Hospital Safety Net Grant Program
Request for Proposals, Fiscal Year 2016
Minnesota Department of Health (MDH)
Office of Rural Health & Primary Care
The purpose of the Hospital Safety Net Grant Program is to provide grant funding to help defray underpayments
to hospitals for high-cost services provided to Emergency Medical Assistance enrollees.
The purpose of this document is to announce the request for proposals, describe the grant program, and provide
instructions that help applicants complete an application. This document has five sections:
Section I
Section II
Section III
Section IV
Section V
Explains the background, eligibility, and funding information of the grant program.
Provides instructions on the preparation of the Step 1 Application.
Provides instructions for the Step 2 Application.
Contains forms and further instructions on completing the Step 1 Application (due April 8, 2016).
Contains forms and/or further instructions on completing the Step 2 Application (due May 13,
2016).
Section I – Legislative Background, Eligibility and other Funding Information
A.
Legislative Background
Minnesota Statute 145.929, Subdivision 4 authorizes the Commissioner of Health to award grants to support
hospitals which provide services to Emergency Medical Assistance (EMA) enrollees. Funds will be awarded
proportionally among all eligible hospitals that apply, based on the total dollar amount of qualifying EMA claims of
over $50,000 between April 1, 2015 and March 31, 2016
B.
Eligible Applicants
Eligible applicants are licensed hospitals in Minnesota that serve EMA enrollees.
C.
Grant Program Requirements
Grant contracts will be for one year. Grant funds may be used for operating costs to offset the cost of treating
EMA enrollees, including hospital:
• Salaries and Fringe Benefits
• Supplies
• Travel
• Equipment and Capital Improvements
• Contracted Services
• Other
D.
Total Available Funding
Up to $1,340,000 is available in Fiscal Year 2016.
E.
Distribution of Grant Funds
Each eligible hospital that submits a complete applications with at least one “Qualifying EMA Claim” will receive a
percentage of the available funding, calculated as a simple ratio of the dollar amount of Qualifying EMA Claims,
compared to the total dollar amount of all submitted Qualifying EMA Claims.
A Qualifying EMA Claim must be in excess of $50,000 and must have been submitted to the Department of
Human Services for payment between April 1, 2015 and March 31, 2016. Multiple Qualifying EMA Claims for the
same enrollee may be submitted. Qualifying EMA Claims may include inpatient hospital services, outpatient
services, and hospital emergency department services.
Upon receipt of grant applications, MDH will calculate the total dollar amount of Qualifying EMA Claims from all
eligible applicants. This total dollar amount will only include Qualifying EMA Claims submitted to MDH for this
grant – if an eligible hospital does not apply for this grant, any potentially Qualifying EMA Claims will not be
included in the total dollar amount used for the grant calculation. After the total dollar amount is calculated, each
eligible hospital will receive a percentage of the available funding. The percentage will be calculated as a ratio of
the dollar amount from each hospital’s qualifying EMA claims in relation to the total dollar amount of all
qualifying EMA claims.
Grantees will be required to enter into a grant agreement with the Department of Health. Grant dollars will only
be reimbursed for activities which take place during the grant period. Payments will be distributed semi-annually,
upon receipt of an invoice and a progress report. The estimated date of the first available semi-annual payment is
December 1, 2016.
F.
Timeline
RFP published
Step 1 Application due to MDH:
Grant distribution announcement:
Step 2 Application (Budget) due to MDH:
Grant Agreements begin (estimated date):
March 7, 2016
April 8, 2016
April 15 2016
May 6, 2016
June 1, 2016
Section II - Completing the Step 1 Application
A complete Step 1 Application consists of the following:
1.
2.
3.
4.
Hospital Business Information and Signature Page (complete the form provided)
Organization Description – (document to be attached)
Qualifying EMA Claims Data – (document/spreadsheet to be attached0
Due Diligence Review Form
• complete the 4-page Due Diligence form provided, AND
• attach the required financial document
The rest of this section provides details about the information required in the forms and documents listed above:
1. Hospital Business Information and Signature Page
Complete the 1-page form provided.
2. Organization Description (5 pages maximum, double-spaced).
Write a summary of the organization, which includes the following:
a) A description of the organization - the history, geographic area, patients served,
administrative structure and budget.
b) A brief description the intended purpose and use of grant funds. A detailed description of
the use of grant funds will be required in the Step 2 Application, along with a budget and
budget narrative. For this Step 1 Application, only a broad description of how the funds will
be spent is required.
