PHS Act.

Item Description

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

CMS Awarding Center Center for Consumer Information and Insurance Oversight (CCIIO)

Notice of Funding Opportunity Title The State Flexibility to Stabilize the Market Grant Program: Grants to Support States in Providing Added Flexibility to Strengthen the Private Health Insurance Market through Implementation of Market Reforms under Part A of Title XXVII of the PHS Act

Authorization Section 2794 of the Public Health Service Act (PHS Act)

Funding Opportunity Type New

Funding Opportunity Number PR-PRP-18-001

Type of Award Grant

Catalog of Federal Domestic Assistance 93.413

Letter of Intent to Apply Due Date (if applicable) February 26, 2018

Application Due Date & Time

April 5, 2018 3:00 PM Eastern U.S.

Time

Anticipated Issuance Notice(s) of Award June 5, 2018

Anticipated Period of Performance

June 6, 2018 – June 5, 2020

Anticipated Total Available Funding $8.1 million

Number of Eligible Applicants 51

A. PROGRAM DESCRIPTION

A1. Purpose

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act and on March 30, 2010, the Health Care and Education Reconciliation Act of 2010 was also signed into law (collectively referred to as “PPACA”).

The PPACA includes a number of provisions that reform the health insurance market and provide Federal consumer protections through amendments to Title XXVII of the Public Health Service Act (PHS Act) and corresponding amendments to the Employee Retirement Income Security Act and the Internal Revenue Code. The PPACA also includes significant grant funding for States to work with the Federal government to implement the market reforms.

Section 1003 of the PPACA adds a new section 2794 to the PHS Act entitled, “Ensuring That Consumers Get Value for Their Dollars.” Specifically, section 2794(a) requires the Secretary of the Department of Health and Human Services (the Secretary) (HHS), in conjunction with the States, to establish a process for the annual review of health insurance premiums1 to protect consumers from unreasonable rate increases. Section 2794(c) directs the Secretary to carry out a program to award grants to States.

Congress appropriated $250 million, to be awarded in Federal fiscal years (FFYs) 2010 through

1 The Patient Protection and Affordable Care Act (PPACA) uses the term “premium”; however, the National Association of Insurance Commissioners uses the term, “rate” for purposes of industry review. To remain aligned with industry terminology, “rate” will be used in lieu of "premium" in this grant announcement.

2014, for the Rate Review Grant Program. From 2010 through 2014, there were four cycles of Rate Review Grants awarded. Section 2794(c)(2)(B)2 specifies that if there are any appropriated Rate Review Grant funds that are not fully obligated by the end of fiscal year (FY) 2014, such amounts shall remain available to the Secretary for grants to States for planning and implementing the insurance market reforms and consumer protections under Part A of Title XXVII of the PHS Act.

The provisions in Part A of title XXVII of the PHS Act include market-wide reforms in the group and individual private health insurance markets intended to protect consumers, increase transparency, and regulate health insurance industry practices.

Please visit the following link on the U.S. Government Publishing Office Website to view the full list of relevant regulations that HHS has published under Title 45 of the Code of Federal Regulations:

https://www.ecfr.gov/cgi-bin/text-idx?SID=0ed4c60c2c0a7e5943a5e18ac5db8636&c=ecfr&tpl=/ecfrbrowse/Title45/45cfrv1_02.tp l

A2. Authority

The State Flexibility to Stabilize the Market Grant Program is being administered by HHS under the authority of section 2794 of the PHS Act entitled, “Ensuring That Consumers Get Value for Their Dollars.” Specifically, section 2794(c) directs the Secretary to carry out a program to award grants to States.3 Section 2794 of the PHS Act appropriates $250 million to the Secretary to award grants to States to assist them with the health insurance rate review process, from FY 2010 through FY 2014. Section 2794(c)(2)(B)4 specifies that any appropriated Rate Review Grant funds that are not fully obligated by the end of FY 2014 shall remain available to the Secretary for grants to States for planning and implementing the insurance market reforms and consumer protections under Part A of Title XXVII of the PHS Act.

2 PHS Act section 2794(c)(2)(B) States in full: “If the amounts appropriated under subparagraph (A) are not fully obligated under grants under paragraph (1) by the end of fiscal year 2014, any remaining funds shall remain available to the Secretary for grants to States for planning and implementing the insurance reforms and consumer protections under part A.”

