ACA - State Innovation Models: Funding for Model Design and Model Testing Assistance

The Center for Medicare and Medicaid Innovation (Innovation Center) announces the second round of funding for the State Innovation Models (SIM) program.

SIM is based on the premise that state innovation with broad stakeholder input and engagement, including multi-payer models, will accelerate
delivery system transformation to provide better care at lower costs.

SIM is focused on public and private sector collaboration to transform the state?s delivery system.

SIM provides financial and technical support to states to test the ability of state governments to use their regulatory and policy levers to accelerate health transformation.

In Round 1, CMS partnered with 6 Model Test states to implement state-wide health transformation strategies and 19 Model Design states to develop and refine State Healthcare Innovation Plans to guide future implementation efforts.

Drawing on lessons from the funding opportunity released in Round 1, State Innovation Models: Funding for Model Design and Testing Assistance (CMS-1G1-12-001) (Round 1 FOA), Round 2 of SIM specifies additional parameters that CMS believes correlate with successful state-wide health transformation.

These parameters are described in this Funding Announcement in the form of requirements for Round 2 applications.

CMS will fund up to 12 Model Test states with approximately $20-100 million grants per state, with funding based in part on the size of the state population and the scope of the transformation proposal.

Additionally, CMS will provide up to $3 million per state for up to 15 Model Design cooperative agreements to design new State Health System Innovation Plans or enhance existing plans developed in Round 1.

All Round 1 Model Design states must apply for Round 2 of SIM.

The Round 1 FOA indicated that states receiving Round 1 Model Design awards must submit a Model Testing proposal for the Round 2 FOA.

CMS is amending that requirement to submit a testing proposal in Round 2, so that a Model Design state may either apply for a Model Test award or may apply for a second Model Design award in order to enhance their State Health System Innovation Plan for future testing.

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.




Selected Recipients for this Program


RecipientAmount Start DateEnd Date
Health & Mental Hygiene, Maryland Department Of $ 2,234,239   2013-04-012014-03-31
Health Care Authority $ 948,916   2013-04-012014-01-30
Policy And Management, Connecticut State Office Of $ 2,638,208   2013-04-012013-12-31
Department Of Health Utah $ 844,167   2013-04-012013-12-30
Health And Human Services, New Hampshire Dept Of $ 771,914   2013-04-012013-11-30
Human Services, Rhode Island Dept Of $ 1,604,186   2013-04-012013-11-30
Human Services, Iowa Department Of $ 1,338,051   2013-04-012013-11-30
Health And Human Services Commission, Texas $ 1,326,820   2013-04-012013-11-30
Executive Office Of The State Of Hawaii $ 937,120   2013-04-012013-11-30
Illinois Dept Of Healthcare & Family Services $ 1,856,899   2013-04-012013-11-30



Program Accomplishments

Not Applicable.

Uses and Use Restrictions

Illustrative List of Allowable Model Test Costs Allowable costs associated with state Model Test work could include: ? Technical resources necessary to implement new models ? Model performance data collection, analysis, reporting cost ? Data center costs, and system information processing associated with the Model Test ? Provider costs for data collection ? Coordination with Innovation Center rapid cycle evaluation, and costs for collecting and preparing data for Innovation Center evaluator and/or state evaluator ? Staff resources associated with model management and project management, including travel to SIM workshops and conferences ? Simulation and modeling cost ? Provider and beneficiary data management system cost ? Costs of certified EHR technology/applications to support the state?s health transformation plan for providers ineligible for the Medicare/Medicaid EHR Incentive Programs.

? Health information exchange costs associated with the model ? Infrastructure costs to build or expand telemedicine system ? Model beneficiary assignment or reconciliation cost ? Web and internet collaborative learning and communication cost ? Project management and reporting cost ? Business operation associated with the model ? Model contract management and administration ? Building a statewide all?payer database ? Impact model evaluation data collection, reporting, beneficiary and provider survey data, and other costs associated with final model evaluation ? Other activities necessary to implement the overall State Health System Innovation Plan that will further the testing of payment and service delivery models and improve outcomes for Medicare, Medicaid and CHIP beneficiaries.

Allowable costs associated with state Model Design work could include: ? State staff costs to engage in model design ? Staff participation and travel to relevant learning collaboratives and workshops and other relevant learning and diffusion opportunities ? Investments in State data collection and analysis capacity and cost and utilization pattern analysis ? Consumer and provider engagement and focus group costs ? Actuarial modeling ? Performance measure development and evidence-based improvement research ? Business process analysis and requirement system analysis ? Policy, legal, and regulatory research to address legislative and legal frameworks for models ? Planning and convening for creating a statewide all?payer data-base ? Planning work relating to public health programs including the state?s Healthy People 2020 plan, and meeting goals for the National Quality Strategy and/or National Prevention Strategy ? Model Design costs, including: ? Model scope development ? Theory of action development ? Target population research ? Setting performance targets ? Financial analysis and analysis of health care trend impacts ? Budget planning ? Travel to SIM workshop and conferences The following are areas that are out of scope and were not be considered under the state Innovation Models initiative: a.

Medicare eligibility changes; b.

Coverage or benefits reductions in Medicare or Medicaid or any changes that would have the effect of rationing care; c.

Increases in premiums or cost sharing; d.

Increases in net federal spending under the Medicare, Medicaid or CHIP programs; e.

Medicaid FMAP formula changes; f.

Changes to the EHR incentive program for eligible professionals and eligible hospitals; g.

Changes in State Financial Alignment Models; h.

Reductions in Medicare beneficiary choice of provider or health plan, or Medicaid choice of provider or health plan beyond those allowed today, or changes to maintenance of effort requirements; i.

Changes to CMS sanctions, penalties, or official denial of participation currently in effect.

CMS will not fund proposals that duplicate models for populations that are already being funded and tested as part of any other CMS and/or HHS initiatives.

For example, if the state receives a Strong Start for Mothers and Newborns cooperative agreement, SIM funding will only be used in a coordinated manner to complement and not to duplicate or supplant funding for Strong Start for Mothers and Newborns.

SIM funding may not supplant existing federal or state funding.

States may propose the use of SIM test funds to support additional costs associated with or created by testing a SIM model.

States may not use SIM funds as state match under the Medicaid or CHIP programs nor use funds to substitute for currently funded Medicaid or CHIP services or administrative activities. Indirect Costs If requesting indirect costs, an Indirect Cost Rate Agreement will be required.

For this Cooperative Agreement funding opportunity indirect costs are limited to 10%. The provisions of 2 CFR Part 225 (previously OMB Circular A-87) govern reimbursement of indirect costs under this solicitation.

A copy of these cost principles is available online at: http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&tpl=/ecfrbrowse/Title02/2cfr225_main_02.tpl. Direct Services Cooperative Agreement funds may not be used to provide individuals with services that are already funded through Medicare, Medicaid, and/or CHIP Reimbursement of Pre-Award Costs No cooperative agreement funds awarded under this solicitation may be used to reimburse pre-award costs. Prohibited Uses of Cooperative Agreement Funds ? To match any other Federal funds.

? To provide services, equipment, or support that are the legal responsibility of another party under Federal or state law (e.g., vocational rehabilitation, criminal justice, or foster care) or under any civil rights laws.

Such legal responsibilities include, but are not limited to, modifications of a workplace or other reasonable accommodations that are a specific obligation of the employer or other party.

? To supplant existing Federal state, local, or private funding of infrastructure or services.

? To be used by local entities to satisfy state matching requirements.

? To pay for the use of specific components, devices, equipment, or personnel that are not integrated into the entire service delivery and payment model proposal. ? To lobby or advocate for changes in Federal and/or state law.

CMS will not fund proposals that duplicate models for populations that are already being funded and tested as part of CMS or HHS initiatives.

For example, if the state receives a Strong Start for Mothers and Newborns cooperative agreement, SIM funding will only be used in a coordinated manner and not to supplant funding for Strong Start for Mothers and Newborns.

States may propose the use of SIM testing funds to support additional costs associated with or created by testing a SIM model.

Indirect Costs If requesting indirect costs, an Indirect Cost Rate Agreement will be required.

For this Cooperative Agreement funding opportunity indirect costs are limited to 10%.

The provisions of 2 CFR Part 225 (previously OMB Circular A-87) govern reimbursement of indirect costs under this solicitation.

A copy of these cost principles is available online at: http://www.whitehouse.gov/sites/default/files/omb/fedreg/2005/083105_a87.pdf Direct Services Cooperative Agreement funds may not be used to provide individuals with services that are already funded through Medicare, Medicaid, and/or CHIP Reimbursement of Pre-Award Costs No cooperative agreement funds awarded under this solicitation may be used to reimburse pre-award costs.

Prohibited Uses of Cooperative Agreement Funds ? To match any other Federal funds.

? To provide services, equipment, or support that are the legal responsibility of another party under Federal or state law (e.g., vocational rehabilitation, criminal justice, or foster care) or under any civil rights laws.

Such legal responsibilities include, but are not limited to, modifications of a workplace or other reasonable accommodations that are a specific obligation of the employer or other party.

? To supplant existing Federal, state, local, or private funding of infrastructure or services.

? To be used by local entities to satisfy state matching requirements.

? To pay for the use of specific components, devices, equipment, or personnel that are not integrated into the entire service delivery and payment model proposal. ? To lobby or advocate for changes in Federal and/or state law.

