v2.MODIFIED 2.28.24_FORHP HRSA-24-006 (U2W) Flex EMS Supplement_FINAL.pdf

U.S. Department of Health and Human Services

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2024

Federal Office of Rural Health Policy

Hospital State Division

Medicare Rural Hospital Flexibility Program – Emergency Medical Services

Supplement

Funding Opportunity Number: HRSA-24-006

Funding Opportunity Type(s): Competing Supplement

Assistance Listing Number: 93.241

Application Due Date: April 26, 2024

MODIFIED on February 28, 2024:

Revision: Extended the Application Due Date to account for scheduled system maintenance. The Grants.gov system will be unavailable to applicants April 20-23, 2024.

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

We will not approve deadline extensions for lack of registration.

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

Issuance Date: January 24, 2024

Tahleah Chappel

Public Health Analyst, Federal Office of Rural Health Policy

Call: 301-443-0197

Email: TChappel@HRSA.gov

See Section VII for a complete list of agency contacts.

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

HRSA-24-006 Flex EMS Supplement i

508 COMPLIANCE DISCLAIMER

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

Contacts.

SUMMARY

Funding Opportunity Title: Medicare Rural Hospital Flexibility Program –

Emergency Medical Services Supplement

Funding Opportunity Number: HRSA-24-006

Assistance Listing Number: 93.241

Due Date for Applications: April 26, 2024

Purpose: The purpose of the Medicare Rural Hospital

Flexibility Program (Flex Program) - Emergency

Medical Services (EMS) Supplement is to enable states to establish or expand programs for the provision of rural EMS by strengthening the EMS workforce in rural areas through recruitment, retention, and financial and operational strategies. This includes, but is not limited to, activities such as:

• Establishing career advancement programs for EMS staff as part of the hiring process;

• Working with local schools and community colleges to recruit students interested in

EMS;

• Educating community leaders on the need for volunteers and/or paid staff;

• Training on EMS billing;

• Updating billing software;

• Establishing cost-sharing agreements for billing services with other EMS agencies;

• Assisting with travel costs for training/certification;

• Assisting with training/certification costs;

• Addressing fatigue and the mental health toll of EMS work.

HRSA-24-006 Flex EMS Supplement ii

The EMS Supplement intends to address EMS workforce challenges in rural areas by offering support and resources to communities struggling with workforce shortages and inconsistent billing practices.

Program Objective(s): To build up and retain rural EMS workforce (both traditional EMS positions, Community Paramedics and Mobile Integrated Health that are within and run by the EMS agency), as appropriate for the community.

To create sustainable recruitment and retention strategies that can be replicated in other communities.

To increase the percentage of runs/transports that are submitted for billing by rural EMS agencies.

Eligible Applicants: Eligible applicants are state recipients funded under HRSA-24-002, Medicare Rural Hospital

Flexibility Program cooperative agreement. This is a competitive supplemental funding opportunity.

Only states eligible for cooperative agreements awarded under HRSA-24-002 are eligible to apply for funding under this notice. See Section III.1 of this notice of funding opportunity (NOFO) for complete eligibility information.

Anticipated FY 2024 Total

Available Funding:

Approximately $2,000,000

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

Estimated Number and Type of

Award(s):

Approximately 8 competing supplement cooperative agreement(s)

Estimated Annual Award

Amount:

Approximately $250,000 per award, subject to the availability of appropriated funds

Cost Sharing or Matching

Required:

No

HRSA-24-006 Flex EMS Supplement iii

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

(5 years)

Agency Contacts: Business, administrative, or fiscal issues:

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

Email: bhaley@hrsa.gov

Program issues or technical assistance:

Tahleah Chappel

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

Email: TChappel@HRSA.gov

Application Guide

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

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

Technical Assistance

We have scheduled the following webinar:

Wednesday, February 7, 2024

2–3 p.m. ET

Weblink: https://hrsa-gov.zoomgov.com/j/1607816750?pwd=bW0yelJSZm4rQzl4UzUreENIMzErdz09