3 Effective July 16, 2014, the definition of “State” for the new Public Health Service Act (PHS Act) requirements for health insurance enacted in title I of the PPACA does not include the United States Territories. See 42 U.S.C. § 18024(d). Also see the July 16, 2014, letters to the United States Territories, available at:

https://www.cms.gov/cciio/Resources/Letters/index.html#Health Market Reforms.

4 PHS Act section 2794(c)(2)(B) States in full: “If the amounts appropriated under subparagraph (A) are not fully obligated under grants under paragraph (1) by the end of fiscal year 2014, any remaining funds shall remain available to the Secretary for grants to States for planning and implementing the insurance reforms and consumer protections under part A.”

https://www.ecfr.gov/cgi-bin/text-idx?SID=0ed4c60c2c0a7e5943a5e18ac5db8636&c=ecfr&tpl=/ecfrbrowse/Title45/45cfrv1_02.tpl https://www.ecfr.gov/cgi-bin/text-idx?SID=0ed4c60c2c0a7e5943a5e18ac5db8636&c=ecfr&tpl=/ecfrbrowse/Title45/45cfrv1_02.tpl https://www.ecfr.gov/cgi-bin/text-idx?SID=0ed4c60c2c0a7e5943a5e18ac5db8636&c=ecfr&tpl=/ecfrbrowse/Title45/45cfrv1_02.tpl

A3. Background

Many of the market reforms and consumer protections in Part A of Title XXVII of the PHS Act are new provisions that became effective for plan years beginning in 2014. The State Flexibility to Stabilize the Market Grant Program (hereafter referred to as “State Flexibility Grants” or “State Flexibility Grant Program”) will provide a funding source to enhance and support the role of States in implementing and planning for several of the Federal market reforms and consumer protections, which are listed below. State Flexibility Grants will provide States with the opportunity to ensure their laws, regulations, and procedures are in line with Federal requirements and that States are able to effectively oversee and enforce these provisions under the PHS Act’s title XXVII Part A market reform and consumer protection with respect to health insurance issuers.

Funding under the State Flexibility Grant Program is available to States for activities related to planning and implementing the following provision of Part A of title XXVII of the PHS Act:

I. Section 2702 – Guaranteed Availability of Coverage II. Section 2703 – Guaranteed Renewability of Coverage III. Section 2707 – Non-discrimination under Comprehensive Health Insurance Coverage

(Essential Health Benefits Package)

A summary of these provisions is found under Appendix VII, List and Summary of Provisions under Part A of Title XXVII of the PHS Act for which Grant Funding is Available.

These pre-selected market reforms were chosen due to their relative complexity and the anticipated benefits that these reforms will have on consumers and the premiums they pay.

These also represent areas that can help States assess the needs of consumers and support the development of innovative measures to ensure access to affordable health coverage in their respective individual and small group markets.

A4. Program Requirements

Applicants may use grant funds for a variety of planning and implementation objectives related to the pre-selected market reforms and consumer protections under Part A of Title XXVII of the PHS Act, including but not limited to implementing or enhancing policy form review, hiring or contracting with a clinician to review formularies, developing actuarial and economic analyses, and performing market scans of the respective State’s health insurance market to improve and expand the number of current healthcare coverage options.

Recommended Areas of Focus for Market Reforms Activities

One of the goals of the State Flexibility Grant Program is to enhance the States’ ability to effectively regulate their respective health insurance markets through innovative measures that support the pre-selected market reforms and consumer protections under Part A of Title XXVII of the PHS Act. Provided below are recommended areas of focus for State market reform activities that can be funded by these grants.

Section 2702 - Guaranteed Availability of Coverage

States may use grant funds to perform or contract services to obtain a market scan of their individual, small group, and large group health insurance markets to ensure that issuers offering health insurance coverage in these markets offer to any individual or employer in the State all non-grandfathered products that are approved for sale in the applicable market, and accept any individual or employer that applies for any of those products, unless an exception applies.

• Perform or obtain market scan of health insurance market

States are responsible for regulating their respective health insurance markets and ensuring that consumers have access to quality affordable health care. The Guaranteed Availability of Coverage provision ensures any non-grandfathered product that is approved for sale in the individual, small group, and large group markets is made available for purchase to any individual or employer that applies for coverage in the respective market, unless an exception applies. In addition to confirming whether approved products are being appropriately offered for purchase, States can use a market scan, actuarial or economic analysis to assess whether the coverage is comprehensive and affordable. States may also use funds to assess whether other innovative measures are needed to strengthen the type of coverage provided by health insurance issuers in the individual, small group, and large group markets. States may also investigate ways to improve access to coverage, including addressing access in underserved areas.