CMS will not fund proposals that duplicate models for populations that are already being funded and tested as part of CMS or HHS initiatives.

For example, if the state receives a Strong Start for Mothers and Newborns cooperative agreement, SIM funding will only be used in a coordinated manner and not to supplant funding for Strong Start for Mothers and Newborns.

States may propose the use of SIM testing funds to support additional costs associated with or created by testing a SIM model.

Indirect Costs If requesting indirect costs, an Indirect Cost Rate Agreement will be required.

For this Cooperative Agreement funding opportunity indirect costs are limited to 10%.

The provisions of 2 CFR Part 225 (previously OMB Circular A-87) govern reimbursement of indirect costs under this solicitation.

A copy of these cost principles is available online at: http://www.whitehouse.gov/sites/default/files/omb/fedreg/2005/083105_a87.pdf Direct Services Cooperative Agreement funds may not be used to provide individuals with services that are already funded through Medicare, Medicaid, and/or CHIP Reimbursement of Pre-Award Costs No cooperative agreement funds awarded under this solicitation may be used to reimburse pre-award costs.

Prohibited Uses of Cooperative Agreement Funds ? To match any other Federal funds.

? To provide services, equipment, or support that are the legal responsibility of another party under Federal or state law (e.g., vocational rehabilitation, criminal justice, or foster care) or under any civil rights laws.

Such legal responsibilities include, but are not limited to, modifications of a workplace or other reasonable accommodations that are a specific obligation of the employer or other party.

? To supplant existing Federal, state, local, or private funding of infrastructure or services.

? To be used by local entities to satisfy state matching requirements.

? To pay for the use of specific components, devices, equipment, or personnel that are not integrated into the entire service delivery and payment model proposal. ? To lobby or advocate for changes in Federal and/or state law.

Eligibility Requirements

Applicant Eligibility

CMS invites the 50 state Governor?s Offices, United States Territories Governors? Offices (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the Virgin islands), and the Mayor?s Office of the District of Columbia to apply.

? Only one application from a Governor per state is permitted for either a Model Design or a Model Test award (assuming the state applied and was not selected for funding under the first round of Model Test awards).

? A state cannot receive multiple Round 2 Model Design or Model Test awards.

? A state cannot receive both a Round 2 Model Design award and a Round 2 Model Test award.

? Each application must include a letter from the Governor (or the Mayor, if from the District of Columbia) officially endorsing the application for a Model Design award or for a Model Test award.

? States currently engaged in a Model Test award with CMS are NOT eligible to apply for funding under Round 2.

A state may propose that an outside organization focused on quality and state delivery system transformation, such as a non-profit affiliated with the State Department of Health or a public-private partnership supported by the Governor?s Office, receive and administer funds through a Model Design or Model Test award.

The Governor?s Office must submit such requests in writing to CMS with its Letter of Intent and include a justification for the request and an attestation that the state will actively participate in all activities described in its proposal.

Approval of such requests will be at the sole discretion of CMS.

Only one such request supported by the Governor will be allowed per state.

A state pursuing this approach will still be expected to address all of the required areas described in this FOA.

Eligibility Threshold Criteria: ? All applicants must have submitted a required letter of intent to the programmatic point of contact in Section VI.

Agency Contacts by June 6, 2014.

If a letter of intent has not been submitted by the required due date, any subsequent application submitted by the entity will be ineligible.

See Section IV.2.A, Letter of Intent to Apply, for more information. ? Application deadline: Applications not received by the application deadline (TBD) through www.grants.gov will not be reviewed. ? Application requirements: Applications will be considered for funding only if the application meets the requirements outlined in Section III, Eligibility Information and Section IV, Application and Submission Information.

? Page limits: Model Test applications shall not be more than 55 pages in length.

Model Design applications shall not be more than 27 pages in length.

Both types of applications must be limited to the page maximums, sequence of sections, and section content specified in Section IV.2 Content and Form of Application Submission, parts C & D. ? In addition, applications should include attestations of support from key stakeholders.

The letters of support will not be included in the page limits for applications.

The letters should attest to stakeholders? active engagement in the model and must contain specific information about how the stakeholders will contribute to the SIM process.

? The standard forms, project abstract, Governor?s endorsement, and curriculum vitae are also not included in these page limits.

States are strongly encouraged to review the criteria information provided in Section V of the FOA, Application Review Information, to help ensure that the proposal adequately addresses all the criteria that will be used in evaluating applications and determining appropriate funding levels for each award.

Beneficiary Eligibility (082): The emphasis is on targeting Medicare, Medicaid, and CHIP populations.

Proposals will describe the target populations, geographic areas, or communities that will be the focus of service delivery and payment model testing, the current quality and beneficiary experience outcomes including current health population status, and the specific improvement targets expected from the model.

Beneficiary Eligibility

The emphasis is on targeting Medicare, Medicaid, and CHIP populations. Proposals will describe the target populations, geographic areas, or communities that will be the focus of service delivery and payment model testing, the current quality and beneficiary experience outcomes including current health population status, and the specific improvement targets expected from the model.

Credentials/Documentation

Employer Identification Number: All applicants must have a valid Employer Identification Number (EIN) assigned by the Internal Revenue Service. Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS number): All applicants must have a Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number in order to apply. The DUNS number is a nine-digit identification number that uniquely identifies business entities. Obtaining a DUNS number is free. To obtain a DUNS number, access the following website: www.dunandbradstreet.com or call 1-866-705-5711. See Section IV, Application and Submission Information, for more information on obtaining a DUNS number. All applicants must register in the System for Award Management (SAM) database (formerly CCR) (https://www.sam.gov/portal/public/SAM) in order to be able to submit an application at http://www.grants.gov. The SAM process is a separate process from submitting an application. Applicants should begin the SAM registration process as soon as possible after the announcement is posted to ensure that it does not impair your ability to meet required submission deadlines. In order to register, applicants must provide their DUNS and EIN numbers. Additional information about SAM is available at https://www.sam.gov/portal/public/SAM/. Applicants must successfully register with SAM prior to submitting an application or registering in the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) as a prime awardee user. Organizations must report executive compensation as part of the registration profile at https://www.sam.gov/portal/public/SAM by the end of the month following the month in which this award is made, and annually thereafter (based on the reporting requirements of the Federal Funding Accountability and Transparency Act (FFATA) of 2006 (Pub. L. 109-282), as amended by Section 6202 of Public Law 110-252 and implemented by 2 CFR Part 170)). Primary awardees must maintain a current registration with the SAM database, and may make subawards only to entities that have DUNS numbers. See Section VI, Award Administration Information, for more information on FFATA. The Grants Management Specialist assigned to monitor the subaward and executive compensation reporting requirements is Iris Grady, who can be reached at divisionofgrantsmanagement@cms.hhs.gov. 2 CFR 200, Subpart E - Cost Principles applies to this program. 2 CFR 200, Subpart E - Cost Principles applies to this program.

Aplication and Award Process

Preapplication Coordination

Preapplication coordination is not applicable.

Environmental impact information is not required for this program.

This program is excluded from coverage under E.O.

12372.

