Flex Program Grant and Cooperative Agreement 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); the Medicare Prescription Drug, Improvement and Modernization Act (MMA); and the Patient Protection and Affordable Care Act (PPACA)). 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 the designation of critical access hospitals (CAH).

To accomplish the intent of the Flex Program, federal resources have been made available to state-appointed designees (commonly within state offices of rural health) to support CAHs by implementing the Flex program in their state. States administer the Flex Program and apply to the Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP), for federal Flex Program funding. Additional federally funded resources to support Flex include the Technical Assistance and Services Center (TASC) to provide technical support to states for program implementation, Rural Quality Improvement Technical Assistance (RQITA) to provide technical support to the Medicare Beneficiary Quality Improvement Project (MBQIP) and the Flex Monitoring Team (FMT) to evaluate overall Flex program impact.

For the current grant cycle (FYs 2015 - 2018), 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, MBQIP, which focuses on improving the quality of care that CAHs provide. CAHs that wish to participate in Flex-funded activities must participate and report in MBQIP core quality measures. MBQIP eligibility information is assessed annually by FORHP when outcome data is available. 

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.

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

  • March: FORHP sends application guidance to states
  • May: Application submission deadline to EHB
  • August: Notice of Award announcements
  • September 1: The federal program year begins

The above schedule is subject to change, particularly in competing continuation years when program guidance may be released earlier. Please contact TASC for the current schedule.

    FYs 2015-2018 Flex Program Grant Materials

    The FY 2015 grant cycle, originally a three-year cycle, was extended to include an additional non-competing year, an extension with funds for FY 2018. 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 and materials.  

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

    FY 2015 Flex Grant Guidance

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

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

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

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

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

    FY 2018 Flex Program Performance Period Close Out

    FYs 2019-2023 Flex Program Cooperative Agreement Materials

    The primary program areas of the Flex Program, beginning Fiscal Year (FY) 2019 (September 1, 2019 - August 31, 2020) include activities in the following program areas:

    • CAH Quality improvement (required)
    • CAH Operational and Financial Improvement (required)
    • CAH Population Health Improvement (optional)
    • Rural Emergency Medical Services (EMS) Improvement (optional)
    • Rural Innovative Model Development (optional)
    • CAH Designation (required if requested)

    Downloads below outline the intent for each program area of the state Flex Cooperative Agreement required and optional program areas and activity categories set forth for the FY 2019 cooperative agreement cycle. Note: The Flex Program award type changed from a three-year grant period (FY 2015 - FY 2018) to a five-year cooperative agreement period effective FY 2019 - FY 2023.

    FY 2019 Notice of Funding Opportunity (NOFO): September 1, 2019 - August 31, 2020


    For more information, please contact Nicole Clement at (218) 216-7028 or nclement@ruralcenter.org.