Iowa Medicare Rural Hospital Flexibility Program

“The Flex Program”refers to the Medicare Rural Hospital Flexibility Program, which was created by Congress in 1997. It allows small hospitals to be certified as Critical Access Hospitals (CAHs) and offers grants to States to help implement initiatives to strengthen the rural health care infrastructure. The grant program is administered by the Health Resources Service Administration’s Federal Office of Rural Health Policy. HRSA is a division of the U.S. Department of Health and Human Services.

The Flex grant is organized into five program areas with goals, objectives and related activities:

  • Quality Improvement
  • Financial and Operational Improvement
  • Population Health Management and EMS Integration
  • Designation of CAHs in the State
  • Integration of Innovative Health Care Models

Flex Funding

Flex funding encourages the development of cooperative systems of care in rural areas, joining together CAHs, EMS providers, clinics and health practitioners to increase efficiencies and quality of care. The Flex Program requires states to develop rural health plans, and funds their efforts to implement community-level outreach and technical assistance to advance the following goals:

  • Improve the financial and operational outcomes of CAHs
  • Improve quality of care provided by CAHs
  • Understand the community health and EMS needs of CAHs
  • Enhance the health of rural communities through community/population health improvement
  • Improve identification and management of time critical diagnoses and engage EMS capacity and performance in rural communities
  • Support the financial and operational transition to value based models of health care transformation models in the health care system

Critical Access Hospital Participation

CAH participation in the Flex program is highly encouraged and at no cost to the hospital. The Iowa Department of Public Health supports various programs that are announced annually. Each Iowa CAH is given the opportunity to participate in all of the Flex programs. This gives the CAHs access to expert consultants, trainings and educations, and technical assistance in the 5 core areas. For additional information on how to participate contact the Iowa Flex Coordinator.


Critical Access Hospital Eligibility

CAHs are reimbursed by Medicare for the reasonable costs of providing services. This reimbursement is designed to ensure that rural populations are able to access essential health care services. An Iowa hospitals must meet the following criteria to be designated as a CAH:

  • be located in a rural area (or an area treated as rural);
  • be more than 35 miles from another hospital (or 15 miles in areas with mountainous terrain or only secondary roads available) or be certified before January 1, 2006 by the State as being a necessary provider of health care services;
  • provide 24-hour emergency care services;
  • have a maximum of 25 acute care and swing beds; and
  • maintain an annual average length of stay of 96 hours or less for their acute care patients
  • A CAH must have reported data on at least one measure for at least one quarter within the reporting period listed below in at least two of the four MBQIP Core Quality Domains.
    • Patient Safety
      • IMM-2: 3Q16 – 2Q17
      • OP-27: Aggregate based on 4Q16 – 1Q17
    • Patient Engagement (HCAHPS): 3Q16 - 2Q17
    • Care Transitions (EDTC): 1Q17 – 4Q17

Additional activities within the Flex Program include facilitating the conversion of hospitals to CAH status; supporting network development; and, supporting for workforce issues.

Iowa has 82 designated Critical Access Hospitals supported by the Flex Program. Click here to view a Map of Iowa Critical Access Hospitals

Flex Resources

Critical Access Hospital Performance Improvement Kickoff Webinar

Flex HIT 2016-17 and The Small Rural Hospital Transition Toolkit

Critical Access Hospital Community Needs Assessment Report

Flex MBQIP Reporting 2017 Introduction Webinar


To learn more about the Iowa Rural Hospital Flexibility Program contact:

Amanda Ramirez | Flex Coordinator

Iowa Department of Public Health
321 E. 12th St., 4th fl. Lucas Bldg
Des Moines, IA 50319
Phone: (515) 314-6912 | Fax: ( 515) 242-6384
E-mail: Amanda.Ramirez@idph.iowa.gov