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 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 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 is in year three of a three-year cycle. The cycle has been extended to an additional non-competing year in 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 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 FY 2015, and related resources.


FY2015 Flex Grant Guidance [PDF - 326 KB]

FY2016 Flex Grant Guidance [PDF - 69 KB]

FY2017 Flex Grant Guidance [PDF - 309 KB]


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.