Date:
August 6, 2015
To:
Sponsoring Institutions
From:
Diane Reger
651/201-3566
Subject:
Medical Education and Research Cost (MERC) Grant Application
Fiscal Year 2014 Clinical Training
The Minnesota Department of Health is accepting MERC grant applications for clinical training in fiscal
year 2014 from sponsoring institutions with accredited teaching programs training:
Advanced Practice Nurses
Clinical Social Workers
Community Health Workers
Community Paramedics
Dental Students or Residents
Dental Therapists or Advanced Dental Therapists
Doctor of Chiropractic Students
Doctor of Pharmacy Students or Residents
Medical Students or Residents
Physician Assistant Students
Psychologists
All data must be submit by 4 p.m. on October 31, 2015, using the online application available
at https://merc.health.state.mn.us/Merc/index.html. Instructions for navigating the online application
are found on the sign-on page. If you are a new sponsoring institution, please contact me for initial
access.
Prior to beginning the application process, please review the application instructions and information
below.
Reporting Period: The grant application should reflect clinical training during the program’s 2014
fiscal year.
MERC Funding: The MERC grant is funded through a carve-out on the Prepaid Medical Assistance
Program (PMAP) rates, an appropriation from the Minnesota cigarette tax, federal matching funds, and
the general fund.
During a LEAN Kaizen that involved a panel of stakeholders, MDH accepted a proposed ‘catch-up
period’ to more closely align the timeframe between the grant application and the grant payment. To
implement this, MDH will combine grant application data from two years of clinical training into one
grant payment that will take place in April 2016. The data collected for training in fiscal year 2014 will
be included in the ‘catch-up period.’ Grants to applicants that had trainees for only one grant period
will not be penalized; and, their grant will be based on the period they had eligible trainees. Eligibility
criteria for each period will be treated separately.
Grant Formula: Grants will be based on the eligibility criteria and formula outlined in the 2015
Minnesota Statutes 62J.692.
Training Site Applications: Provide the enclosed clinical training site application materials to your
Minnesota clinical training facilities with instructions to return a signed grant application to your
attention.
When you receive the application from your clinical training facility, you will have the necessary
information to enter their data into the sponsoring institution’s online application.
If a teaching program applied in the previous fiscal year, the previous application data is available as a
starting point. Because changes occur between application periods, it is imperative that application
fields are updated based on the training site applications and that FTEs reflect training in fiscal year
2014. Sites that are not applying or that did not have trainees should be removed.
The provider identification number(s) on the facility’s application will be used to gather Medicaid
revenue from the Minnesota Department of Human Services and used in the formula which determines
the grant. Some providers have the same NPI number for multiple facility locations. Each location is
required to enroll in the Minnesota Health Care Program (MHCP) under what is considered a
consolidated or shared NPI. Likewise, each location with trainees would be considered separately for
the MERC grant. If the training location is not enrolled in MHCP, they are not eligible. Entering the
correct training location is crucial to calculating the grant correctly. The taxonomy code and
zip+4 found on the training site application are not currently captured on the MERC online application
but may be useful should assistance be necessary in distinguishing between facilities with consolidated
NPIs. If these circumstances arise, please submit a PDF copy of the signed training site application
along with your question to [email protected] for assistance.
MDH may require the submission of the signed clinical training site grant application. Should this be
necessary, we will communicate this in future correspondence.
Once the online grant application is completed, submit the signed application and required documents to:
Minnesota Department of Health
MERC Grant Applications
Attn: Diane Reger, 2nd Floor
85 East Seventh Place, Suite 220
St. Paul, MN 55101
Please sign-up for MERC announcements using the GovDelivery link found on the right menu bar of
our website at http://www.health.state.mn.us/divs/hpsc/hep/merc/index.html.
If you have any questions regarding the MERC grant, please visit our website or contact me
at [email protected].