Section 2703 - Guaranteed Renewability of Coverage

States may use grant funds to perform or contract services to obtain a market scan of its markets to ensure that issuers offering non-grandfathered health insurance coverage in the individual, small group, and large group markets health insurance renews or continues to offer coverage at the option of the individual or plan sponsor, unless an exception applies.

• Perform or obtain market scan of health insurance market

States are responsible for regulating their respective health insurance market and ensuring that consumers have access to quality affordable health care. The Guaranteed Renewability of

Coverage provision ensures that issuers renew or continue coverage at the option of the individual or plan sponsor, unless an exception applies. States can use funds to perform or obtain the services of a contractor to assess whether issuers are in compliance with this provision. In addition to confirming whether products are being appropriately renewed or continued in force, States can use a market scan, actuarial or economic analysis to assess whether the coverage is comprehensive and affordable. States may also use funds to assess whether other innovative measures are needed to strengthen the type of coverage provided by health insurance issuers in the individual, small group, and large group markets. States may also investigate ways to improve access to coverage, including addressing access in underserved areas.

Section 2707 – Non-Discrimination under Comprehensive Health Insurance Coverage (Essential Health Benefits Package)

As primary regulators of their respective health insurance markets, States are best positioned to assess the needs of consumers and develop innovative measures to ensure consumers have access to affordable health coverage in the individual and small group markets.

States may use grant funds to enhance existing policy filing review processes to ensure health insurance issuers do not include discriminatory benefit designs that discourage people with potentially high-cost medical conditions from enrolling in those plans.

Section 2707(a) of the PHS Act requires issuers that offer non-grandfathered coverage in the individual and small group markets to ensure that such coverage includes the EHB package required under section 1302(a) of the PPACA. The accompanying nondiscrimination provisions under section 1302(b)(4) of the PPACA and 45 C.F.R. § 156.125 prohibit issuers from using or implementing benefit designs that have the effect of discriminating against individuals on the basis of, among other things, age, expected length of life, present or predicted disability, quality of life, or other health conditions. In addition, 45 C.F.R. § 156.200(e), which applies to plans subject to the EHB requirements under 45 C.F.R. § 156.125(b), and 45 CFR § 147.104(e), prohibit issuers from discriminating on the basis of, among other things, race, color, national origin, disability, age, sex, gender identity or sexual orientation. The protections under § 147.104(e) apply market-wide, to all non-grandfathered plans in the individual and group markets.

Discriminatory benefit designs that discourage people with potentially high-cost medical conditions from enrolling in coverage could be contrary to the regulations discussed above.

However, § 1563(d) of the PPACA specifies that the Secretary may not prohibit a group health plan or health insurance issuer from carrying out utilization management techniques that were commonly used as of the date of enactment of the PPACA (March 23, 2010).

• Procedures and/or tools to identify discriminatory benefit design

States may develop standard operating procedures and/or tools or use currently available tools to review plans to identify discriminatory benefit design. There are various CMS tools currently available that States could use, including the Non-Discrimination Formulary Clinical Appropriateness and Formulary Outlier Tools. The Qualified Health Plan (QHP) Application Review Tools for Plan Year 2018 can be found on the CCIIO website at:

https://www.qhpcertification.cms.gov/s/Review%20Tools.

• Review of EHB Benchmark plan

States may perform an assessment of their EHB-Benchmark plans to inform whether plans offering EHB in the State are meeting the needs of their respective individual and small group markets and are affordable for consumers. States may use funds to research other State EHB- Benchmark plans and perform an analysis of potential adjustments to the respective State’s existing EHB-Benchmark plan, in accordance with applicable EHB-Benchmark plan selection criteria. States may use funds to assess whether potential modifications to the set of benefits included in the State’s EHB-Benchmark plan or modification of specific categories of benefits will increase affordability for consumers and provide an EHB-Benchmark plan that best reflects the needs of the State’s health insurance market(s) and population within the statutory and Federal regulatory requirements. States may also use funds to enhance or reconcile State law with Federal EHB requirements.

States may use funds to assist with the costs associated with providing public notice and opportunity for public comment on a State’s selection of an EHB-benchmark plan.

To the extent that States intend to utilize State Flexibility Grant funds in conjunction with reselecting or adjusting their State’s EHB-Benchmark plan, States must do so in accordance with the timeline, document collection, and EHB-Benchmark selection requirements specified in Federal EHB regulation.