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

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

Meeting ID: 160 781 6750

Passcode: 168252106

We will record the webinar. Please contact Tahleah Chappel (tchappel@hrsa.gov) to access the recording.

mailto:bhaley@hrsa.gov mailto:TChappel@HRSA.gov http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://www.hrsa.gov/grants/apply-for-a-grant/prepare-your-application https://hrsa-gov.zoomgov.com/j/1607816750?pwd=bW0yelJSZm4rQzl4UzUreENIMzErdz09%20 https://hrsa-gov.zoomgov.com/j/1607816750?pwd=bW0yelJSZm4rQzl4UzUreENIMzErdz09%20 mailto:tchappel@hrsa.gov

HRSA-24-006 Flex EMS Supplement iv

Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

2. BACKGROUND

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AWARD

2. SUMMARY OF FUNDING

III. ELIGIBILITY INFORMATION

1. ELIGIBLE APPLICANTS

2. COST SHARING OR MATCHING

3. OTHER

IV. APPLICATION AND SUBMISSION INFORMATION

1. ADDRESS TO REQUEST APPLICATION PACKAGE

2. CONTENT AND FORM OF APPLICATION SUBMISSION

i. Project Abstract

ii. Project Narrative

iii. Budget

iv. Budget Narrative

v. Attachments

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

4. SUBMISSION DATES AND TIMES

5. INTERGOVERNMENTAL REVIEW

6. FUNDING RESTRICTIONS

V. APPLICATION REVIEW INFORMATION

1. REVIEW CRITERIA

2. RESPONSE

3. EVALUATIVE MEASURES

2. REVIEW AND SELECTION PROCESS

3. ASSESSMENT OF RISK

VI. AWARD ADMINISTRATION INFORMATION

1. AWARD NOTICES

2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

3. REPORTING

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

APPENDIX A: HELPFUL RESOURCES

APPENDIX B: PAGE LIMIT WORKSHEET

HRSA-24-006 Flex EMS Supplement 1

I. Program Funding Opportunity Description

1. Purpose

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

Hospital Flexibility Program (Flex Program), Emergency Medical Services (EMS)

Competing Supplement (EMS Supplement). Throughout this NOFO, the term Flex

Program will refer to the larger, primary program while EMS Supplement will refer to the supplemental projects that are the focus of this NOFO.

The purpose of the EMS Supplement is to enable states to establish or expand programs for the provision of rural EMS by strengthening the EMS workforce in rural areas through recruitment, retention, and financial and operational strategies. This includes, but is not limited to, activities such as:

• Establishing career advancement programs for EMS staff as part of the hiring process;

• Working with local schools and community colleges to recruit students interested in EMS;

• Educating community leaders on the need for volunteers and/or paid staff

• Training on EMS billing;

• Updating billing software;

• Establishing cost-sharing agreements for billing services with other agencies;

• Assisting with travel costs for training/certification;

• Assisting with training/certification costs;

• Addressing fatigue and the mental health toll of EMS work;

The EMS Supplement intends to address and improve EMS workforce challenges in rural areas by offering support and resources to communities struggling with workforce shortages and inconsistent billing practices.

2. Background

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

Security Act, which authorizes funding “for the establishment or expansion of a program for the provision of rural emergency medical services.”

With declining numbers of volunteers to staff ambulances, declining financial resources, inconsistent support from local governments, and increased educational standards for emergency medical technicians and paramedics; access to emergency care is at risk in many rural communities. Access to hospitals that offer maternity services in rural areas

HRSA-24-006 Flex EMS Supplement 2 have also decreased considerably. An article published in January 2023, in the JAMA

Health Forum on Maternity Care Deserts states that “between 2004 and 2014, 9 percent of rural counties lost hospital maternity services; another 45 percent had no maternity services to begin with.”1 EMS providers are trained to deliver babies and may become relied on more and more for this service. It is for all these reasons that addressing the workforce needs of struggling EMS agencies is a key issue to maintaining more equitable access to emergency care in rural communities.