3
Medical Education and Research Cost (MERC)
Grant Application Instructions
Application for clinical training in fiscal year 2014
Application deadline: October 31, 2015
Estimated distribution: April 30, 2016
For more information: http://www.health.state.mn.us/divs/hpsc/hep/merc/index.htm
MERC Grant Applications
Minnesota Department of Health
Attention: Diane Reger, 2nd Floor Golden Rule Building
85 East Seventh Place, Suite 220
St. Paul, MN 55101
[email protected]
(651)-201-3566
Page Intentionally Blank
Medical Education and Research Cost
(MERC) Grant Application Instructions
Background
The MERC grant was established in 1996, and funded for the first time in 1997. Its purpose is to
provide support for certain medical education activities in Minnesota that historically were supported
in significant part by patient care revenues. Due to Minnesota’s competitive health care market,
payers became increasingly unwilling to pay the extra costs associated with the purchase of services
at teaching facilities. Teaching facilities are forced to compete with non-teaching facilities, which
results in greater difficulty in funding teaching activities. The Commissioner of Health has been
responsible for administering the MERC grant since 1998.
Eligibility
Accredited medical education programs are eligible for funding through the MERC grant if they
meet additional criteria, as required by the MERC legislation:
1) The sponsoring institution, program and site of training must all be in Minnesota. The training site
must also have a National Provider Identification (NPI) number currently active medical assistance
enrollment status in Minnesota along with fiscal year 2014 MA/PMAP claims reimbursements in
Minnesota.
2) The training program must provide clinical training to one of the following designated provider
types:
*Advanced
Practice Nurses:
Certified Nurse Midwives
Certified Registered Nurse Anesthetists
Clinical Nurse Specialists
Doctor of N ursing Practice
Nurse Practitioners
**Clinical
Social Workers
Health Workers
**Community Paramedics
**Community
Dental Students or Residents
**Dental Therapists or Advanced Dental Therapists
Doctor of C h i ropractic Students
Doctor of P harmacy Students or Residents
Medical Students or Residents
Physician Assistant Students
**Psychologists *Training
programs for Advanced Practice Nursing must be sponsored by the University of Minnesota Academic Health
Center, the Mayo Foundation, or institutions that are part of the Minnesota State Colleges and Universities System or
members of the Minnesota Private College Council.
**Eligible for PMAP funds. Requires approval by CMS for tobacco funding.
3) The training program must provide “accredited clinical training” that is funded in part by patient
care revenues, and that occurs in either an inpatient or ambulatory patient care training site. All
training programs must be accredited by an organization that is recognized by the Department of
Education, the Centers for Medicare and Medicaid Services, or another national body that reviews the
accrediting organizations for multiple disciplines.
4) Training that occurs in a nursing facility setting is not eligible.
Medical Education and Research Cost
(MERC) Grant Application Instructions
5) Training facilities must host a combined 0.1 FTE minimum across all teaching programs and provider
types in fiscal year 2014 to be eligible for MERC funding. Programs may submit applications for sites
hosting fewer than 0.1 FTE at a program level if the program is uncertain if the training facility meets
this minimum. The determination will be made when grant applications are reviewed by MDH.
6) The use of funds are limited to expenses related to clinical training program costs for eligible
programs. MDH will collect clinical training expenses from training facilities after review of the initial
application.
Online Application
https://merc.health.state.mn.us/Merc/index.html
Data is collected through an online application available to sponsoring institutions by password.
Instructions for navigating the online application are available on the sign-on page. Please contact
Diane Reger at [email protected] if you are new sponsoring institution and require initial
access.
The Application Process
The “sponsoring institution” must submit the online application for a MERC grant on behalf of one or
more teaching programs. A “sponsoring institution” may be a hospital, school, or consortium located
in Minnesota that sponsors and maintains primary organizational and financial responsibility for a
clinical medical education program in Minnesota and which is accountable to the accrediting body.
The sponsoring institution is designated as the applicant because, in some cases, programs are not
prepared to handle funding directly, but rely on the sponsoring institution or consortium for those
functions. This system also reduces the administrative complexity in the event that more than one
program at a given institution is receiving funding because the application and reporting process can
be coordinated at a higher level. In some cases, the sponsoring institution, the teaching program and
the training site will be three different entities. However, because other models also exist, the
sponsoring institution may be the same as both the program and training site.
Grant are awarded based on a legislative formula found in Minnesota Statute 62J.692.
Funding is distributed to the sponsoring institutions along with a letter indicating the amount awarded
to each training site. MERC’s enabling legislation requires the sponsoring institution to complete a
Grant Verification Report (GVR) verifying that the sponsoring institution distributed the MERC grants
consistent with the Commissioner’s award letter.