• Use tools or hire staff to conduct formulary review

Pursuant to 45 C.F.R. § 156.122, a health plan providing EHB must cover at least the greater of

(1) one drug in every United States Pharmacopeia (USP) category and class, or (2) the same number of prescription drugs in each USP category and class as the State’s EHB-Benchmark plan. States may not currently have clinicians on staff to conduct formulary review.

States could use tools currently available, including the Category Class Drug Count Tool on the CCIIO website at https://www.qhpcertification.cms.gov/s/Review%20Tools.

https://www.qhpcertification.cms.gov/s/Review%20Tools https://www.qhpcertification.cms.gov/s/Review%20Tools http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/qhp.html

States could also hire or contract with a clinician to review formularies or create a standard operating procedure so that form filing reviewers can successfully review formularies and any related documentation. CCIIO suggests that a successful clinician would have the following:

• A clinical background in pharmacology including pharmacotherapeutics, pharmacokinetics, pharmacodynamics.

• A broad understanding of common disease conditions and the drugs used in their treatment, based on nationally recognized treatment guidelines and recommendations.

• An understanding of 45 C.F.R. § 156.122 and PPACA policies in benefit plan design, including EHB-Benchmarks and non-discrimination requirements. Staff should also be able to keep track of developing drug policies and guidance.

• A working knowledge of prescription formulary plan design, development, and implementation.

• Analytical skills to identify potential issues and develop recommendations to address those issues.

A5. Technical Assistance and Information for Prospective Applicants

HHS will hold a pre-application conference call for potential applicants. During the call, HHS staff will provide an overview of the grant program, offer budget guidance, review the guidance provided by this Notice of Funding Opportunity (“Funding Opportunity”) and other available materials, and provide an opportunity for States to ask questions. Details on the date, time, and call-in information will be provided prior to the conference call.

B. FEDERAL AWARD INFORMATION

B1. Total Funding

Under section 2794 of the PHS Act, funds are available to support grants as necessary to fulfill the purpose of this funding opportunity to all eligible States and the District of Columbia. CMS is anticipating approximately $8.1 million will be available for the State Flexibility Grants, pending availability of funds.

The amount of funds awarded to each recipient will be conditional upon funding availability. As a result, all applicants must submit the mandatory Letter of Intent by the deadline given, February 26, 2018. HHS will use this information to determine the amount of funding available to each recipient. The project period is expected to be 24 months (see Section B.2. Award Amount for more information). HHS will provide applicants with information on funding allocation prior to March 2, 2018.

Baseline funding for the State Flexibility Grants consists of a minimum of approximately $156,000 for the length of the award. Provided sufficient funds are available after providing each State with baseline funding for a one-year project period, States may also receive supplemental awards called “Workload” funds. Workload funds are determined based on the population and number of health insurance issuers in the State, as further described in Appendix VI, “Workload” Funds Allocation and Example. Following submission of the mandatory Letters of Intent, HHS will inform States of funding allocations, including whether baseline award amounts have increased and if there are sufficient funds available for the “Workload” supplemental awards. The baseline funding formula will be consistent, regardless of how many market reforms an Applicant selects.

B2. Award Amount

Award amounts will consist of Baseline and Workload awards, as follows:

• Baseline Award Amount: Each eligible State will be awarded a minimum of $156,000 baseline award for 24 months.

• Workload Awards: Workload funds will only be available if there are sufficient funds available after providing baseline awards for all eligible applicants.

Funding Formula for Workload Awards: States will be eligible to receive additional grant funds based on the State population size and the number of issuers with five percent or more market share (combined individual and small group markets) within the State, as further described in Appendix VI, “Workload” Funds Allocation and Example.

If funding is available for Workload awards, the Workload funds will be awarded along with the Baseline Award. HHS will inform States whether sufficient funds are available for Workload funds following submission of the mandatory Letters of Intent.

See Appendix VI, “Workload” Funds Allocation and Example, for additional information.

B3. Anticipated Award Date

The State Flexibility Grant awards will be issued by June 5, 2018.

B4. Period of Performance

The grant will have a project and budget period of 24 months from the award date, June 6, 2018 to June 5, 2020.

B5. Number of Awards

There will be no more than fifty-one initial Baseline Amounts awarded, for each of the fifty States and the District of Columbia. Only one State is currently eligible for its Baseline Amount award to be issued as two separate awards.5 All awards are subject to funding availability.

B6. Type of Award

These awards will be issued and structured as grants.

B7. Type of Competition

This will be a competitive Funding Opportunity open to all eligible applicants identified in C1.

Eligible Applicants.