Application Procedures

2 CFR 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards applies to this program. This Funding Announcement offers two separate funding opportunities: (1) Model Test awards and (2) Model Design awards. Model Test: Proposal Requirements The Innovation Center will award up to 12 Model Test awards to states through this Funding Announcement. Model Test awards will provide financial and technical support to implement fully developed proposals for successful state-wide transformation. Awards will range from $20-100 million per state totaling $700 million over a four-year period, based on the size of the state?s population and the scope of the proposal. If a Model Test applicant is not selected for a Model Test award, CMS may select the state/entity for a Model Design award if (1) after all possible states/entities which applied for Model Design awards are selected and funding is still available to issue additional Model Design awards (not to exceed overall maximum of 15 Model Design awards); and (2) CMS determines the state/entity is not ready for a Model Test award and would benefit from Model Design funding. States currently engaged in a Model Test award with CMS will not be eligible to apply for funding in Round 2. The selection criteria for the Round 2 Model Test application will be based on a state?s ability to successfully apply policy and regulatory levers over the award performance period to address three focus areas: (1) improving population health; (2) transforming health care delivery systems; and (3) decreasing per capita total health care spending. During the selection process, CMS will require additional discussions with applicants regarding their proposals. Selection for a Round 2 Model Test will not constitute nor guarantee approval of a request for a Medicaid State Plan Amendment (SPA) or a Medicaid 1115 Waiver. States seeking a Medicaid SPA or Medicaid 1115 waiver may do so under established processes. In addition to an expert panel review, selected applicants for Model Test cooperative agreements will be required to present their Round 2 proposals. Selected applicants will be invited and strongly encouraged to present their proposal in person, or conversely can present virtually to a panel comprised of external experts as well as HHS leadership. The state?s presentation must be led by a cabinet-level health official, such as the Secretary of Health, and include providers and commercial payers who have committed to actively participate in the model. In the case of public-private partnership entities applying for a state innovation model test, senior leaders from the private and public sector, including senior leaders of the applicant entity, shall be present. All travel expenses incurred by applicants will not be reimbursed by CMS nor can they be reimbursed by any funding awarded under this FOA. In addition, if a state does not participate in the required presentation, it will not be eligible for funding. Model Test applications must address the following required areas: A. Model Test Project Narrative. The state must produce a detailed and fully developed proposal capable of creating state-wide health transformation for the preponderance of care within the state. For each individual element and/or program in the test proposal, the state must highlight how the element or program will (1) improve population health; (2) transform the health care delivery system; and/or (3) decrease per capita health care spending, drawing on a supporting evidence base. B. While Round 2 provides states with significant flexibility to design contextually-specific plans for state-wide health transformation, each proposal must also include the following core elements: (1) Plan for improving Population Health. The state must develop a state-wide plan to improve population health during the project period. The state will be offered the opportunity to obtain technical support from the Centers for Disease Control in developing the plans. The plans should include integration of population health strategies with public health officials and health care delivery systems for all populations. At a minimum, plans should address the core measures identified in the population health metrics document, namely: tobacco use and the incidence of obesity, and diabetes. (See Appendix 1.) In addition, states should consider integrating state strategies to address child wellness and prevention priorities, as applicable, including such factors as reducing childhood obesity, preventing early childhood dental caries, and addressing maternal depression to foster healthy child development. (2) Health Care Delivery System Transformation Plan. CMS has identified the following characteristics to be closely associated with transformed health care delivery systems: a. Providers across the state and across the care continuum participate in integrated or virtually integrated delivery models; b. Over 80% of payments to providers from all payers are in fee-for-service alternatives that link payment to value; c. Every resident of the state has a primary care provider who is accountable both for the quality and for the total cost of their health care; d. Care is coordinated across all providers and settings; e. There is a high-level of patient engagement and quantifiable results on patient experience; f. Providers leverage the use of health information technology to improve quality; g. There is an adequate health care workforce to meet state residents? needs; h. Providers perform at the top of their license and board certification; i. Performance in quality and cost measures is consistently high; j. Population health measures are integrated into the delivery system; and k. Data is used to drive health system processes. The state must describe in detail how it will engage providers in health care delivery system transformation across the state, working towards the goals described above. CMS recognizes that individual state proposals will vary considerably. However, in reviewing the Health Care Delivery Transformation Plan, and the proposed cost and quality targets, CMS will consider state, regional, and national demographics, proposal parameters, alignment/overlap of existing CMS programs, and other factors that impact health. One or more specific payment and/or service delivery models that include, but are not limited to, the state?s Medicaid population, state employee population, and/or commercial payers? populations. The payment and/or service delivery models must identify the targeted populations, the number of beneficiaries served, the number of participating providers, and the services to be delivered. CMS encourages applicants to propose payment models that directly align with one or more existing Medicare programs, demonstrations, and/or models, such as accountable care organizations (ACOs), primary care medical homes, and bundled payment programs. Medicare?s participation is not guaranteed and will be assessed on a case-by-case basis after thorough review of the proposed model. As SIM aims to reach a preponderance of a state?s population and Medicaid can serve as an important lever for driving health care delivery system transformation, the state should describe any Medicaid expansion activities and the percentage of the state?s population that is covered by Medicaid. The state must commit to using multiple regulatory authorities to influence the structure and performance of the state?s health care system. Regulatory authorities whose uses are envisioned under SIM include, but are not limited to the following: a. Aligning certificate of need processes and criteria (if applicable) to reinforce accountable care and delivery system transformation or developing alternative approaches to certificate of need programs, such as community-based approaches that could include voluntary participation by all providers and payers; b. Developing regulatory approaches to improve the effectiveness, efficiency and appropriate mix of the health care work force, such as through professional licensure/accreditation of providers and/or expanding scope of practice statutes; c. Creating opportunities to align state regulations and requirements for health insurers with the broader goals of multi-payer delivery system and payment reform; d. Integrating value-based principles into health insurance exchange Qualified Health Plan (QHP) certification processes, state employee plans, or Medicaid managed care plans including through selective contracting with carriers to provide health care coverage plans that provide the most competitive combination of value, quality, and choice; and e. Requiring academic medical centers and professional schools to integrate transformation-based teachings into medical education programs. f. This list is not intended to be exhaustive. States may propose alternative regulatory authorities that support delivery system transformation to satisfy this requirement in consultation with CMS. CMS recognizes that health information technology and data analytics will be important to achieving optimal efficiency and improved outcomes in state-wide health care delivery. States may propose to use SIM funds for the implementation of specific technology, software, applications, or other analytical tools as part of state infrastructure development to support the Model Test as long as the state provides a clear strategy for how, if applicable, the technological approach will be financed in addition to SIM, how it will not supplant other funding sources, and how it will be sustained after the cooperative agreement period has ended. Proposals must document the current state of health information technology adoption and utilization in the state, including current EHR adoption levels, percentage of providers meeting Meaningful Use requirements in the EHR Incentive Programs, and use of technology to support HIE activities. The Model Test proposals must also provide detailed descriptions for health information technology plans in the following domains: a. Governance: Describe how state leadership will direct the planning and oversight of implementation; supply a comprehensive plan to implement infrastructure to support the Model Test that leverages existing assets and aligns with federally-funded programs and state enterprise IT systems; and explain how the governance structure will incorporate and expand existing public/private health information exchanges, including those operated by ACOs. b. Policy: Describe policy and regulatory levers that will be used to accelerate standards based health information technology adoption to improve care in the state Model Test; describe methods to improve transparency and encourage innovative uses of data; offer a plan for promotion of patient engagement and shared-decision making; and propose multi-payer strategies to enable and expand the use of health information technology. c. Infrastructure: Describe how the state will implement analytical tools and use data driven evidence based approach to coordinate and improve care across the state Model Test; offer plans to utilize telehealth and perform remote patient monitoring to increase access to care and the timeliness of care; articulate plans to use standards based health IT to enable electronic quality reporting; explain how public health IT systems (such as clinical registry systems) will be integrated; and describe how support of electronic data will drive quality improvement at the point of care. d. Technical Assistance: Define how the state will provide technical assistance to providers; identify targeted provider groups that will receive assistance and what services will be delivered; and identify how the state intends to extend resources to providers ineligible for Meaningful Use incentive payments, if applicable. This list is not intended to be exhaustive. States may propose alternative approaches to data analytics and health information technology that support delivery system transformation. States will be offered the opportunity to obtain technical support from the Office of the National Coordinator for Health IT in developing the plans. In addition to explaining the individual components of the test, the State must address its rationale for how the specified elements and/or programs, in combination, will achieve state-wide health transformation. States may elect to focus on select areas of the state and/or to sequence elements or programs in the test geographically or temporally. The state should identify the test?s geographic scope in this section and address any sequencing of individual elements and/or programs in its response to ?Section I.4.A.iv., Operational Plan,? below. The state must demonstrate how it will use its unique role as a stakeholder convener to accelerate state-wide health transformation. The state must (1) demonstrate that there are a significant number of key stakeholders representative of the entire state population engaged and actively committed to the implementation of the state?s Model Test proposal and (2) present a clear and pragmatic strategy for maintaining stakeholder commitment throughout implementation of the proposed test. Stakeholders must include health care providers/systems, commercial payers/purchasers, state hospital and medical associations, community-based and long term support providers, consumer advocacy organizations, and, as applicable, tribal communities. The state must submit attestations of support from each identified stakeholder as part of its application (template provided in Appendix 3). Notwithstanding the above, representatives from stakeholder organizations must be prepared to travel to CMS or participate in a virtual teleconference during the selection process to discuss their commitment to the state?s proposal. The state must provide plans to develop a state-wide plan to align quality measures across all payers in the state. If the state and key stakeholders have not yet reached consensus on such a plan at the time of submission, the proposal must describe in detail any progress to date on quality measure alignment, including the successes and challenges faced, and must articulate a path for developing a realizable plan by the conclusion of the up to 12 month pre-implementation period. The plan should also demonstrate the payers? commitment to reducing the administrative and/or non-clinical burden to providers in the state. The state must provide quantifiable measures for regularly monitoring the impact of its proposed model, including the effectiveness of the policy and regulatory levers applied under the Model Test, on the three key outcomes of (1) strengthening population health; (2) transforming the health care delivery system; and (3) decreasing per capita health care spending. Measures should be selected with a focus on the particularized state health demographics and health needs the Model Test proposal aims to address. All quality and cost measures must use the state?s entire population in the denominator. Examples of measure domains that may apply include: ? Population health: percentage of state residents using tobacco ? Health care delivery system transformation: percentage of state residents attributed to a primary care doctor ? Per capita cost spending: per capita Medicare inpatient costs Final measures will be refined in conjunction with CMS during the up to 12 month pre-implementation period. The state also will be responsible for monitoring and reporting to CMS on the progress and impact of its Model Test at regular intervals. In addition, CMS will conduct an independent evaluation of funded proposals in accordance with the requirements set forth in Section 1115A of the Social Security Act (added by Section 3021 of the Affordable Care Act). The state must identify all existing health care innovation initiatives occurring within the state, including CMS, HHS, federal, and external initiatives (e.g., the Robert Wood Johnson Foundation Aligning Forces for Quality program), and demonstrate how the proposal aligns with these health care innovation efforts. The state must describe how the proposal will (1) coordinate with and build upon existing initiatives and (2) ensure that federal funding will not be used for duplicative activities, or to supplant current federal or state funding. For example, if a state is participating in the State Financial Alignment Model, the state should describe how the State Financial Alignment Model complements the state?s proposed SIM model. As part of its application, the state must submit a SF-424A and a budget narrative. The budget narrative must be consistent with the SF-424A and Model Test requirements as well as limit overhead and administrative costs to no more than 10% of direct costs. States should indicate other resources that will aid in implementing the Model Test plan. See Section IV. 2. Content and Form of Application Submission for more information. As part of its application, the state must submit a Financial Analysis. The Financial Analysis must estimate the proposal?s return on investment for the Model, and specifically for Medicare, Medicaid, and/or CHIP populations, over the performance period of the award as well as on a projected annualized basis after the term of the award is finished. The state must explain how its interventions will reduce total cost of care for the beneficiaries its model serves. The Financial Analysis also must provide financial models explaining the logic driving their forecasted cost of care savings. The state must obtain and submit an external actuarial certification of their Financial Analysis with their application. A qualified actuary who is a member of the American Academy of Actuaries must complete the external certification. The CMS Office of the Actuary will assist in reviewing the reasonableness of the estimated cost to the government, and will review the potential for federal savings. The external actuarial certification, as well as the review of the CMS Actuary, will be considered in final selection of Model Test awards. The state must submit a detailed Operational Plan that describes the activities and budgets for each year of the model and provide a detailed timeline for implementation and major milestones for successfully executing the Plan. The Operational Plan must show how the applicant plans to scale implementation activities to ramp up to an operational start within twelve months of receiving funding. The applicant must also establish accountability targets for the project, including specific quarterly milestones and metrics associated with each investment or activity that would be financed in whole or in part by this award. Projected quarterly targets for the test period should indicate the number and/or proportion of health care providers, hospitals, and beneficiaries that will be engaged by each Model Test component. The Operational Plan must also address any assumptions made and risks to the operational timeline, probability and impact of identified risks actually occurring, and projected strategies for mitigating identified risks. In addition, the application should show that the applicant has the resources and track record needed to operate the model and report on the progress it is making during the operation. Applicants shall include a list of key personnel; and for each person on this list, applicants should describe their relevant background, their roles, and overall responsibility. Applicants should address the Governor?s existing and future involvement in the model?s design and implementation, and the state agencies and/or departments that will be actively involved in executing the model. Applicants may also propose an operational plan that implements their State Health System Innovation Plan through a public-private partnership. Under