If the sponsoring institution fails to submit the GVR by the deadline stated in the letter, the
sponsoring institution must return the full amount of the grant to MERC staff within 30 days of
receiving notice from the Commissioner.
The online application consists of two parts:
Part I requests information on the sponsoring institution and basic summary data regarding the
teaching programs included in the sponsoring institution’s application. For each application
there will be only one Part I submitted.
2
Medical Education and Research Cost (MERC)
Grant Application Instructions
Part II requests information on teaching program(s). For sponsoring institutions applying on
behalf of more than one teaching program, multiple Part IIs must be completed, one for each
teaching program included in the application. Only teaching programs located in Minnesota
should be included in the application.
The information requested on the application form is either required by the MERC statute (Minn. Statute
62J.691 and 62J.692), or needed to determine eligibility and appropriate share of the MERC grant.
Throughout the development of this form, compromises were reached to collect enough information to
assure the fair distribution of the grant within the constraints of the enabling legislation.
Reporting Period
The application requests information from audited fiscal year 2014. All data reported on this application, with the
exception of names and addresses (Part I Questions, A, B, D; Part II Questions 1, 3, 6), should reflect fiscal year
2014.
Due Date
The MERC application has a statutory deadline. Applications will be accepted until 4 p.m. on October 31, 2015, as
indicated by a date/time stamp placed on the application by the Minnesota Department of Health receptionist at the
following location:
MERC Grant Applications
Minnesota Department of Health
Diane Reger, 2nd Floor Golden Rule Building
85 East Seventh Place, Suite 220
St. Paul, MN 55101
3
Medical Education and Research Cost
(MERC) Grant Application Instructions
Training Sites
Each training facility must complete a MERC grant application and provide the application to the
sponsoring institution. The sponsoring institution will include training facility application on the
respective teaching program’s online application. The site application can be found online at:
http://www.health.state.mn.us/divs/hpsc/hep/merc/mcapinfo.html.
Training facilities must be located in Minnesota and actively enrolled as Medicaid providers in the Minnesota
Health Care Program (MHCP). Facilities with multiple locations must complete separate applications based on
where the actual training occurred. Each facility location must be enrolled in the MHCP. Only those sites that
had trainees and whose practice location are enrolled with the MHCP can apply for MERC funding.
MHCP Training Site Addresses: When the training site identification numbers are entered on the online
application, the address will populate based on the site’s MHCP enrollment. If the address on the training
site’s application does not match what they enrolled, either their Medicaid enrollment is not up-to-date or the
location that is applying is not enrolled with the ID they provided. If this situation occurs, contact the site and
inform them that the address they provide is not on record with the MHCP. Providers are responsible for
keeping MHCP enrollment addresses up-to-date. MERC staff does not have access to change provider
enrollment records. If the training site has an address change, they are already required to contact MHCP
within 30-days of the change at 800/366-5411 or 651/431-2700. Addresses in the MERC application will be
updated with the most current information on record with the MHCP prior to grant payments. If the practice
location is not enrolled in the MHCP, they are not eligible. (See references under provider identification
numbers.)
Training Site Contact: Contacts must be consistent across all programs and sponsoring institutions. The
contact must have sufficient information about the site’s Medicaid enrollment status and training activities in
order to provide accurate information to all teaching programs. The contact accepts responsibility for providing
accurate site data and must be an authorized representative of the training facility, preferably the CEO or CFO.
Grantee Pay-To Address: The grant will be mailed to the address on record with the MHCP unless the
authorized representative named in the training site contact section has a separate mailing address where the
grant should be mailed. Alternate addresses must be consistent across all teaching programs.
Provider Identification Numbers
The CEO, CFO, or an authorized representative of the clinical training site must provide the identification
number used for Medicaid billing by the practice address where training occurred. Each practice address has a
unique identification number in Minnesota which is used to gather Medicaid revenue from the Department of
Human Services. The revenue is used to calculate the MERC grant. Individual preceptors or departments within a
facility should not be listed as the training site.
National Provider Identification Numbers (NPI): The Centers for Medicare and Medicaid Services
(CMS) requires all health care providers to apply for a National Provider Identification (NPI) Number. This
number must be reported on the MERC application.