C. ELIGIBILITY INFORMATION

C1. Eligible Applicants

This Funding Opportunity is open to all fifty States6 and the District of Columbia for planning and/or implementing one or more of the pre-selected market reforms and consumer protections in Part A of Title XXVII of the PHS Act. Please refer to Section A.3. for the PHS Act provisions applicable to this Funding Opportunity.

Only one application per State is permitted, except in a State in which there is more than one regulating entity, each with a primary responsibility over the regulation of a portion of the private health insurance market.

Applicants must submit the following letters (or other permissible document as outlined):

• A letter attesting that the State is not receiving other Federal grant dollars for the same activity(ies) for which it will receive (if awarded) State Flexibility Grant funds.7

5 This provision currently applies to the State of California, which has two regulatory agencies that are each primarily responsible for regulating a portion of the private health insurance market. A State eligible to submit multiple applications will be required to split the total grant award allocated for that State and therefore the regulatory agencies involved must collaborate with each other regarding a proposed budget. However, each State regulatory agency will be viewed as a distinct grantee responsible for submitting separate programmatic and financial reports.

6 Effective July 16, 2014, the definition of “State” for the new Public Health Service Act (PHS Act) requirements for health insurance enacted in title I of PPACA does not include the United States Territories. See 42 U.S.C. § 18024(d). Also see the July 16, 2014, letters to the United States Territories, available at:

https://www.cms.gov/cciio/Resources/Letters/index.html#Health Market Reforms. The United States Territories are thus not eligible to apply for awards under the State Flexibility Grant Program.

7 New EHB grant activities not previously funded through the Cycle I Health Insurance Enforcement and Consumer Protections (HIECP) Grant are allowable under the State Flexibility Grant Program.

• A State certification of Maintenance of Effort verifying that the grant funds will not supplant existing State expenditures for related consumer protection activities.

Additional eligibility criteria:

Each State seeking to plan and implement the pre-selected PPACA market reforms and consumer protections under Part A of Title XXVII of the PHS Act must include in its Project Narrative and Work Plan a proposal for program activities that enhance its current oversight and implementation of the pre-selected reforms.

C2. Cost Sharing or Matching

Cost sharing or matching is not a requirement of this Funding Opportunity.

C3. Mandatory Letter of Intent

The purpose of the Letter of Intent is to determine the number of applications and total funding for award planning purposes. A Letter of Intent should include a brief explanation of a State’s intent to apply and clearly list which provision(s) it seeks funding for under the State Flexibility Grant Program. Following review of the Letters of Intent, eligible applicants will be notified of their potential funding eligibility. Please note that submitting a Letter of Intent to apply is not binding on an applicant. The Letter of Intent must be submitted electronically in PDF format to James.Taing@cms.hhs.gov by the deadline stated in the Executive Summary.

C4. Ineligibility Criteria

Applicants must ensure that they are only seeking funding to plan and implement those provisions that they are not currently receiving Federal grant funding to plan and implement.8 Each award made under this Funding Opportunity should support different activities and should not be used for activities funded by other grant awards. In the budget request, States should distinguish between activities that will be funded under this application and activities funded with other sources.

C5. Single Application Requirements

Only one application may be submitted by a single eligible State for funding, except in a State in which there is more than one regulating agency, each with a primary responsibility over the regulation of a portion of the private health insurance market. A State with more than one application will be required to split the total grant award allocated for that State and therefore must collaborate with the other applicable State agencies regarding a proposed budget.

8 EHB grant activities that are funded through the Cycle I Health Insurance Enforcement and Consumer Protections (HIECP) Grant may not also be funded through the State Flexibility Grant Program.

However, each State regulatory agency will be viewed as a distinct grantee responsible for submitting separate programmatic and financial reports.

C6. Continued Eligibility

A State must meet the milestones proposed in the grant application and outlined in the Work Plan to continue to be eligible throughout the project period. A State must continue to meet the eligibility criteria described in Subsection 1, Eligible Applicants, of Section C, Eligibility Information, throughout the project period.

C7. EIN, DUNS, and SAM Regulations

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

C8. Foreign and International Organizations

Foreign and International Organizations are not eligible to apply.

C9. Faith-Based Organizations

Faith-based organizations are not eligible to apply.

D. APPLICATION AND SUBMISSION INFORMATION

D1. Address to Request Application Package

Application materials will be available at http://www.grants.gov. Please note that HHS requires applications for all announcements to be submitted electronically through Grants.gov. Applicants will be able to download a copy of the application packet, complete it off-line, and then upload and submit the application via the Grants.gov website. Refer to Appendix II, Application and Submission Information, for specific instructions.