such an approach, the state must demonstrate active engagement and participation in the public-private partnership. Model Design: Proposal Requirements The Innovation Center will award up to 15 Model Design states through this Funding Announcement. Model Design awards will provide financial and technical support to design proposals for successful state-wide transformation. Awards will range from $1-3 million over a one-year project period. Eligible states include both those that did not participate in Round 1, as well as Round 1 Model Design states that met the terms and condition of the Round 1 project but require additional design work in order to implement the plan (i.e. increased stakeholder engagement, measurable public health value, cost and quality targets). Round 1 Model Design state proposals shall include the extent to which the state will develop a design that enhances the existing state plan for delivery transformation. To the extent feasible, Round 2 Model Design awardees will be required to implement and test the plans they develop. Model Design applications must address the following required areas: The state must demonstrate a clear process for designing or refining a plan with the engagement of multiple components of state government. The state should address the elements detailed in Section I.4.A.i, Model Test Project Narrative, and listed by name below, including specifically identifying the levers the state will aim to incorporate into a comprehensive state plan, such as the state?s Medicaid program, state employee health plans, and stated-owned academic medical centers. In their design plans, states must explain the unique features of their design efforts and their strategies for designing a plan that aligns with existing CMS efforts. Further, state plans must include multiple payers. This narrative must include a modified stakeholder engagement strategy, as outlined in Section I.4.B.i.6 below. o Plan for Improving Population Health o Health Care Delivery System Transformation Plan o Payment and/or Service Delivery Model o Leveraging Regulatory Authority o Health Information Technology o Stakeholder Engagement. The application must identify the proposed stakeholders that will actively participate in the Model Design process and present a clear and pragmatic strategy for engaging and maintaining their commitment to developing a State Health System Innovation Plan. States are expected to work with a broad group of stakeholders representative of the entire state population in their Model Design process, including, but not limited to, a significant number of health care providers/systems, long term service and supports providers, commercial payers, state hospital and medical associations, tribal communities and consumer advocacy organizations. The state must describe the strategy for designing a state health plan that includes multi-payer payment innovation and measure alignment. o Quality Measure Alignment o Monitoring and Evaluation Plan o Alignment with State and Federal Innovation As part of its application, the state must submit a SF-424A and a budget narrative. The budget narrative must be consistent with the SF-424A and Model Design requirements as well as limit overhead and administrative costs to no more than 10% of direct costs. States should indicate other resources that will aid in designing the State Health System Innovation Plan. See Section IV. 2. Content and Form of Application Submission for more information. As part of its application, the state must submit a Financial Analysis. The Financial Analysis must, at minimum, describe the populations being addressed and their respective total medical and other services costs as per member per month and population total. If known, the Financial Analysis should also describe (1) anticipated cost savings resulting from specified interventions, including the types of costs that will be affected by the model and the anticipated level of improvement by target population and (2) expected total cost savings and return on investment for the overall state model and basis for expected savings (previous studies, experience, etc.). The state must submit a detailed Operational Plan that describes the activities and budgets for the performance period of the award and a detailed timeline for the design process with major milestones. The plan should also include roles and responsibilities of key partners and payer participants (if applicable) and major milestones and dates for successfully executing the Operational Plan. Applicants also should include a list of key personnel; for each person on this list, applicants should describe their relevant background, their roles, and overall responsibility. Applicants should address the Governor?s existing and future involvement in the model?s design and implementation, and the state agencies and/or departments that will be actively involved in designing the model. Applicants may also propose an operational plan that seeks to design the State Health System Innovation Plan through a public-private partnership. Under such an approach, the state must demonstrate active engagement and participation in the public-private partnership. The operational plan must also address any assumptions made and risks to the operational timeline, and projected strategies for mitigating identified risks. The Funding Opportunity Announcement serves as the application package for this cooperative agreement and contains all the instructions to enable a potential applicant to apply. The application should be written primarily as a narrative with the standard forms required by the Federal government for all cooperative agreements. A separate and complete application must be submitted for each type of submission and for each round of submission. A non-binding letter of intent to apply must be submitted to the CMS programmatic contact listed in Section VI. Agency Contacts by June 6, 2014. Entities which do not submit a letter of intent by this deadline will be ineligible to apply. As explained in Section III. Eligibility Information, a Governor must submit an official request, along with its letter of intent, if it plans to propose that an outside organization focused on quality and state delivery transformation, such as a non-profit affiliated with the State Department of Health or a public-private partnership supported by the Governor?s Office, receives and administers funds through a Model Design or Model Test award. A justification must be included with the request as well as an attestation that the state will actively participate in all activities described in the proposal. Approval of such requests will be at the sole discretion of CMS. Only one application supported by the Governor will be allowed per state. Application materials will be available for download at http://www.grants.gov. Please note that HHS requires applications for all announcements to be submitted electronically through http://www.grants.gov. For assistance with Grants.gov, contact support@grants.gov or call 1-800-518-4726. The Funding Opportunity Announcement can also be viewed on the Innovation Center website at http://innovations.cms.gov. Specific instructions for applications submitted via http://www.grants.gov: ? You can access the electronic application for this project at http://www.grants.gov. You must search the downloadable application page by the CFDA number shown on the cover page of this announcement. ? At the http://www.grants.gov website, you will find information about submitting an application electronically through the site, including the hours of operation. HHS strongly recommends that you do not wait until the application due date to begin the application process through http://www.grants.gov, because of the time needed to complete the required registration steps. ? All applicants under this announcement must have an Employer Identification Number (EIN) to apply. Please note, the time needed to complete the EIN registration process can be substantial, and applicants should therefore begin the process of obtaining an EIN immediately upon posting of this FOA to ensure the EIN is received in advance of application deadlines. ? All applicants, as well as sub-recipients, must have a Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number at the time of application in order to be considered for a grant or cooperative agreement. A DUNS number is required for using the Government-wide electronic portal, www.grants.gov. The DUNS number is a nine-digit identification number that uniquely identifies business entities. To obtain a DUNS number, access the following website: www.dunandbradstreet.com or call 1-866-705-5711. This number should be entered in the block with the applicant's name and address on the cover page of the application (Item 8c on the Form SF 424, Application for Federal Assistance). The name and address in the application should be exactly as given for the DUNS number. Applicants should obtain this DUNS number as soon as possible after the announcement is posted to ensure all registration steps are completed in time. ? Authorized Organizational Representative: The Authorized Organizational Representative (AOR) who will officially submit an application on behalf of the organization must register with Grants.gov for a username and password. AORs must complete a profile with Grants.gov using their organization?s DUNS Number to obtain their username and password, at http://grants.gov/applicants/get_registered.jsp. AORs must wait one business day after registration in SAM before entering their profiles in Grants.gov. Applicants should complete this process as soon as possible after successful registration in SAM to ensure this step is completed in time to apply before application deadlines. ? When an AOR registers with Grants.gov to submit applications on behalf of an organization, that organization?s E-Biz point-of-contact will receive an e-mail notification. The e-mail address provided in the profile will be the e-mail used to send the notification from Grants.gov to the E-Biz POC with the AOR copied on the correspondence. ? The E-Biz POC must then login to Grants.gov (using the organization?s DUNS number for the username and the special password called ?M-PIN?) and approve the AOR, thereby providing permission to submit applications. ? Any files uploaded or attached to the Grants.Gov application must be PDF file format and must contain a valid file format extension in the filename. Even though Grants.gov allows applicants to attach any file format as part of their application, CMS restricts this practice and only accepts PDF file formats. Any file submitted as part of the Grants.gov application that is not in a PDF file format, or contains password protection, will not be accepted for processing and will be excluded from the application during the review process. In addition, the use of compressed file formats such as ZIP, RAR, or Adobe Portfolio will not be accepted. The application must be submitted in a file format that can easily be copied and read by reviewers. It is recommended that scanned copies not be submitted through Grants.gov unless the applicant confirms the clarity of the documents. Pages cannot be reduced in size, resulting in multiple pages on a single sheet, to avoid exceeding the page limitation. All documents that do not conform to the above constraints will be excluded from the application materials during the review process. ? After you electronically submit your application, you will receive an automatic email from http://www.grants.gov that contains a Grants.gov tracking number. Please be aware that this notice does not guarantee that the application will be accepted by Grants.gov. Rather, this email is only an acknowledgement of receipt of the application by Grants.gov. All applications must be validated by Grants.gov before they will be accepted. Please note, applicants may incur a time delay before they receive acknowledgement that the application has been validated and accepted by the Grants.gov system. In some cases, the validation process could take up to 48 hours. If for some reason the application is not accepted, then the applicant will receive a subsequent notice from Grants.gov indicating that the application submission has been rejected. Applicants should not wait until the application deadline to apply because notification by Grants.gov that the application is incomplete may not be received until close to or after the application deadline, eliminating the opportunity to correct errors and resubmit the application. Applications submitted after the deadline because the original submission failed validation and is therefore rejected by Grants.gov, as a result of errors on the part of the applicant, will not be accepted by CMS and/or granted a waiver. For this reason, CMS recommends that applicants apply in advance of the application due date and time. ? After HHS retrieves your application package from Grants.gov, a return receipt will be e-mailed to the applicant contact. This will be in addition to the validation number provided by http://www.grants.gov. ? Each year organizations and entities registered to apply for Federal grants and cooperative agreements through http://www.grants.gov will need to renew their registration with the System for Award Management (SAM). You can register with SAM online; registration will take about 30 minutes to complete (https://www.sam.gov/portal/public/SAM/). Failure to renew SAM registration prior to application submission will prevent an applicant from successfully applying via Grants.gov. Similarly, failure to maintain an active SAM registration during the application review process can prevent HHS from issuing your agency an award under this program. Applications cannot be accepted through any email address. Full applications can only be accepted through http://www.grants.gov. Full applications cannot be received via paper mail, courier, or delivery service. All applications for the awards must be submitted electronically and be received through http://www.grants.gov by the deadlines listed below. All applications will receive an automatic time stamp upon submission and state applicants will receive an e-mail reply acknowledging the application?s receipt. Please be aware of the following: 1) Search for the application package in Grants.gov by entering the CFDA number. This number is shown on the cover page of this announcement. 2) If you experience technical challenges while submitting your application electronically, please contact Grants.gov Support directly at: www.grants.gov/customersupport or (800) 518-4726. Customer Support is available to address questions 24 hours a day, 7 days a week (except on Federal holidays). 3) Upon contacting Grants.gov, obtain a tracking number as proof of contact. The tracking number is helpful if there are technical issues that cannot be resolved. To be considered timely, applications must be received by the published deadline date. However, a general extension of a published application deadline that affects all state applicants or only those in a defined geographical area may be authorized by circumstances that affect the public at large, such as natural disasters (e.g., floods or hurricanes) or disruptions of electronic (e.g., application receipt services) or other services, such as a prolonged blackout. Grants.gov complies with Section 508 of the Rehabilitation Act of 1973. If an individual uses assistive technology and is unable to access any material on the site, including forms contained with an application package, he or she can e-mail the Grants.gov contact center at support@grants.gov for help, or call 1-800-518-4726. Each application must include all contents described below, in the order indicated, and in conformance with the following specifications: ? Use 8.5? x 11? letter-size pages with 1? margins (top, bottom, and sides). Other paper sizes will not be accepted. This is particularly important because it is often not possible to reproduce copies in a size other than 8.5? x 11?. ? All pages of the project narrative must be paginated in a single sequence. ? Font size must be 12-point with an average character density no greater than 14 characters per inch. ? The budget and project narrative portions of the application must be double-spaced. ? The project abstract is restricted to a one-page summary, which can be single-spaced. Applications and attached proposals must not be more than 55 pages in length for Model Test awards, and no more than 27 pages for Model Design awards. For Model Test applications this total includes the project narrative, budget narrative, financial analysis, and operational plan. For Model Design, this total includes the project narrative, budget narrative, financial analysis, and operational plan. The maximum page limit includes all supporting materials, including documentation related to financial projections, profiles of participating organizations, etc. In addition, states should submit letters of support from other payers and stakeholders. The standard forms, project abstract, Governor?s letter of endorsement, and attestations of support from other payers and stakeholders are NOT included in the page limits. The state must ensure that its submission meets the technical requirements outlined above. Failure to adhere to these technical requirements may exclude an application from consideration for a cooperative award. The following standard forms must be completed with an electronic signature and enclosed as part of the proposal. Failure to submit these forms will result in the application not being reviewed: a. SF 424: Official Application for Federal Assistance (see note below) b. SF 424A: Budget Information Non-Construction c. SF 424B: Assurances-Non-Construction Programs d. SF LLL: Disclosure of Lobbying Activities All applicants must submit this document. If your agency does not engage in lobbying, please insert ?Non-Applicable? on the document and include the required Authorized Organizational Representative (AOR) name, contact information, and signature e. Project Site Location Forms(s) f. Project Abstract Summary (see description below) Note: On SF 424 ?Application for Federal Assistance?: a. On Item 11 ?Descriptive Title of Applicant?s Project?, state the specific cooperative agreement opportunity for which you are applying: State Innovation Models. b. For Item 15 please provide a succinct descriptive title of the applicant?s project. Please do not add attachments in Item 15. c. Check ?No? to item 16b, as Review by State Executive Order 12372 does not apply to these cooperative agreements. A letter from the Governor (or Mayor, if from the District of Columbia) endorsing the project and identifying the title of the project, the principal contact person and the major partners, departments, and organizations collaborating on the project. The letter (addressed as below) must be uploaded in the application. The original signed letter must be sent to the following address: Gabriel Nah Grants Management Specialist Office of Acquisition and Grants Management Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services Mailstop # 7700 Bethesda 5600 Fishers Lane Rockville, MD 20857 The one-page abstract (single-spaced) must succinctly describe the proposal and should include the goals of the proposal; the total budget; the number of included beneficiaries, providers, and payer participants; the projected total cost of care savings; and a description of how the funds will be used. The abstract is often distributed to provide information to the public and Congress, so it must be written in a manner that it is clear, accurate, concise, and without reference to other parts of the application. Personal identifying information should be excluded from the abstract.