Minnesota Health Care Program Enrollment (MHCP): Only NPIs enrolled in Minnesota have
MAID/Legacy IDs. IDs are specific to the location enrolled. If the training location is not enrolled in Minnesota,
the site is not eligible for MERC. If the training site has a consolidated NPI shared across many locations, each
location must enroll in the MHCP regardless of shared NPI status. If the address where training took place does not
match MHCP enrollment, the facility may not qualify.
Federal Tax ID Numbers (FEIN): Sites must provide the FEIN on record with the MHCP.
4
Medical Education and Research Cost
(MERC) Grant Application Instructions
Hospitals sometimes choose to have multiple identification numbers enrolled in the MHCP instead of one ID
that covers all services of the licensed hospital. It is important that the main hospital be listed as the overall
training site, not the individual department where training took place.
In cases where the hospital has enrolled departments individually with the MHCP, these additional hospital IDs
must all be listed as subparts for their Medicaid revenue to be included in the hospital’s grant calculation.
These separately enrolled identification numbers must be hospital components according to CMS guidelines
and must be located in Minnesota.
 The facility must be included on the hospital’s current Minnesota license.
 Consolidated NPI numbers separately enrolled in the MHCP must list each hospital component separately
enrolled.
 Clinics must be provider-based hospital clinics.
 If a hospital owns a facility, but the facility is not defined and licensed as a hospital or provider-based
hospital clinic, according to CMS guidelines, the facility and ID should not be included as a subpart under
the hospital. If the actual training was completed in the facility in question, a separate application should
be submitted for each non-hospital training location.
Clinics should apply as a physician clinic, unless they are a provider-based hospital clinic. Clinics with
multiple locations must apply for each location separately, based on where the clinical training occurred. The
location where training took place must be actively enrolled in the MHCP. If the location of training is
considered a provider-based hospital clinic, see reference to hospitals.
Pharmacies which indicate they are a hospital pharmacy on the pharmacy license and bill as a hospital
component should apply for a grant under the hospital. See reference to hospitals.
If a pharmacy bills as a retail/community pharmacy, they should apply separately as a pharmacy (retail).
Retail chains must apply for each training location separately.
Nursing homes are not eligible.
5
Medical Education and Research Cost (MERC)
Grant Application Instructions
Part I Sponsoring Instruction
MERC grant applications must be submitted online by the sponsoring institution on behalf of the teaching program.
Part I requests information about the sponsoring institution, which is defined in statute as “a hospital, school, or consortium
located in Minnesota that sponsors and maintains primary organizational and financial responsibility for a clinical medical
education program in Minnesota and which is accountable to the accrediting body.” Minnesota Statute §62J.692, subdivision
1(d). In some cases, the sponsoring institution will be the same as the teaching program; in other cases, the two will be
separate.
A. Sponsoring Institution
Name:
List the name and address of the sponsoring institution
submitting this application.
Address:
Name:
B. Person Responsible for Grant
List the name and mailing address of the person
responsible for managing grant money received from the
MERC grant.
Address:
Email:
Phone:
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Medical Education and Research Cost (MERC)
Grant Application Instructions
Part I Sponsoring Instruction
0B
Program
C. Programs Included in this Application
Advanced Practice Nurses
This is a summary of fiscal year 2014 programs and
trainee FTEs contained in the application. Indicate the
number of teaching programs included in this application
and the total number of trainee FTEs.
Chiropractic Students
In some cases, the sponsoring institution will be applying
on behalf of several programs. The numbers reported in
this section must represent a sum of those programs and
trainee FTEs reported in Part II-Training Programs.
Community Paramedics
Clinical Social Workers
Community Health Workers
Dental Residents
Dental Students
Advanced Dental
Therapists
Dental Therapists
Medical Residents
Medical Students
PharmD Residents
PharmD Students
Physician Assistants
Psychologists
TOTAL
Signature
Name
D. Certification by Officer
Title
This application must be signed by an officer authorized
by the sponsoring institution. This signature verifies that
the information contained in all parts of the application is
true and correct to the best knowledge of the officer.
Phone
Date
FTE = Full time equivalent
2|Page
1B
# Programs
2B
FTEs
Medical Education and Research Cost (MERC)
Grant Application Instructions
Part II Teaching Program – Fiscal Year 2014
Complete a separate Part II for each teaching program for fiscal year 2014.Part II may be completed by the teaching
program or by the sponsoring institution on behalf of a teaching program. However, the sponsoring institution must certify
that the information contained in the application is true and correct.