D2. Content and Form of Application Submission

a. Application format Each application must include all contents of the application package, in the order indicated, and conform to the following formatting specifications.

• The following page size must be used: 8.5” x 11” letter-size pages (one side only) with 1” margins (top, bottom, and sides). Other paper sizes will not be accepted. This is particularly important because it is often not possible to reproduce copies in a size other than 8.5” x 11”.

https://www.sam.gov/portal/public/SAM/ http://www.grants.gov/

• All pages of the project and budget narratives and implementation plan must be paginated in a single sequence.

• Font size must be at least 12-point with an average of 14 characters per inch (CPI).

• The Project Narrative must be double-spaced. The page limit for this document is 20 pages.

• The Work Plan may be single-spaced. The page limit for this document is 15 pages.

• The Budget Narrative may be single-spaced. The page limit for this document is 10 pages.

• The Business Assessment of Applicant Organization may be single spaced. The page limit for this document is 10 pages.

• Tables included within any portion of the application must have a font size of at least

12- point with a 14 CPI and may be single spaced. Tables are counted towards the applicable page limits.

• The project abstract is restricted to a one-page summary which may be single-spaced.

• The following required application documents are excluded from the page limitations described above: Standard Forms, Project Abstract, Copy of Letter of intent (if applicable), Application Cover Letter/Cover Page (if applicable), Project Site Location Form and Indirect Cost Rate Agreement.

• The total page limit (minus those documents excluded from the page limitations) is 55 pages.

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

b. Standard forms

The following forms must be completed with an original signature and enclosed as part of the application:

• Project Abstract Summary A one-page abstract should serve as a succinct description of the proposed project and must include the goals of the project, the total budget, and a description of how the funds will be used. The abstract is often distributed to provide information to the public and Congress, so please write the abstract so that it is clear, accurate, concise, and without reference to other parts of the application. Personal identifying information should be excluded from the abstract. In the Grants Application Package that can be found at www.grants.gov (or alternatively www.GrantSolutions.gov for single-source applications), select the Project Abstract Summary and complete the form.

• SF-424: Official Application for Federal Assistance Note: On SF 424 “Application for Federal Assistance”:

On Item 15 “Descriptive Title of Applicant’s Project”, State the specific cooperative agreement opportunity for which you are applying.

Check “No” to item 19c, as Review by State Executive Order 12372 does not apply to this cooperative agreement funding opportunity.

• SF-424A: Budget Information Non-Construction

• SF-424B: Assurances-Non-Construction Programs

• SF-LLL: Disclosure of Lobbying Activities.

All applicants must submit this document. If your entity does not engage in lobbying, please insert “Non-Applicable” on the document and include the required Authorized Organizational Representative (AOR) name, contact information, and signature. Please note that the application kit available online on the Grants.gov website is utilized for many programs and therefore Grants.gov may designate this form as optional to allow for flexibility amongst programs. This form is required as part of your application package and must be submitted for your application to be considered eligible for review.

• Project Site Location Form(s) All applicants must submit this form. Please note that the application kit available online in Grants.gov is utilized for many programs and therefore Grants.gov may designate this form as optional to allow for flexibility amongst programs. This form is required as part of your application package and must be submitted for your application to be considered eligible for review.

c. Mandatory Application cover letter or cover page

A letter from the applicant must identify the:

• Project Title

• Applicant Name

• Project Director Name (with email and phone number)

• Authorized Official (person with authority to sign off on all decisions for the award)

d. Project narrative (maximum of 20 pages)

The applicant must provide a Project Narrative that articulates in detail the proposed goals, measurable objectives, and milestones to be completed in accordance with the instructions and content requirements provided below and the specific criteria described in E1. Criteria. Please include the title “Project Narrative’ at the beginning of the Project Narrative.

Both the required and optional sections of the Project Narrative are described below.

For each selected market reform that the State plans on pursuing with the grant funds, the applicant must address the following sections:

• Section (i), “Description of Current Market Reform Implementation Processes and Activities;”

and

• Section (ii), “Proposed Activities for Planning and/or Implementing Market Reform Activities”

Section (i), Eligibility

Mandatory: This section is mandatory for all applicants.

Each applicant must identify the criteria under which they are eligible for a State Flexibility Grant, and describe how the applicant meets the relevant eligibility criteria. An applicant must be an agency responsible for oversight and implementation of one or more of the pre-selected market reform provisions in one of the 50 States or the District of Columbia.