3. Qualifying EMA Claims Data
In order to determine the award amount, applicants must include a document or spreadsheet which
contains the total number of Qualifying EMA Claims. The document or spreadsheet must be HIPAA
compliant, and must include the number and dollar amount of Qualifying EMA Claims, the date each claim
was submitted to DHS for payment, and whether multiple claims are for the same enrollee.
4. Due Diligence Review (Financial Questionnaire) Form
This form is a standard MDH financial review required for all grants in excess of $50,000. Complete all
fields on the form. No single answer will disqualify an applicant – the form is merely an assessment of
potential risk.
MDH reserves the right to request audited financial statements and/or claims at any time to verify the
accuracy of the data used to determine the award amount for this grant.
Step 1 Application Submission Instruction and Deadline
Submit one copy of the complete application. Applications must be received at the MDH Office of Rural Health
and Primary Care no later than 3:00 PM Central Standard Time on Friday, April 8, 2016.
If sending application via the US Post Office, the
If sending application via courier or next day delivery
envelope must be post-marked by 3:00 PM Central
services, send to:
Standard Time. Mail to:
Lina Jau, Grant Manager
Lina Jau, Grant Manager
Minnesota Department of Health, ORHPC
Minnesota Department of Health, ORHPC
85 East 7th Place, Suite 220
PO Box 64882
St. Paul, MN 55164-0882
St. Paul, MN 55101
Questions regarding these grant application guidelines should be directed to Lina Jau at [email protected] or
651-201-3809 or 800-366-5424.
Section III – Completing the Step 2 Application (the Budget)
Prior to the Step 2 Application process, the Grant Distribution Announcement will be made via email to the
applicant contact person listed on the Applicant Business Information and Signature Page of the Step 1
Application. This announcement will provide the award amount to the applicant. Using the award amount
information, the applicant will begin working on the Step 2 Application.
Grant awardees will have roughly three weeks to complete the Step 2 Application which consists of a project
narrative and a budget explaining how state grant funds will be spent during the grant period.
A complete Step 2 Application consists of the following documents:
1. Hospital Business Information and Signature Page (complete the form provided)
2. Project Narrative (document to be attached)
3. Budget Summary (complete the form provided)
4. Personnel Budget page (completer the form provided)
5. Budget Narrative (complete the form provided)
The rest of this section will give details about the information required in the forms and documents listed above:
1. Hospital Business Information and Signature Page
Complete the 1-page form provided.
2. Project Narrative (5 pages maximum, double-spaced)
Attach the document where required. The Project Narrative must include:
a) A description of the project.
b) A description of activities to be funded with grant dollars.
c) A problem statement describing what issues or concerns the project will address.
d) A description of the group or population who will benefit from the project.
3. Budget Summary
Using the form provided, list the amounts of all expenses that you are proposing to pay out of this grant
program.
The information provided on the form will become the basis for tracking grant payments. Grant funds are
for operating costs to defray underpayment for services provided to EMA enrollees.
4. Budget Narrative – Salaries and Fringe Benefits
Using the table provided, list all staff positions paid partially or wholly with this grant fund in the first
column. The totals should be the same as the Salaries and Fringe Benefits line items listed in the Budget
Summary form.
5. Budget Narrative – Other Line Items
Explain in detail each line item (except salaries and fringe benefits) listed on the Budget Summary form,
including showing how expenses are estimated. List the line items in order as they appear in the Budget
Summary.
For Contracted Services, include the vendor names, services provided, fees and cost per unit of
service.
For supplies, include descriptions and brand names.
Travel - include a detailed description of the proposed travel as it relates to the direct operation
of the hospital. Provide the number of miles planned for program activities as well as the rate of
reimbursement per mile.
Equipment and Capital Improvements - include a description of any grant funding to be used to
purchase equipment, or to make capital improvements. Include the name and brand of
equipment.
Other Expenses - if it is necessary to include expenditures in this general category, include a
detailed description of the activities as it relates to the direct operation of the hospital. If possible,
include a separate line-item budget and budget narrative.
Special submission instruction for “umbrella” organizations with multiple hospitals:
One “umbrella” organization may submit an application on behalf of multiple hospitals. In this case, the primary
applicant organization must complete the entire application. Sub-applicants must also complete the Qualifying
EMA Claims Data document to determine eligibility and award amounts in Step 1, and, if eligible, the Project
Narrative and Budget documents in Step 2. The primary applicant will be responsible for distributing funds to
sub-grantees based on the allocation determined by MDH, and for collecting and submitting any invoices and
required reports on behalf of all sub-applicants.