Award Procedures

Successful applicants will receive a Notice of Award (NoA) signed and dated by the CMS Grants Management Officer. The NoA is the document authorizing the cooperative agreement award and will be sent through electronic mail to the applicant organization as listed on the SF424. Any communication between CMS and applicants prior to issuance of the NoA is not an authorization to begin performance of a project. Unsuccessful applicants are notified within 30 days of the final funding decision for each cooperative agreement and will receive a disapproval letter via the U.S. Postal Service and/or electronic mail.

Deadlines

Oct 31, 2014 to Dec 31, 2018: Please see 'Other Deadline Information'. Oct 31, 2014 to Dec 31, 2018: Please see 'Other Deadline Information'. Anticipated Notice of Cooperative Agreement Announcement Dates: Round Two Model Design: October 31, 2014 Round Two Model Test: October 31, 2014 Anticipated Cooperative Agreement Period of Performance: Round Two Model Design: January 1, 2015 to December 31, 2015 Round Two Model Test: January 1, 2015 to December 31, 2018 (Inclusive of a pre-implementation period of up to 12 months).

Authorization

Section 1115A of the Social Security Act (Added by Section 3021 of the Affordable Care Act).

Range of Approval/Disapproval Time

Anticipated Notice of Cooperative Agreement Award Dates: Model Design Phase: Award Date: November 15, 2012 Round One Model Testing: Award Date: November 15, 2012.

Appeals

CMS reserves the right to approve or deny any or all proposals for funding. Note that section 1115A of the Social Security Act states that there is no administrative or judicial review of the selection of organizations, sites, or participants to test models.

Renewals

CMS reserves the right to approve or deny any or all proposals for funding. Note that section 1115A of the Social Security Act states that there is no administrative or judicial review of the selection of organizations, sites, or participants to test models.

Assistance Considerations

Formula and Matching Requirements

Statutory formulas are not applicable to this program. Matching requirements are not applicable to this program. MOE requirements are not applicable to this program.

Length and Time Phasing of Assistance

Initial funding of Model Test and Model Design awards is contingent upon the state?s acceptance of the award?s terms and conditions through the initial drawdown of funds and, in the case of Model Test awards, explicit CMS approval of an operational plan submitted by the state. States that received Model Design awards had twelve months from the award start date to complete their State Health System Innovation Plans and Model Designs. The project period and budget period for Model Design was one year, anticipated to be until December 31, 2015. See the following for information on how assistance is awarded/released: The 48-month project period for Round 2 Model Test is divided into four budget periods, with an initial budget period of twelve months for pre-implementation work followed by three budget periods of 12 months each. Following the initial twelve-month budget period, non-competing continuation awards have been/will be granted for each additional year of the cooperative agreement contingent upon availability of funding, state performance, and demonstrated progress towards the goals and objectives of this FOA. The anticipated test completion date for states receiving Model Test Round 2 awards is January 31, 2019. The specific period of performance for each state model will be included in the cooperative agreement and be executed upon the initial drawdown of funds by the recipient. See the following for information on how assistance is awarded/released: The 48-month project period for Model Test will be divided into four budget periods, with an initial budget period of twelve months for pre-implementation work followed by three budget periods of 12 months each. Following the initial twelve-month budget period, non-competing continuation awards will be granted for each additional year of the cooperative agreement contingent upon availability of funding, state performance, and demonstrated progress towards the goals and objectives of this FOA. The anticipated test completion date for states receiving Model Test awards is December 31, 2018. The specific period of performance for each state model will be included in the cooperative agreement and be executed upon the initial drawdown of funds by the recipient.

Post Assistance Requirements

Reports

The Innovation Center takes an active and substantial role in the evaluation and monitoring of the SIM Model Test awards.

The activities funded under the cooperative agreement and their resulting State responsibilities are part of performance tracking, measuring, and evaluation responsibilities of CMS and the Innovation Center.

For Model Test states CMMI will examine the extent to which states? plans are being implemented, whether health care spending in those states changed over time, and the impact on health care quality. Performance assessment, monitoring, and evaluation for Model Test awards focus on: ? impact on quality of care, patient experience, and health status ? Impact on health care costs ? Implementation and test performance, including: o Meeting proposed design and planning or implementation and test milestones. o Demonstrating readiness to carry out design and planning work or implementation activities required to test the proposed model. o Producing timely and accurate reports showing clear progress on design and planning activities or providing the required data, and/or reports on health care cost, quality, and population health performance, as delineated in the cooperative agreement.

o Community integration of health care Awardees must agree to cooperate with any federal evaluation of the model and performance results and provide required quarterly, semi-annual (every six months), annual and final (at the end of the cooperative agreement period) reports in a form prescribed by CMS.

Reports are submitted electronically and include information on how cooperative agreement funds were used, describe project or model progress, and describe any barriers, delays, and measurable outcomes.

CMS provides the format for project and model reporting and technical assistance necessary to complete required report forms.

States must also agree to respond to requests that are necessary for the evaluation of their Model Test efforts and provide data on key elements of model performance and on results from the cooperative agreement activities.

CMS will continue to make requests for data related to its evaluation beyond the end of the state?s performance period.

The period for which CMS may continue to make such requests is further clarified in the terms and conditions of award.

CMS has enlisted a third party entity to assist in evaluating the model implementation and testing performance results and outcomes.

All awardees are required to cooperate in providing the necessary data elements to CMS or CMS contractor.

The contractor assists CMS in developing cost, quality, beneficiary experience, and population health monitoring and review model performance to ensure model requirements are met; tracking performance across awardees and providing for monitoring and early detection of model performance issues; developing a system to collect, store, and analyze data to assess health care cost and utilization, quality performance, beneficiary experience, and population health improvements and assisting with state implementation, including coordination between states and CMS and its other contractors.

Data for monitoring includes process, safety, and performance measures including beneficiary experience.

It includes, but is not limited to, data on the background characteristics of the target population and target area, data characterizing the activities of the Model Test and a battery of follow-up data describing relevant characteristics of the target population or target area and metrics at selected intervals after commencement of the delivery system and/or payment model.

This will include detailed information on participant characteristics and outcomes reported in a standard format.

Data for monitoring is collected from awardees and/or CMS claims data, electronic health record, public health or other sources.

The model monitoring aspect of this initiative balances the examination of the extent to which awardees demonstrate fidelity to their proposed delivery system and payment models and the potential need to make mid-course corrections that improve or optimize performance of the delivery system or payment models based on feedback from the monitoring and rapid cycle evaluation findings.

The evaluation also assess whether there is evidence of harm or unintended consequences as a result of the models or testing methods.

The evaluation strategy for this initiative includes an overall design and data collection phase and an impact evaluation.

Broadly, CMS evaluates each state model and then compares all models to identify themes related to improved care and health outcomes and reduced costs.

CMS has ultimate responsibility for the evaluation process and reports.

An external evaluation contractor supports the Innovation Center during the Implementation and Test process.

This Innovation Center evaluator works with each state to develop standards for data collection and use and for data reporting, as well as requirements for those data elements that will be collected by the states and reported to CMS.

The Innovation Center evaluator also defines the measures to be used and evaluation methods to be employed.

Data collection is central to the success of the evaluation.

Adhering to the data collection requirements is a condition of participating in this initiative.

States are expected to cooperate in the evaluation process and provide the necessary data to evaluate state models.

This data is shared with the state evaluator team and with Innovation Center evaluation contractors.

The evaluation relies on multi-pronged data collection in order to understand the context of the model and to capture the nuances occurring at the model sites.

Data for the analyses is collected collaboratively between the Innovation Center evaluation contractor and the states themselves, and comes from sources including, but not limited to: provider surveys; Medicare administrative claims; state Medicaid and CHIP programs; beneficiary experience surveys; site visits with practices; and focus groups with beneficiaries and their families and caregivers, practice staff, direct support workers and others (e.g., payers).

Additional data requirements may include states providing Medicaid encounter data (baseline and during the model test period) if relevant to program evaluation.

The Innovation Center evaluation will assess the impact of the models on the quality of care, health outcomes, community health, and net saving in total costs.

Towards the end of the Model Test, the Innovation Center evaluation contractor will conduct impact evaluations of the effectiveness of each state model on key outcomes for target Medicare, Medicaid, and CHIP beneficiaries.

This Innovation Center?s impact evaluation should provide key messages about what types of state strategies are associated with success.

Ultimately, the evaluation results will identify and characterize the most effective models to inform future policy making around improving beneficiary care, improving beneficiary health, and reducing costs. The State self-evaluation contractor creates State-specific evaluations relevant to all populations and payers involved in their SIM initiative; data collection, storage, cleaning and creation of analytic datasets; continuous quality improvement and analysis of evaluation metrics on a quarterly basis; and working with the Innovation Center evaluator to supply necessary data.

The State self-evaluation contractor needs to be an independent entity.

The goal is for states to continue these evaluations once the SIM initiative is complete.

The State?s agreement with their evaluation contractor will be reviewed by CMS to ensure the evaluator?s capabilities. This State self- evaluation contractor will provide data to both CMS evaluators and the Innovation Center external evaluation contractor(s).

.

. The Federal Financial Report (FFR or Standard Form 425) has replaced the SF-269, SF-269A, SF-272, and SF-272A financial reporting forms.

All grantees must utilize the FFR to report cash transaction data, expenditures, and any program income generated. States must report on a quarterly basis cash transaction data via the Payment Management System (PMS) using the FFR in lieu of completing a SF-272/SF272A.

The FFR, containing cash transaction data, is due within 30 days after the end of each quarter.

The quarterly reporting due dates are as follows: 4/30, 7/30, 10/30, 1/30.

A Quick Reference Guide for completing the FFR in PMS is at: www.dpm.psc.gov/grant_recipient/guides_forms/ffr_quick_reference.aspx.

In addition to submitting the quarterly FFR to PMS, states must also provide, on an annual basis, a FFR to CMS which includes their expenditures and any program income generated in lieu of completing a Financial Status Report (FSR) (SF269/269A).

Expenditures and any program income generated should only be included on the annually submitted FFR, as well as the final FFR.

Annual FFRs must be submitted within 90 calendar days of the applicable year end date.

The final FFR must be submitted within 90 calendar days of the project period end date. More details are outlined in the Notice of Award.

Awards issued under this FOA are subject to the reporting requirements of the Federal Funding Accountability and Transparency Act of 2006 (Pub.

L.

109?282), as amended by section 6202 of Public Law 110?252 and implemented by 2 CFR Part 170.

Grant and cooperative agreement recipients must report information for each first-tier sub-award of $25,000 or more in Federal funds and executive total compensation for the recipient?s and sub-recipient?s five most highly compensated executives as outlined in Appendix A to 2 CFR Part 170 (available online at www.fsrs.gov).

Non-Competing Continuation awardees may be subject to this requirement and will be so notified in the Notice of Award.

States must submit a quarterly electronic SF-425 via the Payment Management System.

The report identifies cash expenditures against the authorized funds for the cooperative agreement.

Failure to submit the report may result in the inability to access funds..

The Federal Financial Report (FFR or Standard Form 425) has replaced the SF-269, SF-269A, SF-272, and SF-272A financial reporting forms.

All grantees must utilize the FFR to report cash transaction data, expenditures, and any program income generated.

States must report on a quarterly basis cash transaction data via the Payment Management System (PMS) using the FFR in lieu of completing a SF-272/SF272A.

The FFR, containing cash transaction data, is due within 30 days after the end of each quarter.

In addition to submitting the quarterly FFR to PMS, states must also provide, on an annual basis, a hard copy FFR to CMS which includes their expenditures and any program income generated in lieu of completing a Financial Status Report (FSR) (SF269/269A).

Expenditures and any program income generated should only be included on the annually submitted FFR, as well as the final FFR.

Annual hard-copy FFRs should be mailed and received within 30 calendar days of the applicable year end date.

The final FFR should be mailed and received within 90 calendar days of the project period end date.

More details are outlined in the Notice of Award.

States must submit a quarterly electronic SF-425 via the Payment Management System.

The report identifies cash expenditures against the authorized funds for the cooperative agreement.

Failure to submit the report may result in the inability to access funds.

Awardees must agree to cooperate with any federal evaluation of the model and performance results and provide required quarterly, semi-annual (every six months), annual and final (at the end of the cooperative agreement period) reports in a form prescribed by CMS.

Reports will be submitted electronically.

These reports will include how cooperative agreement funds were used, describe project or model progress, and describe any barriers, delays, and measurable outcomes.

CMS will provide the format for project and model reporting and technical assistance necessary to complete required report forms.

States must also agree to respond to requests that are necessary for the evaluation of the Model Design, pre-testing assistance, or Model Testing efforts and provide data on key elements of model performance and on results from the cooperative agreement activities.

The Federal Financial Report (FFR or Standard Form 425) has replaced the SF-269, SF-269A, SF-272, and SF-272A financial reporting forms.

All grantees must utilize the FFR to report cash transaction data, expenditures, and any program income generated.

States must report on a quarterly basis cash transaction data via the Payment Management System (PMS) using the FFR in lieu of completing a SF-272/SF272A.

The FFR, containing cash transaction data, is due within 30 days after the end of each quarter.

In addition to submitting the quarterly FFR to PMS, states must also provide, on an annual basis, a hard copy FFR to CMS which includes their expenditures and any program income generated in lieu of completing a Financial Status Report (FSR) (SF269/269A).

Expenditures and any program income generated should only be included on the annually submitted FFR, as well as the final FFR.

Annual hard-copy FFRs should be mailed and received within 30 calendar days of the applicable year end date.

The final FFR should be mailed and received within 90 calendar days of the project period end date.

More details will be outlined in the Notice of Award.

CMS will enlist a third party entity to assist us in monitoring the model implementation and testing performance results and outcomes.

CMS plans to collect data elements to be part of monitoring for all of the different state models, and these monitoring and surveillance elements will feed into the evaluation.

All awardees will be required to cooperate in providing the necessary data elements to CMS or a CMS contractor.

The contractor would assist CMS in developing a cost, quality, beneficiary experience, and population health monitoring and review model performance to ensure model design requirements are met; tracking performance across awardees and providing for rapid cycle evaluation and early detection of model performance issues; developing a system to collect, store, and analyze data to assess health care cost and utilization, quality performance, beneficiary experience, and population health improvements and assisting with state implementation, including coordination between states and CMS and its other contractors.

Data for monitoring will include process, safety, and performance measures including beneficiary experience.

It will include, but will not be limited to, data on the background characteristics of the target population and target area, data characterizing the activities of the model testing and a battery of follow-up data describing relevant characteristics of the target population or target area and metrics at selected intervals after commencement of the delivery system and/or payment model.

This will include detailed information on participant characteristics and outcomes reported in a standard format.

Data for monitoring will be collected from awardees and/or CMS claims data, electronic health record, public health or other sources.

The model monitoring aspect of this initiative will balance the examination of the extent to which awardees demonstrate fidelity to their proposed delivery system and payment models and the potential need to make mid-course corrections that improve or optimize performance of the delivery system or payment models based on feedback from the monitoring and rapid cycle evaluation findings.

The evaluation will also assess whether there is evidence of harm or unintended consequences as a result of the models or testing methods.

Audits

In accordance with the provisions of 2 CFR 200, Subpart F - Audit Requirements, non-Federal entities that expend financial assistance of $750,000 or more in Federal awards will have a single or a program-specific audit conducted for that year. Non-Federal entities that expend less than $750,000 a year in Federal awards are exempt from Federal audit requirements for that year, except as noted in 2 CFR 200.503. In accordance with the provisions of 2 CFR 200, Subpart F - Audit Requirements, non-Federal entities that expend financial assistance of $750,000 or more in Federal awards will have a single or a program-specific audit conducted for that year. Non-Federal entities that expend less than $750,000 a year in Federal awards are exempt from Federal audit requirements for that year, except as noted in 2 CFR 200.503. 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.

Records

States must comply with the audit requirements of Office of Management and Budget (OMB) Circular A-133. Information on the scope, frequency, and other aspects of the audits can be found on the Internet at www.whitehouse.gov/omb/circulars. States must submit a quarterly electronic SF-425 via the Payment Management System. The report identifies cash expenditures against the authorized funds for the cooperative agreement. Failure to submit the report may result in the inability to access funds. The SF-425 Certification page should be faxed to the PMS contact at the fax number listed on the SF-425, or it may be submitted to: Division of Payment Management HHS/ASAM/PSC/FMS/DPM PO Box 6021 Rockville, MD 20852 Telephone: (877) 614-553.

Financial Information

Account Identification

75-0522-0-1-551 - N/A.

Obigations

(Salaries) FY 16 $173,078,366; FY 17 est $157,368,867; and FY 18 Estimate Not Available

Range and Average of Financial Assistance

Model Test: 11 Model Test cooperative agreements were awarded under this State Innovation Models initiative. Awards for Model Test states range from $20-100 million per state, based on the size of the state population and the scope of the proposal. The amount awarded will include any state cost of testing the model and meeting state and federal evaluation requirements as specified in Section V.3 below. While the Innovation Center is responsible for the evaluation of each Model Test, states must also develop their own model evaluation process, under the guidance of the Innovation Center. The state evaluations should include an examination of the model?s impact on the entire state population. In general, CMS expects that Model Test awards will cover only costs that are not normally part of a state?s operational cost, data collection cost, or administrative cost.

Regulations, Guidelines, and Literature

Cooperative agreements issued under this FOA are subject to the Health and Human Services Grants Policy Statement (HHS GPS) at http://www.hhs.gov/asfr/ogapa/aboutog/hhsgps107.pdf. Standard terms and special terms of award will accompany the Notice of Award. Potential awardees should be aware that special requirements could apply to awards based on the particular circumstances of the effort to be supported and/or deficiencies identified in the application by the HHS review panel. The General Terms and Conditions that are outlined in Section II of the HHS GPS will apply as indicated unless there are statutory, regulatory, or award-specific requirements to the contrary (as specified in the Notice of Award). The following categories of special terms of award are in addition to, and not in lieu of, otherwise applicable OMB administrative guidelines, OMB cost principles at 2 CFR Part 225 (previously OMB Circular A-87), HHS grant administration regulations at 45 CFR Part 92 (Part 92 is applicable when state and local Governments are eligible to apply), and other HHS and PHS grant administration policies. CMS reserves the right to include any of the terms outlined below in the cooperative agreement with an appropriate level of specific details: ? Reporting (financial, quality, operational and accountability targets progress) ? Learning and Diffusion (training) ? Stakeholders (public notice, tribal consultation) ? Beneficiaries (access, enrollment, change in rights) ? Providers (approval of training) ? Payers (rate setting, marketing) ? Project Monitoring (contract review, audits) ? Data Collection (data integrity, use of data) ? Evaluation (rapid cycle and impact) ? Termination ? Funding ? Financial Arrangements ? Operations (information technology, claims, personal health information) ? Program Integrity The administrative and funding instrument used for this program will be a cooperative agreement, an assistance mechanism in which substantial CMS programmatic involvement with the State is anticipated during the performance of the activities. Under each cooperative agreement, CMS? purpose is to support and stimulate the state's activities by involvement in and otherwise working jointly with the award state in a partnership role. To facilitate appropriate involvement during the period of this cooperative agreement, CMS and the state will be in contact monthly and more frequently when appropriate. Cooperative Agreement Roles and Responsibilities are as follows: CMS will have substantial involvement in program awards, as outlined below: ? Technical Assistance: CMS will provide technical assistance throughout the period of the cooperative agreement. ? Collaboration: To facilitate compliance with the terms of the cooperative agreement and to more effectively support states, CMS will actively coordinate with certain critical stakeholders, such as: state-designated entities and other relevant federal agencies including but not limited to the Centers for Disease Control, the Administration for Community Living, the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration, the U.S. Office of Personnel Management, the Indian Health Service, the Internal Revenue Service, the Department of Homeland Security, the Administration for Children and Families, the Department of Veterans Affairs, and the Social Security Administration. ? Program Evaluation: CMS will work with states to implement lessons learned to enable other states to undertake health transformation plans. ? Progress against the Model Test and Model Design Work Plans: CMS will evaluate grant performance and progress against the state?s operational plan and will allow access to funding in alignment with state progress. ? Project Officers and Monitoring: CMS will assign specific Project Officers to each Cooperative Agreement award to support and monitor States throughout the period of performance. HHS Grants Management Officers and Project Officers will monitor, on a regular basis, progress of each State. This monitoring may be by phone, document review, on-site visit, other meeting and by other appropriate means, such as reviewing program progress reports and Federal Financial Reports (SF425). This monitoring will be to determine compliance with programmatic and financial requirements. ? Conference and Training Opportunities: CMS will host opportunities for training and/or networking, including conference calls and other vehicles.

Information Contacts

Regional or Local Office

None.