Part II must be submitted online through the sponsoring institution.
1. Teaching Program
Name:
Provide the name and address of the teaching program
and the date the program began operating.
Address:
Date program was established and began teaching
activities.
2. Program Type
Check one of the boxes to identify the type of provider trained in
this program. A separate form must be completed for each
training program; therefore, only one box should be checked.
1|Page
Program Type
Advanced Practice Nurses
Chiropractic Students
Clinical Social Workers
Community Health Workers
Community Paramedics
Dental Residents
Dental Students
Advanced Dental Therapists
Dental Therapists
Medical Residents
Medical Students
PharmD Residents
PharmD Students
Physician Assistants
Psychologists
Check One
Medical Education and Research Cost (MERC)
Grant Application Instructions
3. Person Responsible for Grant
Identify the name and Federal Express address of the
person responsible for handling financial aspects of the
program, including managing any grant funds which may be
awarded from the MERC grant.
Name:
Address:
Email:
Phone:
Fax:
4. This Program’s Fiscal Year 2014
Fiscal year 2014 began:
Indicate the beginning and ending dates for this program’s
fiscal year 2014.
month/day/year
Fiscal year 2014 ended:
month/day/year
5. Program Specialty
List the trainee specialty for this program (e.g. clinical nurse
specialist, pediatric dentistry, internal medicine).
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Medical Education and Research Cost (MERC)
Grant Application Instructions
6. Accreditation
All teaching programs applying for a MERC grant
must be currently accredited through an
organization recognized by the U.S. Department of
Education (“Current List of Nationally Recognized
Accrediting Agencies and the Criteria for
Recognition by the U.S. Secretary of Education.”
U.S. Department of Education Office of
Postsecondary Education, September 1998), the
Centers for Medicare and Medicaid Services (42
C.F.R. §§ 413.85, 413.86) or another national body
who reviews the accrediting organizations for
multiple disciplines and whose standards for
recognizing accrediting organizations are reviewed
and approved by the Commissioner of Health.
Provide the name, address and phone number of
the accrediting organization. Also provide a
description of your accreditation status and the
effective dates.
Accreditation status must be attested to by an officer
who has personal knowledge of the program’s
accreditation status. Depending on the
circumstances, this may be an officer of the teaching
program or the sponsoring institution.
Accreditation Organization:
Address:
Phone:
Current Accreditation Status:
Initial Accreditation*
(Recently accredited or first time MERC applicant)
Continued Accreditation
(ongoing accreditation)
Other (describe)
Accreditation Began:
Currently Approved Through:
If your accreditation status changes, you must notify the Minnesota Department of Health.
I,
Print Name
Print Title
AFFIRM THAT THE INFORMATION ON ACCREDITATION IS TRUE AND CORRECT. I UNDERSTAND THAT
ONLY CURRENTLY ACCREDITED PROGRAMS QUALIFY FOR MERC FUNDING AND I AM ATTESTING TO
THE ACCREDITATION STATUS OF THIS PROGRAM IN ORDER FOR THE MINNESOTA DEPARTMENT OF
HEALTH TO DETERMINE PROGRAM ELIGIBILITY.
Signature
*
Date
New programs are required to submit outside documentation, such as a letter from the accrediting body, verifying the
program’s accreditation status and accreditation effective dates.
3|Page
Medical Education and Research Cost (MERC)
Grant Application Instructions
7. Training Site Information: Identification and Trainee FTEs
Question 7 requests data on eligible and non-eligible trainees, calculated as FTEs. To determine non-eligible
FTEs, follow the instructions in 7a, below. To determine eligible FTEs, follow the instructions in 7b, vii. Note that
non-eligible trainees are to be reported in FTEs using the summary data for the teaching program. In comparison,
eligible trainees are to be reported in FTEs for each training site. Eligible and non-eligible FTEs are added
together in Question 7c. This total must match the total number of trainees in the teaching program in FY 2014 or
the designated reporting period.
FTE is defined as a full-time equivalent. Full-time is considered a minimum of 2,080 hours, 52 weeks, or 260
days. One person cannot exceed one FTE.
