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The Flex 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.

What’s the difference between a hospital and a Critical Access Hospital?

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. CAHs are required to:

  • 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 that a State determines are necessary;
  • 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.

Who can participate in the Flex Grant Program?

Participating states (currently 45 of 50) are required to develop a rural health care plan that:

  • provides for the creation of one or more rural health networks;
  • promotes regionalization of rural health services in the state; and
  • improves the quality and accessibility of hospital and other health services for rural residents of the state.

Where can I learn more about the Flex Program and CAHs?

Check out the legislative authority for the program: Social Security Act, Title XVIII, Sections 1814 and 1820.
The Federal Office of Rural Health Policy maintains an informational website about their programs which support rural hospitals, including the Flex Program
The National Rural Health Resource Center provides technical assistance, information, tools, and resources for the improvement of rural health care. It serves as a national rural health knowledge center and strives to build state and local capacity. Programs include:

  • Technical Assistance and Services Center (TASC): provides information, tools and education to CAHs and state Flex Programs on quality, finance, operations, systems of care and population health
  • Small Rural Hospital Improvement Grant Program (SHIP): provides funding to approximately 1,600 participating hospitals via 46 SORHs to help small rural hospitals participate in value-based payment and care delivery models
  • Small Rural Hospitals Transition Project (SRHT): supports small rural hospitals nationally by providing on-site technical assistance to assist bridging the gaps between the current health care system and the newly emerging health care delivery and payment system
  • Delta Region Community Health Systems Development (DRCHSD) Program: works with rural Delta communities to address health care needs and strengthen the local health care system through comprehensive technical assistance.
  • Network Technical Assistance (TA): provides TA to over 60 networks in the Development and Allied Health rural health network grant programs to support successful program outcomes and network sustainability.

Centers for Medicare and Medicaid Services

RHIhub’s CAH Topic Guide, including a list of Frequently Asked Questions

Other rural resources include the RHIhub’s main site and the Rural Health Research Gateway, both of which are also funded by the Federal Office of Rural Health Policy.