All States applying to fund Market Reform Activities must provide the following:

• A letter attesting that the State is not receiving other Federal grant dollars for the same activity for which it will receive State Flexibility Grant funds.

• A State certification of Maintenance of Effort verifying that the grant funds will not supplant existing State expenditures for related consumer protection activities.

Section (ii), Description of Current Market Reform Processes

Mandatory: This section is required for all applicants.

As part of the Project Narrative, applicants must provide a detailed description of their current efforts to implement the pre-selected market reforms. States must include in the Project Narrative a comprehensive description of the State’s current authority and/or process for each of the market reform activities that they plan on pursing with the grant.

Section (iii), Proposed Activities for Planning and/or Implementing Market Reforms and Consumer Protections

Mandatory: This section is required for all applicants.

The State Flexibility Grant provides States a funding source to enhance States’ role in regulating and implementing one or more of the three pre-selected provisions that they deem most necessary in order to stabilize their respective health insurance market and protect consumers’ access to affordable health care coverage. The State Flexibility Grant will provide States with the opportunity to ensure their laws, regulations, and procedures are in line with Federal law and that they are able to effectively implement the pre-selected market reform provisions under Part A of Title XXVII of the PHS Act.

Applicants may use grant funds for a variety of planning and implementation objectives, including but not limited to implementing or enhancing policy form review, obtaining a market analysis of the individual and small group market, and actuarial and economic analysis of the health plans offered in the State. Grant funds can be used for, but are not limited to being used for the following activities:

• Hiring staff and/or consultants to ensure issuer compliance;

• Providing staff training;

• Developing internal manuals, checklists, and training materials;

• Implementing recommended areas of focus for consumer protection activities identified in the Funding Opportunity;

• Hiring consultants to develop best practices, market analysis, and/or process improvement;

• Purchasing or using software or other technological services, including staff training on using the technology. Software examples include TeamMate to assist with policy form review;

• Developing consumer-friendly outreach information on the pre-selected Part A provisions, such as fact sheets or FAQs, which could lead to more consumer education about their rights and the complaint process to report issuer noncompliance;

• Enhancing or reconciling State requirements with Federal standards; and/or,

• Enhancing State websites to: (1) provide information on the pre-selected Part A provisions to the public and/or issuers; and/or (2) develop or enhance the ability to receive comments/questions/complaints from consumers about the pre-selected market reforms or issuer compliance with those requirements.

Section (iv), Evaluation Plan

Mandatory: This section is required for all applicants.

To ensure accountability, States are required as part of the grant application to describe the current state of their program, identify the goal of the grant funding, specify how the grant funds would be used to achieve the identified goal, and provide a description of how the State would measure success of the outcome. Throughout the course of the grant period, States will be required to provide quarterly reports that specify the milestones being met to achieve the goal or outcome.

The Project Narrative must include specific measures on how the grantee will evaluate its progress and measure success within its market reforms program. Please provide baseline information or data for each measurable objective to be evaluated. The grantee will be expected to update information and data for each measure as part of the quarterly report and provide an evaluation plan that will assess the program on the overarching goals of the project. The grantee will also be expected to comply with Federal evaluation requirements. Specifically, applicants are required to include all of the following:

• Discussion of chosen key indicators to be measured;

• A description of baseline data for each indicator;

• Methods to monitor progress and evaluate the achievement of program goals both on an ongoing basis and at the conclusion of the program; and

• Inclusion of plans for timely interventions when targets are not met or obstacles delay progress.

Section (v), Commitment to Mentor States9

This section is optional for all grant applicants.

States may agree to mentor and collaborate with other States on the planning and/or implementation of relevant consumer protection activities and best practices.

e. Work plan (maximum of 15 pages)

Each State will be required to develop and submit a Work Plan that outlines specific milestones for successful planning and/or implementation of activities related to the pre-selected Federal market reforms and consumer protections established under Part A of Title XXVII of the PHS Act that the State seeks grant funding for. These milestones must be articulated clearly, be measureable, and be appropriate for the award time period. Each State will also provide Progress Metrics towards each of their objectives as described in Section D, Application and Submission Information. Section B, Federal Award Information, provides additional information regarding the process that will be used to inform States of the funding availability.

Additionally, States will need to provide Progress Metrics, as described below, Demonstrating Progress towards Milestones, for each of the grant’s activity.