The Flex Program provides a platform and resources for states to strengthen rural health care by supporting improvement initiatives with Critical Access Hospitals (CAH) and rural EMS agencies. State Flex programs have supported EMS improvement activities in the past but have faced challenges with limited capacity to address EMS needs given other rural health care priorities. This supplemental funding enables up to eight states to establish or expand programs for the provision of rural EMS by implementing focused EMS workforce projects that address the challenges faced by rural EMS agencies, while contributing to the rural EMS evidence base.

The EMS Agenda 2050, published in 2019, incorporates the 14 key attributes of an

EMS agency from the 2004 Rural and Frontier Emergency Medical Services Agenda for the Future report, and creates a people-centered approach to EMS. This updated report notes, “in rural communities, a lack of personnel and other critical EMS resources compounds the overall strained healthcare infrastructure.”2 The EMS Supplement will provide needed funding to enhance the recruitment and retention strategies and develop new ones. This funding address two of the six guiding principles listed in the

2019 report, “reliable and prepared”, and “adaptable and innovative” EMS systems.

In November of 2022, the National Advisory Committee on Rural Health and Human

Services published a policy brief and recommendations to the Secretary titled: Access to Emergency Medical Services in Rural Communities. This brief recognizes that rural

EMS agencies provide essential services to their communities, but that workforce shortages of both volunteers and paid staff are widespread. “Rural EMS is generally heavily reliant on volunteers” and that those working in rural areas “are seeing a decline in the level of volunteerism, which adds to staffing difficulties.” The brief also acknowledged the need for more support for staff “to help them deal with the trauma associated with their jobs.” This funding specifically targets recruitment and retention activities as well as mental health support related to the stress and trauma that is often experienced by those working in the EMS field.

1 Sonenberg A, Mason DJ. Maternity Care Deserts in the US. JAMA Health Forum. 2023;4(1):e225541.

doi:10.1001/jamahealthforum.2022.5541. Accessed on September 25, 2023 at https://jamanetwork.com/journals/jama-health-forum/fullarticle/2800629.

2 EMS Agenda 2050 Technical Expert Panel. (2019, January). EMS Agenda 2050: A People-Centered Vision for the Future of Emergency Medical Services (Report No. DOT HS 812 664). Washington, D C:

National Highway Traf f ic Safety Administration. Accessed September 22, 2023 at https://www.ems.gov/assets/EMS-Agenda-2050.pdf https://jamanetwork.com/journals/jama-health-forum/fullarticle/2800629 https://jamanetwork.com/journals/jama-health-forum/fullarticle/2800629 https://www.ems.gov/projects/ems-agenda-2050.html https://www.ems.gov/assets/EMS_Rural_Frontier_Agenda.pdf https://www.ems.gov/assets/EMS_Rural_Frontier_Agenda.pdf https://www.hrsa.gov/advisory-committees/rural-health/publications https://www.hrsa.gov/advisory-committees/rural-health/publications https://jamanetwork.com/journals/jama-health-forum/fullarticle/2800629 https://www.ems.gov/assets/EMS-Agenda-2050.pdf

HRSA-24-006 Flex EMS Supplement 3

Additionally, in May of 2023 the Maine Rural Health Research Center published a chartbook identifying “ambulance deserts” in 41 states across the country. These ambulance deserts represent locations and people that are located more than 25 minutes from an ambulance station. Rural counties were found to be more likely to have an ambulance desert when compared to urban counties. 3 While this funding will not establish new ambulance stations, it will help to address the shortage of EMS providers in rural areas which will increase the availability of critical and lifesaving services, including in ambulance deserts.

II. Award Information

1. Type of Application and Award

Application type(s): Competing Supplement

We will fund you via a cooperative agreement.