All submitted grant application documents and data become public information once grant agreement contracts
have been executed.
Step 2 Application Submission Instruction and Deadline
Step 2 Applications must be sent via electronic mail (email) to Lina Jau at [email protected] by 3:00 PM Central
Standard Time on Friday May 6, 2016.
Section IV - Step 1 Application
The following 6 pages contain forms and instructions for completing the Step 1 Application of the Fiscal Year 2016
Hospital Safety Net grant program.
Step 1 Application Submission Instruction and Deadline
Submit one copy of the complete application. Applications must be received at the MDH Office of Rural Health
and Primary Care no later than 3:00 PM Central Standard Time on Friday, April 8, 2016.
If sending application via the US Post Office, the
envelope must be post-marked by 3:00 PM Central
Standard Time on April 8, 2016. Mail to:
Lina Jau, Grant Manager
Minnesota Department of Health, ORHPC
PO Box 64882
St. Paul, MN 55164-0882
If sending application via courier or next day delivery
services, send to:
Lina Jau, Grant Manager
Minnesota Department of Health, ORHPC
85 East 7th Place, Suite 220
St. Paul, MN 55101
Questions about the Fiscal Year 2016 Hospital Safety Net grant application should be directed to Lina Jau at
[email protected] or 651-201-3809 or 800-366-5424.
2016 Hospital Safety Net Grant Program – Step 1 Application
Minnesota Department of Health
1.
Hospital Business Information and Signature Page
Please provide hospital name, business address, and SWIFT Vendor Number.
Hospital Name:
Hospital Business Address:
SWIFT Vendor Number:
Please provide the name and contact information of the person responsible for this grant application.
Name:
Position:
Email address:
Phone:
Eligibility
This grant program is for Minnesota hospitals with at least one “Qualifying EMA Claim” in excess of
$50,000 between April 1, 2015 and March 31, 2016.
Certification and Authorized Official’s Signature
I certify that the information contained herein is true and accurate to the best of my knowledge, that no
changes were made in the organization’s accounting and record-keeping practices or policies for
providing free or reduced-cost care to uninsured patients for the purpose of creating eligibility or
increasing the organization’s allocation, and that I submit this application on behalf of the applicant
organization.
Signature of Authorized Official:________________________________________________________
Print Name:_________________________________________________________________________
Title:______________________________________________________________________________
Date:_______________________________________
2016 Hospital Safety Net Grant Program – Step 1 Application
Minnesota Department of Health
Hospital Name:
2.
Organization Description – attach document
(5 pages maximum, double-spaced)
Please provide a written summary of your hospital, which includes the following:
• A description of the hospital - the history, geographic area, patients served, administrative structure and
budget.
• A brief description of the intended purpose and use of the grant funds. A detailed description of the use
of grant funds will be required in the Step 2 Application, along with a budget and budget narrative. For
this Step 1 Application, only a broad description of how the funds will be spent is required.
2016 Hospital Safety Net Grant Program – Step 1 Application
Minnesota Department of Health
Hospital Name:
3.
Qualifying EMA Claims Data – attach document
In order to determine the award amount, applicants must include a document or spreadsheet. The document or
spreadsheet:
• must be HIPAA compliant, and
• must include the following a. the number of Qualifying EMA Claims
b. dollar amount of each Qualifying EMA Claims
c. the date each claim was submitted to the Minnesota Department of Human Services (DHS) for
payment
d. whether multiple claims are for the same enrollee, and
e. the total dollar amount of Qualifying EMA Claims
A Qualifying EMA Claim must be in excess of $50,000 and must have been submitted to the Department of
Human Services for payment between April 1, 2015 and March 31, 2016. Multiple Qualifying EMA Claims for the
same enrollee may be submitted. Qualifying EMA Claims may include inpatient hospital services, outpatient
services, and hospital emergency department services.
Upon receipt of grant applications, MDH will calculate the total dollar amount of Qualifying EMA Claims from all
eligible applicants. This total dollar amount will only include Qualifying EMA Claims submitted to MDH for this
grant – if an eligible hospital does not apply for this grant, any potentially Qualifying EMA Claims will not be
included in the total dollar amount used for the grant calculation. After the total dollar amount is calculated, each
eligible hospital will receive a percentage of the available funding. The percentage will be calculated as a ratio of
the dollar amount from each hospital’s qualifying EMA claims in relation to the total dollar amount of all
qualifying EMA claims.