The reasonableness and completeness of the specific tasks to be conducted throughout the project period will be reviewed as well as the adequacy of the projected timeframes. The Work Plan must indicate which milestones the Program plans to meet within the associated timeframes. The incremental steps to achieving these milestones should also be identified by the months in which they start, are carried out, and completed. States are permitted to do a separate Work Plan for different aspects of their grant application. There is not a specified template for the Work Plan. At the beginning of the Work Plan, please include a title that includes the words “Work Plan” in it.

Demonstrating Progress towards Milestones

Progress toward the milestones outlined in the Work Plan will be reported in quarterly programmatic progress reports and in the required programmatic final report. States will have the opportunity to update and amend their Work Plans on a quarterly basis throughout the grant program. HHS will work closely with a State in the event that a State updates its Work Plan as its plans evolve, and HHS will make technical assistance available to facilitate and support State progress throughout the Grant Program.

9 See D.8, “Other Submission Requirements,” on page 26.

States will be required to describe the current State of their implementation of the selected market reform(s), identify the goal(s) to be met through use of the grant funding, specify how the grant funds would be used to achieve the identified goal, and provide a description of how the State would measure success of the outcome. To establish quantitative measurement of the goals, the grant will require States to provide updates on the completion of each activity on a quarterly basis, based on the Reporting Metrics described in Section F5.a, Progress Reports, which will provide metrics for CMS to monitor the progress of each proposed activity.

Additional technical assistance will be available to States that are not showing progress toward the required milestones; however, HHS may restrict future grant funds for certain grant activities if milestones are not met.

Progress Metrics:

In order to provide metrics for CMS to monitor the progress of each activity, each State will be required to report quantitative measurements on a quarterly basis on each of their activity objectives, as described below:

Stage 0 - No work has begun on stated goal.

Stage 1 - Project Plan has been created and staff has been assigned to task. The work on achieving the goal has initially begun.

Stage 2 - Goal of the Project Plan is underway, and any refinements or adjustments to original Project Plan were made.

Stage 3 - Goal of the Project Plan is half way complete and continuously being worked on.

Stage 4 - Deliverables are beginning to finalize and proposed goals are nearly completed.

Stage 5 - 100% of stated goal has been completely achieved.

e. Budget narrative (maximum of 10 pages)

Applicants must supplement Form SF-424A with a Budget Narrative. The Budget Narrative must include a yearly breakdown of costs according to a 12-month period. See Section B.

Federal Award Information for more information on the performance period. Applicants must include a clear description of the proposed set of services that will be covered with grant funds.

The Budget Narrative should provide a detailed cost breakdown for each line item outlined in the SF- 424A by grant year, including a breakdown of costs for each activity/cost within the line item. The proportion of the requested funding designated for each activity should be clearly defined and should justify the applicant’s readiness to receive funding. The budget must separate out funding that is administered directly by the lead agency from funding that will be subcontracted to other partners.

For more specific information and instructions for completing the SF-424A and Budget Narrative, please refer to Appendix I, Guidance for Preparing a Budget Request and Narrative.

f. Business assessment of applicant organization (maximum of 10 pages)

As required by 45 CFR §75.205 for competitive grants and cooperative agreements, CMS will evaluate the risk posed by an applicant before they receive an award. This analysis of risk includes items such as financial stability, quality of management systems, and the ability to meet the management standards prescribed in 45 CFR Part 75.

An applicant must review, answer, and submit the business assessment questions outlined in Appendix III, Business Assessment of Application Organization (Questions). There are ten (10) topic areas labeled A-J, with a varying number of questions within each topic area. Applicants MUST provide an answer to each question. Moreover, applicants should refrain from solely answering yes or no to each question – i.e., a brief, substantive answer should be given for almost all questions (referring to sections of official agency policy is acceptable). If the answer to any question is non-applicable, please provide an explanation. Please note, if CMS cannot complete its review without contacting an applicant for additional clarification, the applicant may not be selected for award.

g. Required Supporting Documentation

The following supporting documentation should accompany the application. This information is excluded from the page limit for applications.

a) Applicants must submit the following letters:

• Each applicant must submit a letter attesting that the State is not receiving other Federal grant dollars for the same activity(s) for which it will receive the State Flexibility Grant funds.

• State certification of Maintenance of Effort verifying that the grant funds will not supplant existing State expenditures for related consumer protection activities. There is no designated form for the State certification of “Maintenance of Effort.”

b) The State must provide a clear delineation of the roles and responsibilities of project staff and how they will contribute to achieving the project’s objectives including:

• The State’s capacity to implement the proposed project and manage grant funds, including a reasonable and cost-efficient budget; and

• An organizational chart and job descriptions of staff who will be dedicated to the project indicating…