State Rural Hospital Flexibility Program

To help States work with rural communities and hospitals to develop and implement a rural health plan, designate critical access hospitals (CAHs), develop integrated networks of care, improve emergency medical services and improve quality, service and organizational performance.

Examples of Funded Projects

States have increasingly used their Flex resources for EMS activities, including training programs, needs assessments, and network building.

Agency - Department of Health and Human Services

The Department of Health and Human Services is the Federal government's principal agency for protecting the health of all Americans and providing essential human services, especially to those who are least able to help themselves.

Office - Program Contact: Steve Hirsch, Office of Rural Health Policy, Health Resources and Services Administration, 5600 Fishers Lane, Room 9A-55, Rockville, MD 20857.

Telephone: (301) 443-0835.
Website Address

Program Accomplishments

In FY 07, 45 continuation awards were made to States. It is estimated that 45 awards will be made in FY 08 and FY 09.

Uses and Use Restrictions

All funds awarded are to be expended solely for the purposes outlined in the approved projects.

Eligibility Requirements

Applicant Eligibility

States that have submitted a State Rural Health Plan to the Centers for Medicare and Medicaid Services (CMS) can apply.

All other States need to submit an application to the Regional Administrator of their CMS Regional Office that expresses the State's interest in developing a Medicare Rural Hospital Flexibility Program before they can apply for grant funds.

Beneficiary Eligibility

States with at least one hospital located in a non-metropolitan statistical area or county and provides CMS with necessary assurances.


Applicants should review the individual HRSA Guidance documents issued under this CFDA program for any required proof or certifications which must be submitted prior to or simultaneous with submission of an application package.

Aplication and Award Process

Preapplication Coordination

This program is excluded for coverage under E.O.


Application Procedures

Grant applications and required forms for this program can be obtained from Please visit the Web site at to both find and apply for all Federal grant opportunities. All qualified applications will be forwarded to an objective review committee which will make funding recommendations to the Associate Administrator for the Office of Rural Health. The Associate Administrator has the authority to make final selections for awards.

Award Procedures

Applications are evaluated by Federal and nonfederal experts. All acceptable applications will be funded. Final decisions on level of funding are made by the Director, Office of Rural Health Policy.



Balanced Budget Act of 1997, Section 4201, Public Law 105-33. Reauthorized in 2003 in Public Law 108-173.

Range of Approval/Disapproval Time

From 3 to 5 months.




Flex grant awards may be made for up to 3-year project periods. Subject to availability of funds, after initial awards, projects may be renewed non-competitively contingent upon submission and approval of an application, availability of appropriated funds, and awardee's satisfactory performance.

Assistance Considerations

Formula and Matching Requirements


Length and Time Phasing of Assistance

Awards are made annually. Funds are available to grantees on an as needed basis throughout the budget period and payments are made through the DHHS Payment Management System.

Post Assistance Requirements


A performance progress report is submitted with each noncompeting continuation application.

A financial status report is to be submitted within 90 days after the close of the budget period.

A final program report is to be submitted within 90 days after the close of the project period.

In addition, grantees are required to participate in a national program evaluation.


In accordance with the provisions of OMB Circular No. A-133 (Revised, June 27, 2003), "Audits of States, Local Governments, and Non-Profit Organizations," nonfederal entities that expend financial assistance of $500,000 or more in Federal awards will have a single or a program-specific audit conducted for that year. Nonfederal entities that expend less than $500,000 a year in Federal awards are exempt from Federal audit requirements for that year, except as noted in Circular No. A-133.


All records must be maintained until expiration of 3 years from the date of submission of the final expenditure report. If questions remain following the 3-uear period, such as those raised as a result of an audit or an on-going enforcement action, recipients must retain records until the matter is completely resolved.

Financial Information

Account Identification



(Flex Grants) FY 07 $22,050,000, FY 08 est $21,600,000; and FY 09 est $21,600,000.

Range and Average of Financial Assistance

$260,000 to $650,000; $490,000.

Regulations, Guidelines, and Literature

This program is subject to the provisions of 45 CFR Part 92 for State, local and tribal governments and 45 CFR Part 74 for institutions of higher education, hospitals, other nonprofit organizations and commercial organizations, as applicable.

Information Contacts

Regional or Local Office

Program Contact: Steve Hirsch, Office of Rural Health Policy, Health Resources and Services Administration, 5600 Fishers Lane, Room 9A-55, Rockville, MD 20857. Telephone: (301) 443-0835.

Headquarters Office

Grants Management Office: Rick Goodman, Director, Division of Grants Management Operations, Health Resources and Services Administration, Department of Health and Human Services, 5600 Fishers Lane, Room 11A-16. Health Services Branch: (301) 443-2385; Research and Training Branch: (301) 443-3099; Government and Special Focus Branch: (301) 443-3288.

Criteria for Selecting Proposals

Contact Headquarters for selection criteria.

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