Grantees will be required to enter into a grant agreement with the Department of Health. Payments will be
distributed semi-annually, upon receipt of an invoice and a progress report.
2016 Hospital Safety Net Grant Program – Step 1 Application
Minnesota Department of Health
Hospital Name:
4.
Due Diligence Review Form
Purpose
The Minnesota Department of Health (MDH) must conduct due diligence reviews for non-governmental
organizations (NGOs) applying for grants, according to MDH Policy 240.
Definition
Due diligence refers to the process through which MDH researches an organization’s financial and organizational
health and capacity (MDH Policy 240). The due diligence process is not an audit or a guarantee of an
organization’s financial health or capacity. It is a review of information provided by a NGO and other sources to
make an informed funding decision.
Instructions
As an applicant for MDH funds you must answer the following questions about your organization, and return the
form (along with any required additional documentation) to the grant manager.
Organization Information Questionnaire
Question
Response
1. How long has your organization been doing business?
2. How many employees does your organization have (both part time and
full time)?
3. What was your organization's total revenue in the most recent 12month accounting period?
4. How many different funding sources does the total revenue come
from?
Question
Yes
No
5. Does your organization have a current 501(c)3 status from the IRS?
Circle Yes or No.
6. Has your organization done business under any other name(s) within
the last five years? Circle Yes or No.
If yes, list name(s) used.
Yes
No
Yes
No
7. Is your organization affiliated with or managed by any other
organizations, such as a regional or national office? Circle Yes or No. If
yes, provide details.
Yes
No
Question
Yes
No
Yes
No
Yes
No
10. Does your organization have written policies and procedures for
accounting processes? Circle Yes or No.
If yes, please attach a copy of the table of contents.
Yes
No
11. Does your organization have written policies and procedures for
purchasing processes? Circle Yes or No.
If yes, please attach a copy of the table of contents.
Yes
No
12. Does your organization have written policies and procedures for payroll
processes? Circle Yes or No.
If yes, please attach a copy of the table of contents.
Yes
No
Manual
Automated
Both
13. Which of the following best describes your organization's
accounting system? Circle one response.
Manual
Automated
Both
14. Does the accounting system identify the deposits and
expenditures of program funds for each and every grant
separately? Circle one response.
Yes
No
Not sure
15. If your organization has multiple programs within a
grant, does the accounting system record the
expenditures for each and every program separately by
budget line items? Circle one response.
Yes or Not
applicable
No
Not sure
16. Are time studies conducted for employees who receive
funding from multiple sources? Circle one response.
Yes or Not
applicable
No
Not sure
17. Does the accounting system have a way to identify overspending of grant funds? Circle one response.
Yes
No
Not sure
18. If grant funds are mixed with other funds, can the grant
expenses be easily identified? Circle one response.
19. Are the officials of the organization bonded? Circle one
response.
Yes
No
Not sure
Yes
No
Not sure
8. Does your organization receive management or financial assistance
from any other organizations? Circle Yes or No.
If yes, provide details.
9. Have you been a grantee of the Minnesota Department of Health
within the last five years? Circle Yes or No.
If yes, from which division(s)?
Question
Question
Yes
No
Not sure
Yes
No
Not sure
Yes
No
Yes
No
Yes
No
22. Are there any current or pending lawsuits against the organization?
Circle Yes or No.
23. If yes, could there be an impact on the organization's financial position?
Circle one response.
Yes
No
Yes
No or Not
applicable
24. Has the organization lost any funding due to accountability issues,
misuse, or fraud? Circle Yes or No.
Yes
No
20. Did an independent certified public accountant (CPA)
ever examine the organization's financial statements?
Circle one response.
Question
21. Has any debt been incurred in the last six months? Circle Yes or No.
If yes, what was the reason for the new debt?
What is the funding source for paying back the new debt?
Current Amount:
What is the current amount of unrestricted funds compared to total revenues?
Question
If yes, please describe the situation, including when it occurred and
whether issues have been corrected.
Additional Documentation Required
The following documentation is required in addition to the due diligence form.
IF you’re an NGO with annual income of…
THEN submit your most recent:
under $25,000
Board-reviewed financial statement.
between $25,000 and $750,000
IRS Form 990.
over $750,000
Certified financial audit.
Section V - Step 2 Application
The following 5 pages contain forms and instructions for completing the Step 2 Application of the Fiscal Year 2016
Hospital Safety Net grant program.
Step 2 Application Submission Instruction and Deadline
Step 2 Applications must be saved in pdf format and sent via electronic mail (email) to Lina Jau at
[email protected] by 3:00 PM Central Standard Time on Friday May 6, 2016.
