Date: September 11, Administrators, Critical Access Dental Clinics, Other Interested Parties

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1 Date: September 11, 2017 To: From: Administrators, Critical Access Dental Clinics, Other Interested Parties Keisha Shaw, Grant Manager Primary Care and Financial Assistance Programs Office of Rural Health & Primary Care Phone: Subject: 2018 Request for Proposals Dental Safety Net Grant Program Application materials for the Dental Safety Net Grant Program will be posted on the Office of Rural Health & Primary Care (ORHPC) website September 11, Attached are the program s Grant Application and Guidelines. Applications for STEP 1 are due October 30, For applicants determined to be eligible, Project Descriptions and Budgets for STEP 2 are due November 17, The website address for application forms and instructions is: In 2014, the Legislature created a new grant program for dental clinics who serve uninsured populations. Eligible providers must meet all of the following criteria: Critical Access Dental provider; Nonprofit organization; Providers not affiliated with a hospital or medical group; Providers who offer free or reduced-cost oral health care to low-income patients under the age of 21 with family incomes below 275% of federal poverty guidelines who do not have insurance coverage for oral health care services; and Providers able to demonstrate that more than 80 percent of patient encounters in the last 12 months were with patients who were uninsured, or covered by Medical Assistance or MinnesotaCare. Grant funds will be allocated proportionally based on the number of individual uninsured patients under the age of 21 served by each eligible provider, compared with the number of uninsured patients under the age of 21 served by all eligible providers.

2 No single eligible provider will receive less than 2 percent or more than 30 percent of the total appropriation for this grant. Please feel free to call me with any questions about this grant program, or while you are working on your application. 1

3 2018 Dental Safety Net Grant Program Grant Application Guidelines Minnesota Department of Health (MDH) Office of Rural Health & Primary Care The purpose of this document is to help you prepare an application for grant funds to preserve access to dental services for uninsured and low-income patients through the Dental Safety Net Grant Program. This document has four sections: I. The first section explains the funding source and background for the program. II. The second section provides instructions on the preparation of STEP 1 of the application. III. The third section provides instructions for STEP 2 of the application IV. The final section is a checklist to be used while preparing the application. The required forms are at the end of the document. BACKGROUND Section I Dental Safety Net Grant Program Minnesota Laws 2014, Chapter 312, Article 23, Section 7 authorizes the Commissioner of Health to award grants to support eligible dental providers who serve the uninsured. Funds will be awarded each year proportionally among all eligible programs, based on the total number of uninsured patients under the age of 21 served. MDH ADMINISTRATIVE/TECHNICAL PROGRAM SUPPORT MDH will provide consultation and guidance in completing the application process. For assistance contact Keisha Shaw, Office of Rural Health and Primary Care, at , toll free from Greater Minnesota at or PROGRAM SUMMARY A. Eligible Applicants Eligible applicants are provider organizations who fulfill all of the following criteria: 1. The provider is a Critical Access Dental provider, as designated by the Minnesota Department of Human Services (DHS); 2. The provider is a nonprofit organization; 2

4 3. The provider is not affiliated with, owned by, or managed by a hospital or medical group; 4. The provider offers free or reduced-cost oral health care to low-income patients under the age of 21 with family incomes below 275 percent of federal poverty guidelines who do not have insurance coverage for oral health care services; and 5. The provider is able to demonstrate that more than 80 percent of patient encounters in the last 12 months were with patients who are uninsured, or covered by Medical Assistance or MinnesotaCare. B. Grant Program Requirements Grant contracts will be for one year. Grant funds may be used for operating costs to offset the cost of treating the uninsured, including: 1. Salaries 2. Fringe 3. Supplies 4. Travel 5. Equipment and Capital Improvements 6. Contracted Services 7. Other (Define) C. Total Available Funding The Minnesota Legislature has appropriated up to $112,500 in Fiscal Year D. Distribution of Funding Eligible dental organizations will receive a percentage of the available funding based on a simple ratio of the number of individual uninsured patients under the age of 21 served by each provider, as a portion of the total number of individual uninsured patients under the age of 21 patients served by all eligible providers. No single eligible provider will receive less than 2 percent or more than 30 percent of the total appropriation for this grant. Payments will be distributed semi-annually, upon receipt of an invoice and a data report, which will be used to track the number of uninsured patients served over the grant period. For eligible providers, the anticipated start date of the grant agreement is January 2, E. Timeline RFP published September 11, 2017 Grant Application for STEP 1 due to MDH: October 30, 2017 Grant distribution announcement: November 6, 2017 Grant Budget and Project Description for STEP 2 due to MDH: November 17,

5 Grant Agreements begin (estimated): January 2,

6 Section II - Preparing the Application: STEP 1 The following outline and instructions should be used to prepare STEP 1 of the grant application, and must be submitted in the prescribed order. Proposals must be typewritten, double-spaced, and all pages consecutively numbered. While additional documentation may be submitted, such material should be relevant to the specific scope of the grant. A. Grant Application Form (form, see enclosed). Applicants are required to complete and submit this form. Complete all items. One copy of the application must bear an original signature, title and date. B. Organization Description (5 pages maximum, plus relevant attachments). Write a summary of the organization, which includes the following: a) Description of the organization. Describe the history, geographic area, patients served, administrative structure and budget. 1) Include the organization s most recent audited financial statement or 990 form. b) Description of the organization s charity care policy. 1) Include original documentation showing that the clinic offers free or reduced-cost oral health care to low-income patients under the age of 21 with family incomes below 275 percent of the federal poverty guidelines who do not have insurance coverage for oral health care services. c) Documentation showing current Critical Access Dental provider status, as determined by the Minnesota Department of Human Services (DHS). C. Data to Determine Eligibility and Award Amount a) In order to determine eligibility, applicants must provide evidence that more than 80 percent of all dental encounters (i.e. visits) from October 1, 2016 to September 30, 2017 were with patients who were uninsured, or covered by Medical Assistance or MinnesotaCare. Data can be in the form of a spreadsheet or table, detailing the total payer mix of the clinic during the timeframe. Encounters must be defined the same for all patient visits. The CEO or CFO of the organization must sign the Application Form (see enclosed) to verify the accuracy of the data. b) In order to determine the award amount, applicants must include a spreadsheet or table which contains the total number of uninsured patients (i.e. 5

7 individuals) under the age of 21 served from October 1, 2016 to September 30, The spreadsheet or table must include the number of uninsured patients under the age of 21 served and the number of encounters per uninsured patient, and may also include HIPAA-compliant data on geography, demographics, gender and age. The CEO or CFO of the organization must sign the Application Form (see enclosed) to verify the accuracy of the data. c) MDH reserves the right to request audited financial statements and/or claims at any time to verify the accuracy of the data used to determine eligibility or the award amount. 6

8 Section III Preparing the Budget: STEP 2 The following outline and instructions should be used to prepare STEP 2 the grant application, and be submitted in the prescribed order. Proposals must be typewritten, double-spaced, and all pages consecutively numbered. While additional documentation may be submitted, such material should be relevant to the specific scope of the grant. A. Grant Distribution Announcement a) After receipt of STEP 1 applications and verification of eligibility, MDH will calculate the grant distribution. b) Using Question # 9 on the Application Form submitted in STEP 1, MDH will use a simple ratio of the number of uninsured patients under the age of 21 served by each eligible provider over the total number of uninsured patients under the age of 21 served by all eligible providers. c) On or before November 6, 2017, MDH will announce the results via to the primary contact listed on the Application Form. d) Grant awardees will have roughly two weeks to draft a detailed budget explaining how state grant funds will be spent during the grant period. The rest of this section will give details about the information required in the forms and documents listed above: B. Grant Project Narrative (5 pages maximum, double-spaced) Attach the document where required. The Grant Project Narrative must include: a) A description of the grant project. b) A problem statement describing what issues or concerns the project will address. c) A description of the group or population who will benefit from the project. d) A description of activities to be funded with grant dollars. C. Budget Eligible applicants who receive awards must submit a detailed budget of how grant funds will be spent. Grant funds may be used for operating costs to offset the cost of treating the uninsured, including: 1. Personnel 2. Salaries 3. Fringe 4. Supplies 5. Travel 6. Equipment and Capital Improvements 7. Contracted Services 8. Other 7

9 When drafting a detailed budget include: A. Budget Form (see enclosed) The standard MDH grant Budget Form provides the categories to be used for defining grant expenditures. B. Budget Justification Narrative For each of the cost items on the budget form for which grant funds are requested, you must provide a rationale and details regarding how the budgeted cost items were calculated. Label this concise narrative Budget Justification and follow the budget form in your narrative. 1. Personnel For this line, describe all grant funds used to pay for program (administrative) staff. Include all salary and fringe to be paid out of grant funds. 2. Salary and Fringe For these lines, describe all salaries and fringe to be paid to residents using grant funds. Include the number of residents to be paid using grant funds and the proportion of total salary and fringe to be paid out using grant funds. 3. Travel Include a detailed description of the proposed travel as it relates to the direct operation of the program. Provide the number of miles planned for program activities as well as the rate of reimbursement per mile to be paid from grant funds. 4. Supplies Include a description of any supplies necessary for the operation of the family medicine residency program. 5. Contracted Services Include any grant funding to be used for fees or costs associated with training sites on this line. 6. Equipment and Capital Improvements Include any grant funding to be used to purchase equipment, or to make capital improvements. 8

10 7. Other Expenses Whenever possible, include proposed expenditures in the categories listed above. If it is necessary to include expenditures in this general category, include a detailed description of the activities as it relates to the direct operation of the program. If possible, include a separate line-item budget and budget narrative. Submission: Proposals for STEP 1 must be received no later than 3:00 p.m., Monday October 30, Late proposals will not be considered. Budgets for STEP 2 must be received no later than 3:00 p.m., November 17, Submit the signed original and one copy of the proposal (Step 1) and budget (Step 2) to: Cindy LaMere Minnesota Department of Health Office of Rural Health & Primary Care P.O. Box St. Paul, Minnesota Courier Address: Golden Rule Building, Suite E. 7 th Place St. Paul, MN Questions regarding these grant application guidelines should be directed to Keisha Shaw at or or

11 Section IV - Application Checklist 2018 Dental Safety Net Grant Program Minnesota Department of Health Office of Rural Health and Primary Care STEP 1 Due by October 30, I. Required Forms: a) Grant Application Form b) Accounting System and Financial Capability Questionnaire II. Program Description (5 pages max, plus attachments) a) Description of the program, current budget of the program, including a financial statement. b) Documentation of current Critical Access Dental provider status. III. Data to Determine Eligibility and Award Amount a) Spreadsheet or table demonstrating that more than 80 percent of patient encounters from October 1, 2016 to September 30, 2017 were with patients who were uninsured or covered by Medical Assistance or MinnesotaCare. b) Spreadsheet or table listing the number of uninsured patients under the age of 21 served from October 1, 2016 to September 30, The Grant Distribution Announcement will be sent out on or before November 6, STEP 2 Due After the Grant Distribution Announcement, by November 17, I. Budget Form a. Signed and dated. II. Budget Justification Narrative a. Include a detailed description of how grant funds will be used for each line of the budget. 10

12 One organization may submit an application on behalf of multiple organizations. In this case, the primary applicant organization must complete the entire application. Sub-applicants must each complete the Grant Application Form to determine eligibility in STEP 1 and, if eligible, the Budget Form, with narrative in STEP 2. Each sub-applicant must submit supporting data and sign the two required forms to verify accuracy of the data. The primary applicant will be responsible for distributing funds to sub-grantees based on the allocation determined by MDH, and for collecting and submitting any invoices and required reports on behalf of all subapplicants. All submitted grant application materials become public information once contracts have been executed. Grant contracts will be prepared and available for signature in December 2017, with an estimated contract start date of January 2, Invoices should be submitted semi-annually, upon execution of the contract. A semi-annual report, including a brief data report, will be required with all invoices, in order to track the number of uninsured patients served through the grant period. MDH will supply grantees with a report template. 11

13 2018 Dental Safety Net Grant Program GRANT APPLICATION FORM 1. Applicant Organization (This information will be used in drafting the grant contract. Sub-applicants must complete this form as well.) Legal Name Address Phone Federal ID Number State Tax ID Number 2. Applicant Organization Manager 3. Fiscal Management Officer of Applicant Organization Name/Title Address Phone address: Name/Title Address Phone address: 5. Primary Contact for Project Administration Name/Title Address Phone address: 6. Contact Person for Further Information on the Application (if different from above) Name/Title Phone address: 7. Total number of patient encounters in the clinic from October 1, 2016 to September 30, 2017: 8. Number of patient encounters between October 1, 2016 and September 30, 2017 with patients who were uninsured or covered by Medical Assistance or MinnesotaCare: (The numbers in Question #7 and Question #8 will be used to determine eligibility for the grant program. The number from #8 must be at least 80 percent of the number from #7 in order to be eligible for the grant program. Separate documentation must be included with the application.) 9. Total number of uninsured patients under the age of 21 served by the applicant from October 1, 2015 to September 30, 2016: (The number from Question #9 will be used to calculate the grant award. Separate documentation must be included with the application.) I certify that the information contained herein is true and accurate to the best of my knowledge, that no changes were made in the organization s accounting and record-keeping practices or policies for providing free or reduced-cost care to uninsured patients for the purpose of creating eligibility or increasing the organization s allocation, and that I submit this application on behalf of the applicant organization. Signature of Authorized Official Print Name Title Date 12

14 ACCOUNTING SYSTEM AND FINANCIAL CAPABILITY QUESTIONNAIRE This is the standard form to be used in order to determine the financial capacity of grant applicants. The creation and implementation of this form is in response to the best practices stated in the Office of Legislative Auditor s report State Grants to Nonprofit Organizations, January This form should be used for applicant agencies that: are requesting, or will receive, more than $50,000; are new to state granting; are recently incorporated (five years or less); had previous unfavorable financial performance with federal and/or state funds; had significant audit findings; or for any applicant whose financial capacity is unknown or questionable. No applicants will be excluded from receiving funding based solely on the answers to these questions. SECTION A: APPLICANT INFORMATION 1. Organization Name and Address 2.Employer 3.Number of Employees Identification Number Full Time: Part Time: 4. When did the applicant receive its 501(c) 3 status? (MM/DD/YYYY)? 5. Is the applicant affiliated with or managed by any other organizations (Ex. regional or national offices)? YES NO If Yes, provide details: 5b. Does the applicant receive management or financial assistance from any other organizations? YES NO If Yes, provide details: 6a. Total revenue in most recent accounting period (12 months). 6b. How many different funding sources does the total revenue come from? 7. Does the applicant have written policies and procedures for the following business processes? a. Accounting Yes No Not Sure If yes please attach a copy of the table of contents b. Purchasing Yes No Not Sure If yes please attach a copy of the table of contents c. Payroll Yes No Not Sure If yes please attach a copy of the table of contents SECTION B: ACCOUNTING SYSTEM 1.Has a Federal or State Agency issued an official opinion regarding the adequacy of the applicants accounting system for the collection, identification and allocation of costs for grants Yes No Note: If a financial review occurred within the past three years, omit Questions 2 6 of this Section and 1-3 of Section C. a. If yes, provide the name and address of the reviewing agency: b. Attach a copy of the latest review and any subsequent documents. 2. Which of the following best describes the accounting system? Manual Automated Combination 3. Does the accounting system identify the deposits and expenditures of program funds for each and every grant separately? Yes No Not Sure 4. If the applicant has multiple programs within a grant, does the accounting system record Yes No Not Sure the expenditures for each and every program separately by budget line items? Not Applicable 5. Are time studies conducted for an employee(s) who receives funding from multiple Yes No Not Sure sources? No Multiple Sources 6. Does the accounting system have a way to identify over spending of grant funds? Yes No Not Sure SECTION C: FUND CONTROL 1. Is a separate bank account maintained for grant funds? Yes No Not Sure 2. If grant funds are mixed with other funds, can the grants expenses be easily identified? Yes No Not Sure 3. Are the officials of the organization bonded? Yes No Not Sure SECTION D: FINANCIAL STATEMENTS 1. Did an independent certified public accountant (CPA) ever examine the organization s financial statements? Yes No Not Sure SECTION E: CERTIFICATION I certify that the above information is complete and correct to the best of my knowledge. 1. Signature 2. Date / / 3. Title 13

15 Minnesota Department of Health (MDH) Dental Safety Net Grant Program Fiscal Year 2018 SUGGESTED BUDGET FORM Categories State Funding Requested Personnel Salaries Fringe Supplies Travel Equipment & Capital Improvements Contracted Services Other TOTAL I certify that the information contained herein is true and accurate to the best of my knowledge and that I submit this application on behalf of the applicant organization. Signature of Authorized Official Print Name Title Date Note: The budget must be accompanied by a budget justification narrative that explains each line item. Itemize and explain all funding requested using state grant dollars. Explain in detail any funding categorized as Other. 14

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