((Student/Resident * Weeks in Rotation)* Hours per Week) = Clinical Training Hours / 2,080 = FTE Count
Round FTEs to two decimals.
7a. Summary of Non-Eligible Trainees
Question 7a requests summary data for the teaching program. Report the total number of non-eligible
trainees across all training sites for this teaching program according to the following categories.
i.
Clinical Training FTEs at Sites Located Outside of Minnesota – Report the total number of clinical
training FTEs for this teaching program that are at training sites outside of Minnesota.
ii.
Didactic/classroom (non-patient care) FTEs – Report the total number of didactic/classroom FTEs for
this teaching program. For example, if trainees in this program spend half of their time in
didactic/classroom activities, then half of the total student/resident FTEs for this program should be
reported here.
Note: A program can be defined to exclude students who do not participate in any clinical training, (for
example, year one medical students whose time is all spent in didactic training). In any case, the definition
of the teaching program should be consistent throughout the application.
iii.
Other Non-eligible Trainee FTEs – Report any other non-eligible trainee FTEs for this teaching program.
Examples of other non-eligible trainees include trainees in sites not enrolled in the Minnesota Health Care
Program (MHCP), trainees in nursing homes or VA/federal sites, or training sites in school-based clinics
not supported by patient care revenues.
iv.
Total non-eligible trainee FTEs for this teaching program – Total items i, ii, and iii.
7b. List of Eligible Training Sites
Question 7b requests specific information on individual training sites that are applying for MERC grants. Training
sites must complete the Clinical Training Site Grant Application.
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Medical Education and Research Cost (MERC)
Grant Application Instructions
i.
Training Site – “Training site” means the facility at a given practice address where clinical training
occurred. Individual preceptors or departments within a facility should not be listed as the training site. If
the training site is a physician owned clinic, the training site is defined as the clinic and not the physician.
The facility where clinical training occurred should be listed as the “training site” even if the preceptor that
provided the training has moved to another facility. Training site must be located in Minnesota and have a
National Provider Identification (NPI) number which is actively enrolled for Medical Assistance in Minnesota
Health Care Program. Site must host a minimum of 0.1 eligible FTEs during fiscal year 2014 across all
teaching programs and have calendar year 2014 MA/PMAP claims reimbursements on record with the
Department of Human Services.
ii.
CEO/CFO or Authorized Representative – Provide for each training site a contact name, email, and
phone number of the CEO/CFO or a representative authorized by the CEO/CFO.
iii.
Address – Provide a complete address where the actual training took place.
iv.
Setting type – Indicate whether the training site is primarily an ambulatory setting, primarily an inpatient
setting, or both.
v.
National Provider Identification Number (NPI) – The Centers for Medicare and Medicaid Services
requires providers apply for an identification number. The NPI must be provided as part of the application
process.
Taxonomy and Zip+4 ­ Providers with multiple locations having one consolidated/shared NPI must
provide the facilities taxonomy and zip+4.
Federal Tax ID Number (FEIN) - Report the training site’s FEIN.
vi.
CEO/CFO or Authorized Representative (Billing) Address – Indicate the mailing address for the site’s
CEO/CFO or Authorized Representative. MERC grants will be mailed to this address. If no address is
provided, grants will be mailed to the site address on record with the MHCP.
vii.
Total Eligible FTEs – Report the total number of eligible FTEs of clinical training for each training site
in fiscal year 2014. To determine eligible FTEs, identify the trainees that are eligible, as explained in 1- 3
below. Next determine the full-time equivalent for eligible trainees at each training site. Only those trainees
that meet the following criteria are to be included in the calculation of “eligible FTEs.”
a. The trainee’s teaching program and training site must be located in Minnesota and the site must be
actively enrolled in the MHCP.
b. The trainee must be one of the following: advanced practice nursing student (clinical nurse
specialist, certified registered nurse anesthetist, nurse practitioner, doctor of nursing practice, or
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Medical Education and Research Cost (MERC)
Grant Application Instructions
certified nurse midwife), chiropractic student, clinical social worker, community health worker, community
paramedic, dental resident, dental student, advanced dental therapists, dental therapists, medical
resident, medical student, doctor of pharmacy resident, doctor of pharmacy student, physician
assistant student, or psychologists.
c. The training must be funded in part by patient care revenues and must occur in either an inpatient
or ambulatory patient care setting.