Questions about the Fiscal Year 2016 Hospital Safety Net grant application should be directed to Lina Jau at
[email protected] or 651-201-3809 or 800-366-5424.
2016 Hospital Safety Net Grant Program – Step 2 Application
Minnesota Department of Health
1.
Hospital Business Information and Signature Page
Please provide hospital name, business address and SWIFT Vendor Number
Hospital Name:
Hospital Business Address:
SWIFT Vendor Number:
Please provide the name and contact information of the person responsible for this grant application.
Name:
Position:
Email address:
Phone:
Eligibility
This grant program is for Minnesota hospitals with at least one “Qualifying EMA Claim” in excess of
$50,000 between April 1, 2015 and March 31, 2016.
Certification and Authorized Official’s Signature
I certify that the information contained herein is true and accurate to the best of my knowledge, that no
changes were made in the organization’s accounting and record-keeping practices or policies for
providing free or reduced-cost care to uninsured patients for the purpose of creating eligibility or
increasing the organization’s allocation, and that I submit this application on behalf of the applicant
organization.
Signature of Authorized Official:________________________________________________________
Print Name:_________________________________________________________________________
Title:______________________________________________________________________________
Date:_______________________________________
2016 Hospital Safety Net Grant Program – Step 2 Application
Minnesota Department of Health
Hospital Name:
2.
Project Narrative
(5 pages maximum, double-spaced)
Attach the document if needed. The Project Narrative must include:
e)
f)
g)
h)
A description of the project or program.
A description of activities to be funded with grant dollars.
A problem statement describing what issues or concerns the project will address.
A description of the patients or population who will benefit from the project.
2016 Hospital Safety Net Grant Program – Step 2 Application
Minnesota Department of Health
Hospital Name:
3.
Budget Summary
Because budgets are best-guess estimates, please round to the nearest dollar. Use only the space provided.
Amount of Hospital Safety Net
grant funds allocated:
Line Item Expense
Salaries (and fill out Budget Narrative – Salaries and Fringe Benefits form)
$
Fringe Benefits (and fill out Budget Narrative – Salaries and Fringe Benefits form)
$
Contract Services
$
Travel
$
Training
$
Printing
$
Postage
$
Telephone
$
Rent
$
Office Supplies
$
Program Supplies
$
Equipment (Specify):
$
Capital Improvement
$
Other (Specify):
$
Other (Specify):
$
Other (Specify):
$
TOTAL: $
2016 Hospital Safety Net Grant Program – Step 2 Application
Minnesota Department of Health
Hospital Name:
4.
Budget Narrative – Salaries and Fringe Benefits
List all staff positions paid partially or wholly with this grant fund in the first column. In the second column, list the
percentage of time each position spends providing services in the program. In the third column, list the amount of salaries
paid for by this grant. Total the salaries at the bottom. In the last column, list the amounts of fringe benefits paid for by this
grant and total the fringe benefits at the bottom. The totals should be the same as the Salaries and Fringe Benefits line items
listed in the Budget Summary form. If necessary this form can be reproduced.
Position/Title
Total
F.T.E.*
Salaries to be paid for by Fringe benefits to be paid for
this grant program
by this grant program
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
*F.T.E. List the amount of staff time each position is charged to this grant program. For example, if you designate this grant
program to pay for 40% of a full-time physician, you would list only 40 percent or 0.4 FTE. And if 4 RNs are to be paid by this
grant program at 50% of their time each, the total FTE is 2.0 (4 X .5)
2016 Hospital Safety Net Grant Program – Step 2 Application
Minnesota Department of Health
Hospital Name:
5.
Budget Narrative – Other Line Items
Using this page and additional pages if necessary, explain in detail each line item (except salaries and fringe benefits) listed on
the Budget Summary form, including showing how expenses are estimated. List the line items in the order as they appear on
the Budget Summary.
For Contracted Services, include the vendor names, services provided, fees and cost per unit of service.
For Supplies, include descriptions and brand names.
Travel - include a detailed description of the proposed travel as it relates to the direct operation of the hospital. Provide the
number of miles planned for program activities as well as the rate of reimbursement per mile.
Equipment and Capital Improvements - include a description of any grant funding to be used to purchase equipment, or to
make capital improvements. Include the name and brand of equipment.
Other Expenses - if it is necessary to include expenditures in this category, specify what this expense is and include a detailed
description of the activities as it relates to the direct operation of the hospital.