Headquarters Office

Karen Murphy 7205 Windsor Blvd., Baltimore, Maryland 21244 Email: Karen.murphy@cms.hhs.gov Phone: 410-786-9726

Criteria for Selecting Proposals

Model Test applications will be reviewed by an expert review panel and scored based on the quality of the proposals. The SIM Round 2 Model Test criteria for selection are as follows: ? Model Test Plan (50 points) a. Model Test applicant must demonstrate the ability to test innovative payment reforms that have the potential to accelerate transformation. The elements of the Model Test plans will be evaluated on the following criteria:  Well developed, detailed and clear annual cost and quality targets, which the state commits to review and report at least annually;  Use of policy and regulatory state levers to support successful health care transformation in the state;  Alignment with existing CMS programs and other state programs;  Number of residents directly affected by the Model Test;  Number of providers and payers participating in the Model Test  Likelihood of accelerating delivery system transformation;  Development and use of health IT infrastructure (See Appendix 2: Health Information Technology Plan). b. As this initiative is intended to reach a preponderance of a state?s population, a state?s decision to expand Medicaid will be an important factor in assessing the state?s readiness to implement a state-wide plan for improving population health. Additionally, because Medicaid can serve as an important lever for driving delivery transformation, states should describe Medicaid expansion activities and the percentage of a state?s population covered by Medicaid. c. The Model Test must offer and clearly demonstrate a pathway to a high potential for success in producing better health, better care and lower costs through improvement for Medicare, Medicaid/CHIP, and Medicare-Medicaid enrollee populations as well as other health care consumers within the state. d. The model must describe in detail the target populations, geographic areas, or communities that will be the focus of Model Testing, the current quality and beneficiary experience outcomes including current health population status, and the specific improvement targets expected from the Model. e. The state must identify specific implementable plans to collaborate with the CDC to develop a state-wide plan for improving population health. The plans will include developing collaborative approaches to improving population health that engage public health officials and provider organizations. (See Appendix 1: Plan for Improving Population Health). f. The state must demonstrate engagement in HHS initiatives to improve health and health care delivery. g. Integrated data is used not only to directly support the implementation of health care interventions but also to inform and improve the model throughout the period of the award. The state must include a clear feedback loop and strategies for continuous monitoring and improvement of the model through collection and analysis of data across payers and partners. h. The state must identify strategies they will employ to leverage State Marketplace Exchanges to further advance value-based payment methodologies. ? Provider Engagement Strategy (10 Points) The state must demonstrate a clear, sustained commitment to participation and implementation of the health transformation model of major stakeholders including but not limited to advocacy groups, local governments, social service providers, and providers of acute health care, behavioral/mental health care, long term care (including home and community services as well as long term care facility services) in the state, including but not limited to state-owned entities, providers of acute health care, behavioral/mental health care, long term care (including home and community services as well as long-term care facility services). ? Payer and Other Stakeholder Strategy (10 Points) The state must also demonstrate participation on the part of commercial payers with respect to both financial and quality measurement alignment. The state should identify a broad group of stakeholders involved in the execution of the Model Test, including but not limited to advocacy groups, local governments and social service providers. ? Operational Plan (20 points) States must demonstrate the organizational and operational capacity, organizational structure, leadership and expertise to successfully implement Model Test processes. The detailed project plan and timeline should be well described and clearly demonstrate how the state will successfully lead health transformation in the state with resources provided. The project leadership must clearly demonstrate the required knowledge, skills, abilities and experience to ensure efficient, smooth and effective implementation. States must also include a sustainability plan for the next 4 years beyond the period of the award that includes changes in personnel or administration as well as a clearly detailed plan for continued financing to support sustained health reform/transformation after CMMI award funding is exhausted. ? Model Test Budget Narrative and Financial Analysis (10 points) The proposed budget is carefully developed, is consistent with the Model Test requirements, and is clearly linked to support of a successful implementation plan. Overhead and administrative costs are limited to 10% of direct costs with funding focused on direct support of the Model Test. States must indicate other specific resources that will aid in implementing the Model Test plan, including descriptions of how these resources directly support health transformation in the state. The proposal must document how the overall Financial Analysis, including population and intervention specific savings, will be developed, how return on investment will be calculated, and how the state will incorporate non-CMMI funding (particularly commitments from the multi-payer collaborators, including but not limited to other state and local government resources) into the overall health transformation plan. Based on scores from the Expert Panel Review, selected applicants will be invited to present in person (in the Baltimore/Washington Metropolitan area) to an HHS Leadership Panel (see Section I.4.A. Model Test: Proposal Requirements for more information). The HHS Leadership Panel members are individuals who possess knowledge or expertise in innovative health care payment and service delivery models. They will review the applications prior to the presentations, consult during the presentations, and subsequently provide advice to the approving official. The presentations will help to ensure that only those applications that offer the greatest potential for furthering program purposes are selected for funding. The presentations will include the information from the FOA but will also be expected to highlight the following: ? State and Stakeholder Commitment o States must demonstrate a commitment by a broad coalition of stakeholders, including state leadership, during the in-person presentation. The role and contribution of each stakeholder will be considered. ? Likelihood of Success o States must demonstrate that their specific approach, through the joint efforts of stakeholders, will be likely to result in achieve success by reducing costs, improving quality and promoting delivery system transformation. ? Novelty of Payment Model o State should demonstrate how their payment model presents a unique approach to delivery reform that would accelerate delivery transformation in a manner that has not been test on a state-wide scale. ? Ability to Align with Medicare Programs o States should articulate how their proposal would align with existing CMS programs. For example, a multi-payer ACO approach could complement and align with the Medicare Share Savings program. State could also demonstrate how this alignment will further delivery transformation and reduces costs and improve care for all-payers, including Medicare. Model Design applications will be reviewed and scored based on the quality of the proposals. In-person presentations are not required for the Model Design applicants. The criteria for Round 2 Model Design selection as follows: ? Model Design Strategy (30 points) States must demonstrate a clear process for designing a plan with the engagement of multiple components of state government and with key stakeholders. The design strategy should specifically identify the levers the state would seek to develop and incorporate into a comprehensive state plan, such as the state?s Medicaid program, state employee health plans, stated-owned academic medical centers, etc. States must explain the unique features of their design efforts and their strategy for designing a plan that aligns with existing CMS efforts and can be implemented on a multi-payer basis. States should demonstrate efforts to improve access to care to vulnerable populations. States should also include strategies that leverage State Marketplace Exchanges in expanding value-based payment methodologies. As this initiative is intended to reach a preponderance of a state?s population, a state?s decision to expand Medicaid will be an important factor in assessing its potential impact. Continuing Round 1 Model Design states must demonstrate progress in developing their design plans and clearly articulate how proposed strategies will enhance their Round 1 efforts. ? Provider Engagement Strategy (15 Points) States must demonstrate the commitment of major providers of health care in the state, including behavioral/mental health care, long term care providers and state-owned entities, behavioral/mental health care, long-term care, and long-term services and supports, to participate in the design of the State Health System Innovation Plan. Continuing Round 1 Model Design states must demonstrate appreciable progress to date in engaging providers. ? Payer and other Stakeholder Engagement Strategy (15 points) The state must describe its strategy for designing a State Health System Innovation Plan that includes multi-payer payment innovation and measure alignment. The design of these aspects of the plan must include the participation of commercial payers and purchasers as well as various stakeholders, including state health associations and advocacy groups. States are expected to identify a broad group of stakeholders and create a mechanism for their effective participation in planning of the State Health System Innovation Plan and document the development of a multi-payer Model Design with stakeholder input. Round 1 Model Design states must demonstrate results in engaging payers and other stakeholders. ? Operational Plan (10 points) The state must demonstrate the organizational capacity, organizational structure, leadership, and expertise to successfully complete the Model Design process. The project plan and timeline should be detailed and well described. The staff or consultants proposed to lead the planning effort should have the skills and experience needed to ensure smooth and effective implementation. ? Model Design Budget Narrative and Financial Analysis (30 points) The proposed budget is carefully developed and consistent with the Model Design requirements. Overhead and administrative costs are reasonable (limited to 10% of direct costs) with funding focused on supporting the Model Design effort. States should indicate other resources that will aid in designing the State Health System Innovation Plan. The proposal should document how the overall Financial Analysis, including population and intervention specific savings, will be developed. Part of the review process will include an analysis of the readiness of the state to complete the design process within one year after approval of a cooperative agreement award.



Social Entrepreneurship
Spotlight



Top iTunesU Courses that Aim to Inspire Social Entrepreneurs


Top iTunesU Courses that Aim to Inspire Social Entrepreneurs

iTunes U has a variety of courses geared towards social entrepreneurship. With this app, it allows students to have customized learning experiences. Through learning that’s tailored to suit every student aspiring to be a social entrepreneur, SocialEarth.org checks off the top iTunes U courses and classes that are free to take. Some have videos, others have only audio. Take your pick:




Social Services Jobs

  Education Jobs
  Foundation Related Jobs
  Human Services Jobs
  Substance Abuse Jobs
  Program Director Jobs





More Federal Domestic Assistance Programs


Rural Development Cooperative Agreement Program | Energy Governance and Reform Programs | Enhanced Hunter Education and Safety  | Education Innovation and Research (formerly Investing in Innovation (i3) Fund) | Cluster Grants |  Site Style by YAML | Grants.gov | Grants | Grants News | Sitemap | Privacy Policy


Edited by: Michael Saunders

© 2004-2019 Copyright Michael Saunders