Flex Grant Guidance

The Medicare Rural Hospital Flexibility (Flex) Program was created by the Balanced Budget Act (BBA) in 1997 (revisions occurred through the Balanced Budget Refinement Act (BBRA); the Medicare, Medicaid and SHIP Benefits Improvement and Protection Act (BIPA); and the Medicare Prescription Drug, Improvement and Modernization Act (MMA)). The Flex Program is intended to preserve access to primary and emergency health care services, improve the quality of rural health services, provide services that meet community needs and foster a health delivery system that is both efficient and effective. In addition, the Flex Program supports designation of a new type of hospital: critical access hospital (CAH).

To accomplish the intent of the Flex Program, federal resources have been made available to state grantees (commonly State Offices of Rural Health) to implement the Program in each state by supporting CAHs, the Technical Assistance and Services Center (TASC) (those who are assisting states with implementing the program), Rural Health Research Centers and the Flex Monitoring Team (those who are monitoring the program nationally). States administer the Flex Program and can apply to the Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP), for federal Flex Program funding.

The primary components of the Flex Program include activities in the following program areas:

  • Quality improvement
  • Financial and operational improvement
  • Population health management and emergency medical services (EMS) integration (optional)
  • Designation of CAHs (required if requested)
  • Integration of innovative health care models (optional)

The Flex Program contains a special project, the Medicare Beneficiary Quality Improvement Project (MBQIP) focused on Medicare beneficiary health status improvement by addressing quality of care in CAHs. 

Each state interested in acquiring federal Flex Program funding must submit an annual grant application to FORHP. The approximate timeline for non-competing continuation (NCC) applications and awards is listed below.

  • March: FORHP sends application guidelines to states
  • May: Grant submission deadline
  • August: Grant award announcements
  • September 1: The federal grant program year begins

The Fiscal Year (FY) 2015 grant, originally a three-year cycle, has been extended to include an additional non-competing year for FY 2018. It is anticipated that FY 2019 will be a competitive continuation cycle. The above schedule is subject to change; please contact FORHP for the current year grant schedule.

Grant Guidance Summary and Related Resources

The Flex Program continues to move toward a more defined program by encouraging the identification of areas for improvement with defined targets and measurable outcomes. A minimum standard of reporting on outcomes is requested for all state Flex Programs. Information on state Flex Program assessment can be found in the Flex Program Evaluation Toolkit. Downloads below outline the intent for each program area of the state Flex Grant, required and/or optional objectives set forth for the FY 2015 grant cycle, and related resources.


Flex FY 2015 Competetive Continuation: September 1, 2015 - August 31, 2016

FY2015 Flex Grant Guidance

Flex FY 2016 NCC: September 1, 2016 - August 31, 2017

Flex FY 2017 NCC: September 1, 2017 - August 31, 2018

FY17 NCC Technical Assistance Webinar Recording

FY 2017 Flex Grant Supplemental Funding: September 1, 2017 - August 31, 2018

Flex Grant Supplemental Funding Opportunity Announcement

Flex Program Supplemental Funding: Reporting and Evaluation Process

Flex Grant Supplemental Funding: Reporting and Evaluation Templates

FY17 Performance Improvement and Measurement System (PIMS) Reporting Process Instructions

FY 2018 Flex Grant Extension: September 1, 2018 - August 31, 2019

FY18 Flex Grant Extension Technical Assistance Webinar (March 19, 2018)

FY18 Flex Grant Funding Increase Webinar Presentation and Recording (April 23, 2018)

FY 2018 Flex EMS Sustainability Projects: September 1, 2018 - August 31, 2019

FY18 Flex Program Appropriations Webinar Presentation and Recording: EMS Sustainability Projects (April 17, 2018)


For more information, please contact Tracy Morton at (218) 216-7027 or tmorton@ruralcenter.org.

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,100,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.