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

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

• Collaborating with award recipients to review and provide input on the Work

Plans in alignment with HRSA priorities, state needs, and changes in the rural

EMS environment through such activities as identifying and prioritizing needs to be addressed using federal funds;

• Monitoring and supporting implementation of the Work Plan through progress report reviews; and

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

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

• Collaborating with HRSA on refining and implementing the Work Plan according to HRSA priorities, state needs, and changes in the rural EMS environment;

• Negotiating with HRSA to update Work Plans at least annually, or more frequently as needed (e.g., in response to identified challenges);

3 Jonk, Y., Milkowski, C., Croll, Z., & Pearson, K. (2023). Ambulance Deserts: Geographic Disparities in the Provision of Ambulance Services [Chartbook]. University of Southern Maine, Muskie School, Maine Rural Health Research Center. Accessed on September 22, 2023 at https://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1013&context=ems .

https://www.ruralhealthresearch.org/publications/1596 https://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1013&context=ems

HRSA-24-006 Flex EMS Supplement 4

• Developing and implementing a state Flex EMS Supplement project as described in this notice;

• Ensuring that proposed EMS activities for this supplement differ from the activities proposed under the main Flex workplan.

2. Summary of Funding

We estimate approximately $2,000,000 will be available each year to fund 8 recipients.

You may apply for a ceiling amount of up to $250,000 annually (reflecting direct and indirect costs).

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

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

Support beyond the first budget year will depend on:

• Appropriation

• Satisfactory progress in meeting the project’s objectives

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

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

Requirements for HHS Awards applies to all HRSA awards.

Limitations on Administrative Expenses

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

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

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

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

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

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

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

https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75#sg45.1.75_1344_675_1350.sg4

HRSA-24-006 Flex EMS Supplement 5

III. Eligibility Information

1. Eligible Applicants

• Eligible applicants are state recipients funded under HRSA-24-002, Medicare

Rural Hospital Flexibility Program cooperative agreement. This is a competitive supplemental funding opportunity. Only states eligible for cooperative agreements awarded under HRSA-24-002 are eligible to apply for funding under this notice.

2. Cost Sharing or Matching

Cost sharing or matching is not required for this program.

3. Other

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

• Exceeds the funding ceiling amount

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

Multiple Applications

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

IV. Application and Submission Information

1. Address to Request Application Package

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

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

Select “Subscribe” and enter your email address for HRSA-24-006 to receive emails about changes, clarifications, or instances where we republish the NOFO. You will also be notified by email of documents we place in the RELATED DOCUMENTS tab that may affect the NOFO and your application. You’re responsible for reviewing all information that relates to this NOFO.

https://www.grants.gov/ http://www.grants.gov/applicants/apply-for-grants.html https://www.grants.gov/web/grants/s2s/applicant-system-to-system.html

HRSA-24-006 Flex EMS Supplement 6

2. Content and Form of Application Submission

Application Format Requirements

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

Application Completeness Checklist in the Application Guide to help you.

Application Page Limit

The total number of pages that count toward the page limit shall be no more than 20 pages when we print them. We will not review any pages that exceed the page limit.

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

Eligibility Information of the NOFO.

These items do not count toward the page limit:

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

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

• Indirect Cost Rate Agreement

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

• Letters of Support

• Biographical Sketches of Key Personnel

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

Section IV.2.vi Attachments.

If you use an OMB-approved form that is not in the HRSA-24-006 workspace application package, it may count toward the page limit.

Applications must be complete and validated by Grants.gov under HRSA-24-006 before the deadline.

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

• When you submit your application, you certify that you and your principals4 (for example, program director, principal investigator) can participate in receiving award funds to carry out a proposed project. That is, no federal department or agency has debarred, suspended, proposed for debarment, claimed you ineligible, or you have voluntarily excluded yourself from participating.

• If you fail to make mandatory disclosures, we may take an action like those in 45 CFR § 75.371. This includes suspending or debarring you.5

• If you cannot certify this, you must include an explanation in Attachment 8: Other Relevant Documents.

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

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

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

HRSA-24-006 Flex EMS Supplement 7

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

Program Requirements and Expectations

• We expect this funding to address provision of rural EMS by strengthening the EMS workforce in rural areas through recruitment, retention, and financial and operational strategies. Recipients should establish or expand a program to address EMS workforce challenges in rural areas by offering support and resources to communities struggling with workforce shortages.

• Letters of support/intent are required from at least five rural EMS agencies willing to participate in the program for the entire 5-year period of performance. Prioritize agencies with the highest need (lack of staff and low percentage of runs billed).

• Participate in information sharing and program improvement activities coordinated by HRSA’s designated Flex EMS Supplement technical assistance providers.

• Participate in the national evaluation of the Flex EMS Supplement.

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

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

i. Project Abstract

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

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

The project abstract must be single-spaced, and limited to one page in length.

Please include the following information at the top of the abstract:

• Project Title

• Applicant Organization Name

• Applicant Organization Address

• Applicant Organization Web Site Address, if applicable

• Project Director Name (if applicable, state that the Project Director is also the

State Flex Coordinator)

• State Flex Coordinator Name (if different from Project Director)

• State Flex Coordinator Contact Phone Number(s)

• State Flex Coordinator E-Mail Address(es)

HRSA-24-006 Flex EMS Supplement 8

In addition, please include the following:

• A brief description of the project including the proposed type of recruitment and retention activities.

• A statement to identify the specific measurable outcomes the project will work to improve.

• A statement to identify the rural EMS agencies (at least 5) that have agreed to participate and provided a letter of intent.

NARRATIVE GUIDANCE

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

Narrative Section Review Criteria

Introduction Criterion 1: NEED

Organizational Information Criterion 5: RESOURCES/CAPABILITIES

Need Criterion 1: NEED

Approach Criterion 2: RESPONSE

Criterion 4: IMPACT

Work Plan Criterion 2: RESPONSE

Criterion 4: IMPACT

Resolution of Challenges Criterion 2: RESPONSE

Evaluation and Technical Support

Capacity

Criterion 3: EVALUATIVE MEASURES

Budget Narrative Criterion 6: SUPPORT REQUESTED

ii. Project Narrative

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

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

This ensures reviewers can understand your proposed project.

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

Briefly describe the purpose of the proposed project, the vision for your EMS

Supplement, and your goals for the five-year period of performance.

HRSA-24-006 Flex EMS Supplement 9

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

RESOURCES/CAPABILITIES

o Describe current staff and/or contractor experience, skills, and knowledge that will support your effective tracking of performance outcomes and execution of workplan activities.

o Briefly describe your organization’s current mission, structure, and scope of current activities, and how these elements all contribute to your ability to implement the program and meet established expectations.

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

o Describe how the organization will properly account for the federal funds and document all costs to avoid audits.

o Include a staffing plan and job descriptions for key staff in Attachment 2.

Include an organizational chart in Attachment 7.

▪ Need-- Corresponds to Section V’s Review Criterion 1: NEED o Provide an overview of the service area and target population to be served by the EMS workforce programs and or investments. Outline the needs of the EMS agencies that will participate. Use and cite demographic data whenever possible to support the information provided.

o Demonstrate understanding of the identified barriers (weak education pipeline, training needs, working with neighboring EMS agencies, maternity care deserts, etc.) related to recruitment and retention, and how the project will address such barriers.

o Identify contact(s) within the state office of EMS, local EMS agencies, and other relevant community leaders willing to work together for the duration of the project.

▪ Approach -- Corresponds to Section V’s Review Criteria #2 RESPONSE and #4

IMPACT

o Tell us how you will increase rural EMS recruitment, retention and financial stability based on the needs identified for at least five rural EMS agencies.

o Explain the criteria used to prioritize agencies with the highest need (lack of staff and low percentage of runs/transports billed).

o Provide letters of support from at least five rural EMS agencies willing and able to fully participate in this project for the entire 5-year period of performance as Attachment 4.

HRSA-24-006 Flex EMS Supplement 10 o Describe how training, technical assistance, and other support will be targeted to the agencies with the highest needs and capacity to make changes.

o Discuss tools and strategies you plan to develop for staff training, outreach, collaborations, clear communication, and information sharing/dissemination with efforts to involve key partners.

o Discuss commitment and possible involvement from town, local and or county leadership.

o Include both recruitment and retention activities. Utilize existing resources on EMS recruitment and retention to help identify activities to implement.

o Propose a plan for continuing recruitment and retention efforts when federal funding ends. We expect you to keep up key strategies or services and actions which have led to improved practices and outcomes for the target population.

o Identify meaningful support and collaboration with key stakeholders in planning, designing, and implementing all activities listed in the workplan.

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

IMPACT

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

Funding Guidance section of the Technical Assistance & Services Center website (TASC) for more information on the structure of the work plan.

o Include a brief description of each activity, year and quarter of anticipated completion date, expected outputs, actual outputs, and responsible staff.

o Describe how you’ll achieve each of the objectives during the five-year period of performance. You find these in the Approach section.

o Include clearly defined outcomes for your project (to be measured annually). Include the goal you are trying to achieve, what the outcome measure is, the agencies participating, space to enter baseline data and data at the end of each project year, and space for comments on whether you met your goal.

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

RESPONSE

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

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

HRSA-24-006 Flex EMS Supplement 11

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

Criterion 3: EVALUATIVE MEASURES o Describe the strategy to collect, track and analyze data to measure impact (for example, assigned skilled staff, data management software) in a way that allows for accurate and timely reporting of those outcomes.

o Describe your plan to evaluate how the program performs and how that will contribute to continuous quality improvement. The evaluation should monitor ongoing processes and the progress towards the project’s goals and objectives. Describe barriers and your plan to address them.

o At a minimum, the outcome measures included in the work plan should include the following (Please note that this is not an exhaustive list and additional project specific measures should be included):

▪ The number of agencies that have increased their total number of paid and/or volunteer staff.

▪ The number of agencies with an increase in EMS providers with advanced certifications, such as paramedics or Advanced

Emergency Medical Technicians (AEMTs).

▪ When applicable, the number of agencies that have increased their percentage of runs/transports submitted for billing.

▪ Please note that all proposed measures will be reviewed by the

PO for project applicability.

iii. Budget

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

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

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

Program Income

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

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

Specific Instructions

The Flex EMS Supplement requires the following:

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

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• If indirect costs are included in the budget, attach a copy of the indirect cost rate agreement as Attachment 5.

• Please review the multi-year award information and include the 5th year budget as Attachment 6.

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

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

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

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

iv. Budget Narrative

See Section 4.1.v. of the Application Guide.

In addition, the Flex EMS Supplement requires the following:

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

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

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

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

CFR part 25).

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

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

https://www.hrsa.gov/sites/default/files/hrsa/grants/sf424-application-guide.pdf https://www.congress.gov/bill/117th-congress/house-bill/2617/text

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v. Attachments

Provide the following attachments in the order we list them.

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

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

Attachment 1: Work Plan

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

Project Narrative details. If you’ll make subawards or spend funds on contracts, describe how your organization will document funds.

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

4.1. of the Application Guide)

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

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

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

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

SSNs. If you include someone you have not hired yet, include a letter of commitment from that person with the biographical sketch.

Attachment 4: Letters of Support (Does not count towards the page limit)

Make sure letters of support are dated and signed. Each letter should clearly describe the entity’s intent to fully participate in the entire 5-year period of performance if your application is funded.

Attachment 5: Indirect Cost Rate (Does not count towards the page limit)

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

Attachment 6: For Multi-Year Budgets--5th Year Budget

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

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

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Attachment 7: Project Organizational Chart

Provide a one-page figure that shows the project’s organizational structure.

Attachments 8–15: Other Relevant Documents (no more than 15)

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

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

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

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

General Service Administration’s UEI Update.

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

an active federal award, application, or plan that an agency is considering.6

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

Administrator.

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

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

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

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

• Grants.gov

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

Here’s what this means:

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

https://www.gsa.gov/entityid https://sam.gov/content/home https://www.fsd.gov/gsafsd_sp?id=gsa_kb_view2&kb_id=f66d8e6cdb76d4100d73f81d0f9619c6 https://www.grants.gov/ https://www.fsd.gov/gsafsd_sp?id=kb_article_view&sysparm_article=KB0017347&sys_kb_id=2e7b07f9dbdda15094439f95f39619ac&spa=1

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

Data Entry role or lower.

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

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

Entity Administrator role to a non-employee.

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

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

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

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

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

4. Submission Dates and Times

Application Due Date

Your application is due on April 26, 2024, at 11:59 p.m. ET. We suggest you submit your application to Grants.gov at least 3 calendar days before the deadline to allow for any unexpected events. See the Application Guide’s Section 8.2.5 – Summary of emails from Grants.gov.

5. Intergovernmental Review

The Medicare Rural Hospital Flexibility Program EMS Supplement does not need to follow the terms of Executive Order 12372 in 45 CFR part 100.

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

6. Funding Restrictions

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

117-328) apply to this program. See Section 4.1 of the Application Guide for information. Note that these and other restrictions will apply in fiscal years that follow, as the law requires.

Program-specific Restrictions

You cannot use funds under this notice for the following:

• For direct patient care services (including health care services, equipment, and supplies);

https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fbuy.gsa.gov%2Finteract%2Fcommunity%2F47%2Factivity-feed%2Fpost%2Fa14726f4-e2a9-47b3-80ec-7ceff5108706%2FA_Change_in_SAM_gov_will_Affect_Access_for_Some_Entity_Administrators&data=05%7C01%7CDDixon%40hrsa.gov%7C80dfe1e3c58a4e26cd0008db143e65c3%7C14b77578977342d58507251ca2dc2b06%7C0%7C0%7C638126030447564740%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=ZTRBuys3iNJZeAUQ7rDx56aVR1BrI3wE4z%2FHBoFbQTU%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fbuy.gsa.gov%2Finteract%2Fcommunity%2F47%2Factivity-feed%2Fpost%2Fa14726f4-e2a9-47b3-80ec-7ceff5108706%2FA_Change_in_SAM_gov_will_Affect_Access_for_Some_Entity_Administrators&data=05%7C01%7CDDixon%40hrsa.gov%7C80dfe1e3c58a4e26cd0008db143e65c3%7C14b77578977342d58507251ca2dc2b06%7C0%7C0%7C638126030447564740%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=ZTRBuys3iNJZeAUQ7rDx56aVR1BrI3wE4z%2FHBoFbQTU%3D&reserved=0 https://www.hrsa.gov/sites/default/files/hrsa/grants/sf424-application-guide.pdf https://www.archives.gov/federal-register/codification/executive-order/12372.html https://www.hrsa.gov/sites/default/files/hrsa/grants/sf424-application-guide.pdf

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• To purchase ambulances and any other vehicles or major equipment (including software that costs more than $5000/unit);

• To purchase or improve real property;

• Authorizing legislation 42 U.S.C. 1395i-4(g)(2) (Title XVIII, §1820(g)(2)) of the

Social Security Act limits indirect costs under the Flex Program. Indirect costs will be budgeted and reimbursed at the lesser of 15 percent of total direct costs or the applicant’s negotiated Indirect Cost Rate Agreement (ICRA). This limitation on indirect cost rates is a requirement of this federal award and, as required in 45

CFR § 75.351-353, the limitation includes subrecipients; and

• For any purpose which is inconsistent with the language of this NOFO or 42

U.S.C. 1395i-4(g)(2) (§1820(g)(2)) of the Social Security Act

You must have policies, procedures, and financial controls in place. Anyone who receives federal funding must comply with legal requirements and restrictions, including those that limit specific uses of funding.

• Follow the list of statutory restrictions on the use of funds in Section 4.1

(Funding Restrictions) of the Application Guide. We may audit the effectiveness of these policies, procedures, and controls.

• 2 CFR § 200.216 prohibits certain telecommunications and video surveillance services or equipment. For details, see the HRSA Grants Policy Bulletin Number:

2021-01E.

V. Application Review Information

1. Review Criteria

We review your application on its technical merit. We have measures for each review criterion to help you present information and to help reviewers evaluate the applications.

We use six review criteria to review and rank Medicare Rural Hospital Flexibility

Program (Flex Program) - Emergency Medical Services Supplement applications. Here are descriptions of the review criteria and their scoring points.

Criterion Number of Points

1. Need 10

2. Response 45

3. Evaluative Measures 15

4. Impact 15

5. Resources/Capabilities 10

6. Support Requested 5

Total Points 100 https://www.hrsa.gov/sites/default/files/hrsa/grants/manage/grants-policy-bulletin-2021.pdf https://www.hrsa.gov/sites/default/files/hrsa/grants/manage/grants-policy-bulletin-2021.pdf

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Criterion 1: NEED (10 points) – Corresponds to Section IV’s Introduction and Needs

Assessment

• How well the application describes the purpose of the proposed project, the vision for the supplemental funds, and the goals for the 5-year period of performance.

• How well the application describes the overview of the service area and target population to be served by the EMS workforce programs and or investments.

o How well the application describes the needs of the EMS agencies that will participate.

o Whether the application makes use of and cites demographic data to support the information provided.

• How well the applicant demonstrates understanding of the identified barriers

(weak education pipeline, training needs, working with neighboring EMS agencies, maternity care deserts, etc.) related to recruitment and retention, and how the project will address such barriers.

• Whether the application identifies contact(s) within the state office of EMS, local

EMS agencies, and other relevant community leaders willing to work together for the duration of the project.

Criterion 2: RESPONSE (45 points) – Corresponds to Section IV’s Approach, Work Plan, and Resolution of Challenges

Approach (25 points)

• How well the applicant’s proposed project responds to the program’s “Purpose.”

• The strength of the proposed goals and objectives and how well they relate to the project.

• How well the activities described in the application will address the problem and meet project objectives.

• How well the application describes the plan to increase rural EMS recruitment, retention and financial stability based on the needs identified for at least five rural

EMS agencies.

• The strength of the criteria used to prioritize agencies with the highest need (e.g., lack of staff and low percentage of runs/transports billed).

• How well the application describes how training, technical assistance, and other support will be targeted to the agencies with the highest needs and capacity to make changes.

HRSA-24-006 Flex EMS Supplement 18

• How well the application identifies tools and strategies for trainings, outreach, collaborations, clear communication, and information sharing/dissemination, including efforts to involve key partners.

• How well the application demonstrates a commitment from town, local and or county leadership to be involved in the project.

• Whether the application included at least five letters of support from different rural EMS agencies willing to fully participate for the entire 5-year period of performance.

• Whether the application included both recruitment and retention activities that utilized existing resources on EMS recruitment and retention. How well the application identifies meaningful support and collaboration with key stakeholders in planning, designing and implementation of all activities listed in the workplan.

Workplan and Resolution of Challenges (20 points)

• Whether the application discusses possible challenges in carrying out the workplan and explains approaches to resolve them.

• Whether the application has a workplan as attachment 1 that includes a brief description of each activity, year and quarter of anticipated completion, expected outputs, actual outputs, and responsible staff.

• Whether the application includes clearly defined outcomes within the workplan that will be measured annually.

• Whether each measure in the workplan includes:

o The goal you are trying to achieve.

o What the outcome measure is for each goal.

o The agencies participating.

o Space to enter the baseline data and data at the end of each project year.

o Space for comments on whether the goal was met.

Criterion 3: EVALUATIVE MEASURES (15 points) – Corresponds to Section IV’s Evaluation and Technical Support Capacity

• How well the application describes a strategy to collect, track and analyze data to measure impact (for example, assigned skilled staff, data management software) in a way that allows for accurate and timely reporting of those outcomes.

• How well the application describes the plan to evaluate how the program performs, and how that will contribute to continuous quality improvement.

o Whether the evaluation will monitor ongoing processes and the progress towards the project’s goals and objectives.

HRSA-24-006 Flex EMS…