Trainees that do not meet these criteria should be counted in Item 7a, above.
viii.
Total Eligible FTEs for all Training Sites in Program – Total the eligible trainee FTEs for all training
sites listed in 7b.
7c. Grand Total of all FTEs for all Training Sites in Program
Total 7a plus 7b. This total must match the total number of trainees in the teaching program in fiscal year
2014.
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Medical Education and Research Cost
(MERC) Grant Application Instructions
7a. Non-Eligible training sites and FTE totals for teaching program
i.
FTEs for sites located outside of Minnesota
ii.
Didactic/Classroom (non-patient care) FTEs
iii.
Other non-eligible FTEs
iv.
Total non-eligible FTEs
7b. Eligible training sites and FTE totals for teaching program
vii. Individually list FTEs for each clinical training site
(Each site is listed individual on the online application)
viii. FTEs for all eligible training sites in program
7c. Overall FTEs for teaching program (7a + 7b)
Applications for the MERC
grants must be submitted
online by the sponsoring
institution. Teaching
programs should NOT submit
Part II applications directly to
the Department of Health.
7|Page
Non- Eligible FTEs
Eligible FTEs
Medical Education and Research Cost (MERC)
Clinical Training Site Grant Application
Fiscal Year 2014 Trainees
Complete one grant application for each facility providing clinical training in Minnesota. The location providing
clinical training must be actively enrolled in the Minnesota Health Care Program (MHCP), and the address of
training must be consistent with the address enrolled.
(Read training facility instructions before completing.)
MHCP Training
Facility
MHCP Address
City
MN
State
Zip+4
CEO, CFO, or
Authorized Representative
Title
Email Address
(REQUIRED)
Phone
Fax
Mail Potential Grant to Training Site Address Provided Above
Yes
No
*If no, provide CEO, CFO, or Authorized Representative’s mailing address below:
Facility Name
*ATTN:
Address
City
State
MN
Zip+4
MHCP Provider Type
Hospital
Physician Clinic (Not provider-based)
Pharmacy (Retail)
Dental Clinic
Chiropractic Clinic
Other (please specify) ____________
MERC Clinical Training Site Grant Application
Fiscal Year 2014 Training
(Page 2)
Facility:
Federal Tax ID (FEIN)
9 digits
National Provider ID (NPI)
10 digits
Taxonomy / Zip+4
(Only applies to consolidated NPIs)
10 alpha / numeric characters
9 digits
Hospital Subparts – In cases where the hospital has enrolled departments individually with the MHCP, the hospital
IDs must all be listed below for their Medicaid revenue to be included in the hospital’s grant calculation. These
separately enrolled identification numbers must be defined and licensed as a hospital or provider-based hospital clinic
according to CMS guidelines, must be located in Minnesota, and must be included on the hospital’s current Minnesota
license (see memo for details). List each applicable MHCP enrolled facility. Do not include nursing homes or individual
practitioners.
Attach additional sheets if necessary.
Subpart Name
Address (Street, City, Zip)
Separately enrolled in MHCP
MHCP enrolled address
blank
Subpart NPI &
Provider Type
FEIN
blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
blank
___Check here if additional sheets are attached
MERC Clinical Training Site Grant Application
Fiscal Year 2014 Training
(Page 3)
Funding & Report Requirements: Grant amounts are determined based on the eligibility
criteria and formula defined in Minnesota Statute 62J.692. Funding will be limited to the facility’s
expenses associated with clinical training for qualifying MERC programs in fiscal year 2014. After
initial review of the grant application, MDH will request clinical training expenditures from the CEO,
CFO, or Authorized Representative. This request will be made in November 2015 to the email
address provided on Page 1. Submission of clinical training expenditures are required to process
the application and make awards.
I certify that I am the CEO, CFO or an authorized representative approved by the CEO or CFO of
the facility named above. I have sufficient knowledge about the facility’s MHCP enrollment,
identification numbers used for Medicaid billing, and clinical medical education costs. I attest that
the training facility hosted clinical trainees in fiscal year 2014. I am aware that the data I provide will
be used for grant eligibility and calculations. The data included in the application is accurate and I
will comply with all laws related to MERC statute 62J.692.
Name (print):
Title:
Email:
Signature:
Rev. 07/20/2015
Date: