PURPOSE: This rule establishes guidelines for implementing the Graduate Medical Education Grant Program.

1. (1) The following definitions shall be used in the interpretation and enforcement of this rule:

   1. (A) “Academic year” is the time period between July 1 to June 30 of the following year;
   2. (B) “Agreement period” or “grant agreement period” is the thirty-seven (37) months, regardless of the length of residency, reflecting the three- (3-) consecutive-year period of performance, during which first-year residents funded by this program start their residency plus a one (1) month period before residents begin during which funding is received;
   3. (C) “Applicant” is an eligible entity applying for a Graduate Medical Education (GME) Program’s Notice of Grant Opportunity (NGO) that meets the specific eligibility requirements set forth in this rule;

   4. (D) “Commitment” or “commitment period” or “grant commitment period” is the duration during which the grantee is expected to fulfill the obligations and deliverables specified in the GME NGO and this rule correlating with the signed grant agreement. This includes the grant agreement period, plus the remaining years for the funded first-year residents to finish their residency, plus two (2) additional months to submit the final report.

      1. 1. For residencies of three (3) years duration, this period is

five (5) years and three (3) months.

1. 2. For residencies of four (4) years duration, this period is

six (6) years and three (3) months;

1. (E) “Department” is the Missouri Department of Health and Senior Services;
2. (F) “Designated institutional official” is the representative from the sponsoring institution who collaborates with their internal graduate medical education committee to ensure the sponsoring institution’s and its program’s substantial compliance with the applicable Accreditation Council for Graduate Medical Education (ACGME) institutional, common, and specialty-specific program requirements;
3. (G) “Eligible entity” is an entity that operates a physician medical residency program in Missouri and is accredited by the ACGME;
4. (H) “General primary care and psychiatry” includes family medicine, general internal medicine, general pediatrics, internal medicine-pediatrics, general obstetrics and gynecology (Ob/Gyn), and general psychiatry;
5. (I) “Graduate medical education” is the required training after graduating from medical school in order for a physician to be eligible for full licensure and board certification. This training includes medical residencies which can last three to four (3-4) years, depending on the specialty;
6. (J) “Graduate Medical Education Grant Program” or “Grant Program” or “GME Grant Program” is the program established within the department to administer the Medical Residency Grant Program Fund, established by section 191.592, RSMo, to support additional medical residency position in existing Missouri medical residency programs;
7. (K) “Grant agreement” is the written instrument that sets forth the terms and conditions of participation in the Graduate Medical Education Grant Program, including all written and executed amendments thereto, between the department and a grantee;
8. (L) “Grantee” is an applicant whose application to the Graduate Medical Education Program was selected for funding by the department according to the eligibility and selection criteria described in this rule and who has a grant agreement signed by both parties;
9. (M) “Health Professional Shortage Area” or “HPSA” is a geographic area, population group, or health care facility that has been designated by the Health Resources and Services Administration (HRSA) as having a shortage of healthcare professionals. There are three (3) categories of HPSAs: primary care, dental health, and mental health. Primary care and mental health are the only relevant HPSAs for the purposes of this rule. HPSA data is available at https://data.hrsa.gov/tools/ shortage-area/hpsa-find;
10. (N) “Match” is the National Resident Matching Program. This is the process by which residency programs rank their preferred candidates, residency applicants rank their preferred programs, and a one-to-one (1-to-1) match is generated;
11. (O) “Medical residency program” or “residency program” are those in the general primary care and psychiatry specialties for the purposes of this rule;

12. (P) “Residency positions” or “positions” or “residency slots” or “slots” refers to the number of residents in a specific medical residency program. This number requires approval from ACGME. These terms are often specified in reference to either the entire multiyear residency program or to a particular postgraduate year (PGY).

    1. 1. “Expanded slots” or “awarded slots” or “assigned slots”

refer to the additional slots added through the grant program as described in this rule;

1. (Q) “Resident” is a physician in an accredited graduate medical education program;
2. (R) “Rural” refers to those counties in Missouri that have less than one hundred fifty (150) people per square mile and do not contain any part of a central city in a Metropolitan Statistical Area; and
3. (S) “Sponsoring institution” is the organization that assumes the financial and academic responsibility for a residency program of GME. The sponsoring institution has the primary purpose of providing educational programs and/or health care services.

1. (2) The following acronyms shall be used in the interpretation and enforcement of this rule:

   1. (A) ACGME—Accreditation Council for Graduate Medical Education. This is the accreditation agency for all medical residencies in the United States;
   2. (B) AHEC—Area Health Education Center;
   3. (C) CMS—Centers for Medicare & Medicaid Services;
   4. (D) FQHC—Federally Qualified Health Centers;
   5. (E) GME—Graduate Medical Education;
   6. (F) HPSA—Health Professional Shortage Area;
   7. (G) NGO—Notice of Grant Opportunity;
   8. (H) NPI—National Provider Identification Number;
   9. (I) NRMP—National Resident Matching Program;
   10. (J) PGY—Post-Graduate Year. This refers to the annual level of training during a multi-year residency program. PGY-1 refers to the first-year class of residents, PGY-2 refers to the second-year class of residents, etc.; and
   11. (K) SOAP—Supplemental Offer and Acceptance Program. This is the process by which the residency applicants and residency programs without a match scramble to find mutually agreeable placements. This was once referred to as “The Scramble.”

2. (3) Communication.

   1. (A) All inquiries during the application process and after selections are made shall be directed to the primary point of contact as noted in the NGO and grant agreement.
   2. (B) Applicants are required to maintain and provide to the department, upon application, a current and valid email address for electronic communication with the department.

3. (4) Grant Award Parameters.

   1. (A) Available Funding and Grant Award Amounts.

      1. 1. The GME Grant Program is subject to appropriations to

the department to provide grant awards to support increased residency slots. The maximum number of residency-position awards is contingent upon the amount of the appropriation available.

1. 2. The grant cannot supplant existing funds for existing

residency positions. The grant funds are only for newly added accredited residency positions to support new residents through the completion of their multiyear residencies.

1. 3. The maximum grant award per resident per training year

shall be specified in the NGO and is subject to appropriations. The department may increase the award amount if funds are not completely allocated.

1. 4. Funding is awarded for the number of approved

residency slots for three (3) years of consecutive incoming firstyear residents to finish the entirety of their residency training.

1. 5. A sponsoring institution may request awards for

multiple qualified residency position in one (1) or more eligible specialties, but each residency program corresponding to each of those different specialties shall submit their own application.

1. 6. Eligible specialties will be specified in the NGO and

are subject to appropriation in that the department may not have appropriation authority in certain years to award grant funds for residency programs in all general primary care and psychiatry specialties.

1. (B) Timing of Grant Agreement Period, Grant Commitment Period, and Payment.

   1. 1. The Grant Agreement Period is three (3) years and one (1)

month for all grantees, regardless of the length of the residency training. Three (3) consecutive years of incoming first-year resident would be funded in an amount corresponding to the entire duration of their multiyear training, subject to appropriations.

1. 2. The duration of the Grant Commitment Period includes

the sum of—

1. A. The Grant Agreement Period (three (3) years and one

1. (1) month); and

   1. B. The remaining years needed for the residents who

matriculated under this funding to finish their residency; and

1. C. An additional two (2) months at the end for final

reporting.

1. 3. The department shall provide funding to grantees

annually in June, prior to the start of the incoming first-year class, in an amount corresponding to the entire duration of the multiyear training for the expanded slots filled by those firstyear residents.

1. A. This payment will occur for three (3) consecutive

years, to cover three (3) consecutive incoming classes of first year residents into the approved number of expanded residency slots. The award amount will be disbursed up front, upon selection of the awardees and execution of the contracts, for the total amount for all three (3) or four (4) years, up to the maximum allowable amount per resident for all three (3) or four (4) years. Payment is subject to—

1. (I) Appropriations; and
2. (II) Grant agreement expectations and deliverables

met satisfactorily, at the sole judgment of the department.

1. (C) Allowable / Unallowable Costs.

   1. 1. Allowable costs, in order of priority, include—

      1. A. Direct graduate medical education costs, including—

         1. (I) Resident salary;
         2. (II) Resident fringe benefits;
         3. (III) Resident malpractice insurance, licenses, and

other required fees; and

1. (IV) Salaries and benefits for faculty and program staff

directly attributable to resident education;

1. B. Indirect costs of graduate medical education

necessary to meet the standards of the ACGME.

1. 2. Unallowable costs include—

   1. A. Capital improvements;
   2. B. Consultant fees;
   3. C. Sub-contracts;
   4. D. Planning activities;
   5. E. Supplanting or replacing existing funds from other

sources, including local, state, or federal resources, for the same purpose; and

1. F. Alcohol.
2. 3. Costs not specifically mentioned in the original budget

submission shall be submitted to the department for prior approval before being expended.

1. (D) Sustainability of the Expanded Residency Slots.

   1. 1. Future sustainability of the expanded residency slots

is the responsibility of the medical residency program and/or sponsoring institution.

1. 2. Subject to appropriations and timely receipt of all grant

agreement deliverables, current grantees will be able to submit a new application any year to request additional residency slots beyond the initial number of expanded residency slots.

1. (E) Cost Sharing. Applicants must agree to provide additional funds or in-kind resources as needed beyond the annual GME Grant Program award to supplement the newly created residency positions according to the requirements of ACGME accreditation.

1. (5) Eligibility and Selection.

   1. (A) An eligible applicant is a Missouri ACGME-accredited—

      1. 1. GME program which intends to increase and fill ACGME-

approved medical residency positions during the grant commitment period; or

1. 2. Sponsoring institution (hospital, medical school,

or consortium) that sponsors and maintains primary organizational and financial responsibility for a Missouri GME program which intends to increase and fill ACGME-approved medical residency positions during the grant commitment period.

1. (B) Mandatory Award Selection Criteria.

   1. 1. Applicant shall be an established ACGME-accredited

residency program, located in the state of Missouri, requesting funding to increase the number of residents in their program.

1. 2. Only those residency program specialties appropriated

funding, as specified in the NGO, shall be considered.

1. 3. Number of residency slots.

   1. A. Residency programs need to demonstrate that they

are currently utilizing one hundred percent (100%) of their maximal allocated federal Medicare GME funding for current residency slots.

1. B. Residency programs need to demonstrate that they

have ACGME accreditation for the additional residency slots they are requesting or have a pending request before the ACGME for a complement increase. The department may specify time periods within the NGO for when such requests must have been submitted to the ACGME and when proof of approval of such requests must be submitted to the department to verify eligibility.

1. 4. Residency programs must demonstrate the ability to

cover the remaining required costs to fund additional residency slots required to supplement the grant award amount.

1. 5. Application for this grant opportunity includes the

satisfactory completion and submission of all requested components.

1. 6. One hundred percent (100%) of the registered slots for the

residency program were filled during the most recent match cycle through both the National Resident Match Program and any additional placement of residents via the Supplemental Offer and Acceptance Program.

1. 7. The residency program is required to have been in

existence for at least five (5) years.

1. (C) Award Selection Criteria – Prioritization. The following criteria for award selection will be applied only if there are applications for more slots than funding available.

   1. 1. Ranking of applicants. Selection priority will be given

according to a point-based scoring system, adding up to one hundred (100) maximum points, as detailed in Exhibit 1 below.

1. 2. Tiebreakers. If there are any scores tied for available

slots, priority will be given in this order:

1. A. If there are two (2) or more OB/Gyn programs tied,

priority will be given to the program(s) whose faculty also train family medicine residents in obstetrics;

1. B. If there are two (2) or more family medicine programs

tied, priority will be given to the program(s) with the highest number of vaginal birth deliveries per resident before graduation;

1. C. If any other programs are tied, priority will be given to

the program(s) whose location of the majority of their resident training during residency is rural;

1. D. If programs are still tied, then priority will be given to

the program(s) whose location of the majority of their resident training during the entire duration of residency has the highest HPSA score; and

1. E. After this algorithm, if there is still a tie between

programs, a lottery will be used to determine preference.

1. 3. Slot assignments.

   1. A. Each awarded slot provides grant funding to cover

the duration of the residency for one (1) resident, for three (3) consecutive years of incoming first-year residents, subject to annual appropriations and the program meeting grant requirements.

1. B. The process of assigning awarded slots is as follows:

   1. (I) Once the residency program applicants are ranked

by the selection criteria above, the expanded residency slots will be assigned in awards up to three (3) slots for each applicant, as funding allows;

1. (II) The highest ranked applicant is eligible for the first

three (3) slots;

1. (III) If the applicant requested only one (1) or two (2)

slots, then the applicant will be awarded the number of slots requested;

1. (IV) If the applicant requested four (4) or more slots,

then the applicant will be awarded only three (3) slots, unless there are remaining slots available after all eligible applicants have been reviewed;

1. (V) The process continues with the next applicant

with the next highest score, receiving the next three (3) slots, or fewer if the applicant requested fewer, until all slots are assigned; and

1. (VI) In the event that there are remaining slots to fund,

the applicants who requested more than three (3) slots will be considered for those remaining slots. The scores rendered from the processes described in paragraphs (5)(C)1. and (5)(C)2. above will be utilized to rank the remaining applicants, and each applicant will receive all of their remaining slots requested, in order of highest ranking score, until available funding is depleted. Exhibit 1 Ranking of applicants— SELECTION PRIORITY will be given according to a point-based score, adding up to 100 maximum points, as follows: Residency Program Attributes— (Note: These are used to rank program applicants; these are not prerequisites. If applicant does not meet the criteria for a category below it will result in zero points for that category.) 1 Average percentage of training time over the full course of residency that includes clinical work in rural counties— -At least 50% (for family medicine, internal medicine, pediatrics) or at least 30% (for OB/Gyn and psychiatry) -Between 25-49% (for family medicine, internal medicine, pediatrics) or between 15-29% (for OB/Gyn and psychiatry) 2 The HPSA score corresponding to the location where the majority of residency training takes place— -15 and above -Between 7-14 -Between 1 and 6 (For family medicine, internal medicine, pediatrics, and OB/Gyn – use primary care HPSA scores. For psychiatry residency applications – use the mental health HPSA scores.)

3 Includes outpatient clinic training in a rural health clinic, federally qualified health center, AHEC, or outpatient family practice clinic in a rural county— -For a weekly continuity clinic throughout the entire duration of residency training program -For a weekly continuity clinic for at least one year, or at least 12 weeks of full-time outpatient clinic in one of these settings

4 Current medical residents with ties to Missouri— -At least 50% graduated from high school in Missouri -At least 50% went to college or other graduate school in Missouri -At least 50% went to medical school in Missouri 5 Data from the previous 5 years of graduates of the residency program indicate that as of the current calendar year— -State: At least 75% practice medicine within the state of Missouri, or ○ At least 67% practice medicine within the state of Missouri ○ -Setting: At least 70% practice medicine in a rural setting ○ 50-74% practice medicine in a rural setting ○ 30-49% practice medicine in a rural setting ○

1. (D) Selection Process.

   1. 1. Application screening. The department will screen the

applications to determine if they were submitted before or by the deadline specified in the timeline and if they adhere to the other grant program mandatory requirements. If there are more applicants meeting these requirements than funding available, then the selection prioritization criteria detailed above will be utilized.

1. 2. Selection of applicants for awards.

   1. A. The department shall evaluate applications which

must demonstrate that the applicant will use grant funding to increase the number or accredited residency positions.

1. B. Priority will be applied to GME programs as described

above.

1. C. The department shall select applications to be funded

according to the criteria listed above.

1. D. Applicants must indicate how they intend to provide

matching funds or in-kind resources to supplement funding as needed to fully support the additional residency slots in line with ACGME accreditation standards. (6) Timeline. The department may set deadlines for application submission; verification of award components, including but not limited to ACGME accreditation; and agreement execution. These deadlines shall be noted in the NGO.

1. (7) Application.

   1. (A) Applicant. For the purposes of this regulation, the applicant refers to the eligible residency program or the institution sponsoring a specific residency program. If one (1) institution is applying for expanded slots in multiple residency programs, then that institution will need to submit a separate application for each residency program.

   2. (B) Submission Instructions. Applicants shall only submit their applications electronically via the online platform as provided and designated by the department.

      1. 1. The applicant is solely responsible for ensuring that

the applicant’s entire online application is completed by the deadline specified in the NGO. Applicant shall retain proof of timely submission.

1. 2. The applicant may contact the department to verify

receipt of their application. Confirmation of receiving the Points (max 100)

15, or

25, or 15, or

15, or

5, and 5, and

15, or

15, or 10, or application is not an indication of a complete application or eligibility.

1. (C) Application Format and Components. Every application shall include the following components and the applicant shall provide documentation providing evidence for the requested items as outlined below:

   1. 1. Certification of the application information.

      1. A. The application must be certified and submitted by an

individual who is legally authorized to submit the application on behalf of the applicant.

1. B. Each medical residency application requires its own

certification, even if a sponsoring organization has multiple medical residency programs applying for the grant;

1. 2. General applicant information—

   1. A. Name of sponsoring institution;
   2. B. Sponsoring institution contact information, including

the name, email, and phone number of the contact person responding to department correspondence;

1. C. Medical residency program for which funding is

being requested;

1. D. List additional medical residency programs by the

same sponsoring organization for which funding is separately being requested; and

1. E. Letter of approval from current Chief Executive Officer

or designated institutional official;

1. 3. Medical residency program information. The following

must be completed for each separate medical residency program for which funding is being requested and include all evidentiary documentation:

1. A. Medical residency general information—

   1. (I) Name of eligible residency program;
   2. (II) Program specialty and length;

   3. (III) Location—

      1. (a) Program main location address;
      2. (b) Program main mailing address; and
      3. (c) County: List the county of the main program

training location, and identify any additional teaching sites located in other counties for routine resident clinical training, if applicable. Identify the percentage of training time occurring at each site;

1. (IV) Current accreditation dates according to the

ACGME;

1. (V) Start date for first-year residents starting in the

next three (3) calendar years;

1. (VI) Medical residency program director contact infor-

mation;

1. (VII) Questions only for Ob/Gyn applicants—

   1. (a) Do your residency program faculty also take

time to train family medicine residents in OB?; and

1. (b) If yes, to what extent? Please describe the volume

of this training; and (VIII) Questions only for family medicine applicants—

1. (a) Does your program require and ensure forty (40)

vaginal deliveries for all residents to graduate?; and

1. (b) If no, or if you wish to comment further, please

provide data on your vaginal delivery rates for your residents prior to graduation;

1. B. Medical residency position data—

   1. (I) Number of new first-year positions requested via

this GME Grant Program; and

1. (II) Number of positions. Provide the following

information for each post-graduate year (PGY) of your program and any comments you wish to provide:

1. (a) Number of first-year residency slots posted in the

match for the past three (3) to four (4) years, pertaining to each of these current classes of residents;

1. (b) Number of current filled positions as of July 1 in

the previous academic year;

1. (c) Maximal number of positions currently eligible

for Medicare GME. Provide verification from Medicare/CMS;

1. (d) Number of positions currently funded by

Medicare GME. Provide verification from Medicare/CMS;

1. (e) Number of positions approved by the ACGME

prior to March of the application year. Provide verification from ACGME. If ACGME accreditation for number of slots is not disaggregated by PGY level, then provide the total number of approved positions for the entire program; and

1. (f) Number of positions currently approved by

the ACGME, if different than above. Provide verification from ACGME. If ACGME accreditation for number of slots is not disaggregated by PGY level, then provide the total number of approved positions for the entire program;

1. C. Residency Program Attributes—Clinical training.

   1. (I) Indicate the average percentage clinical training

time for the entire residency program in the following locations. Provide the name, location, timing, and nature of the training exposure at these sites. Distinguish what is a blockrotation and/or what serves as a continuity clinic that meets approximately weekly and for how many months or years in duration:

1. (a) Rural county;
2. (b) Rural Health Clinic;
3. (c) Federally Qualified Health Center (FQHC);
4. (d) Outpatient community-based clinic in a rural

setting;

1. (e) Area Health Education Center (AHEC); and
2. (f) Health Center Program Look-Alikes.
3. (II) Provide documentation of the highest HPSA score

associated with any of the routine training sites for your residency.

1. (a) For primary care residencies, use the primary

care HPSA score.

1. (b) For psychiatry residencies, use the mental health

HPSA score;

1. D. Current resident data. Provide each of the following

for current post-graduate years (PGY1, PGY2, PGY3, and PGY4 if applicable):

1. (I) Number and percentage of current residents who

graduated from high school in Missouri;

1. (II) Number and percentage of current residents who

went to college (or other non-medical school or graduate school) in Missouri; and

1. (III) Number and percentage of current residents who

attended medical school in Missouri;

1. E. Residency graduate outcomes. Provide each of the

following for residents who graduated during the current calendar year and the previous four (4) calendar years:

1. (I) Total number of residents who graduated;
2. (II) Number of graduates who currently practice in the

same field as their residency training;

1. (III) Number of graduates who currently practice in

Missouri;

1. (IV) Number of graduates who are currently practicing

in a rural setting; and

1. (V) Number of graduates who are currently practicing

in an underserved urban setting;

1. F. Budget.

   1. (I) Each applicant shall include a detailed budget and

budget narrative documenting utilization of grant funds for each year of the commitment period.

1. (a) The applicant shall develop a line-item budget

for allowable costs for each year of the commitment period. The budget must indicate how applicants intend to provide out-of-pocket funds or in-kind resources to supplement the funding as needed to support the added residency slots in a manner consistent with ACGME standards.

1. (II) The budget narrative shall include—

   1. (a) Justification and calculations for each line item

by year;

1. (b) Fringe benefits and malpractice insurance

calculated separately as a percentage of salary;

1. (c) Brief descriptions and justifications for training

expenses for faculty development;

1. (d) If providing stipends or honoraria for faculty,

explain individual activities covered;

1. (e) For faculty travel, include the purpose;
2. (f) Information about other funding sources

supporting the resident, including amounts per year and covered costs;

1. (g) Brief discussion about how the new residency

positions will be sustained after the grant ends; and

1. (h) Address potential strategies to engage local

and regional health systems, community-based organizations, employers, and other GME stakeholders in developing new physicians and approaches for encouraging new physicians to practice in underserved areas.

1. (III) The budget shall demonstrate how the funds will

be utilized, including amounts spent for each allowable grant fund expenditure over the grant commitment period.

1. (IV) Reports will be required each year detailing

expenditures for which grant funds were used. Refunds for unallowable or unspent funds will be required; and

1. G. Financial viability. Provide a financial statement

for the previous fiscal year for the existing medical residency program for which funding is being requested. Include a summary overview of amounts and sources of income and amounts and categories of expenses related to operation of the program; and

1. 4. Documentation of eligible residency programs. Appli-

cations must include the following documentation for each program, in order to verify eligibility and to indicate that the residency program is not using grant funding to supplant any existing funding:

1. A. ACGME—

   1. (I) ACGME program identification number;
   2. (II) ACGME sponsoring institution identification num-

ber;

1. (III) Documentation of current program’s ACGME

accreditation. Provide each program’s and institution’s most recent accreditation letter from the ACGME, listing current accreditation status, any citations or areas of concern, or quality improvement assignments or activities;

1. (IV) Provide evidence from ACGME of accreditation

for the exact number of allowed residency positions in the residency program; itemize this by post-graduate year or, if not available, then by the total program;

1. (V) If applicable, provide evidence of applicant’s

request to and approval from ACGME for an increase in the number of residency positions, also itemized by PGY or, if not available, by the total program. If the complement request has not yet been approved, provide evidence of the applicant’s submission for a complement on or prior to the deadline specified in the NGO. Complement increase approval letters must be submitted to the department by the date specified in the NGO for the program to be eligible for the GME grant program; and

1. (VI) If the request and approval are for a temporary

increase, provide a plan, including a timetable, for obtaining accreditor approval for a permanent increase in the number of program positions;

1. B. Match results from the past three (3) years. Provide

verification for each of the following for Match Day of the current calendar year and the two (2) previous calendar years:

1. (I) Number of PGY1 slots submitted for NRMP;
2. (II) Number of PGY1 slots matched via NRMP;
3. (III) Number of unmatched PGY1 slots filled via SOAP;
4. (IV) Number of PGY1 slots filled outside of NRMC/SOAP;

and

1. (V) Number of unfilled PGY1 slots after NRMP and

SOAP; and

1. C. Medicare GME funding. Provide documented

verification from Medicare/CMS of the maximal number of positions eligible for Medicare GME and the costs. Submit the most recent year of complete cost report data, including the following Medicare Cost Report Workbooks:

1. (I) Worksheet S-2—Part I: Hospital and Hospital Health

Care Complex Identification Data;

1. (II) Worksheet S-2—Part II: Hospital and Hospital

Health Care Complex Reimbursement Questionnaire;

1. (III) Worksheet A—Reclassification and Adjustment of

Trial Balance of Expenses;

1. (IV) Worksheet B—Part I: Cost Allocation—General

Service Costs;

1. (V) Worksheet E—Part A: Calculation of Reimburse-

ment Settlement—Inpatient PPS;

1. (VI) Worksheet E-4: Direct Graduate Medical Education

1. (GME) & ESRD Outpatient Direct Medical Education Costs; and

   1. (VII) Worksheet L: Calculation of Capital Payment.

2. (8) Distribution of Grant Funds.

   1. (A) Verification of Filled Positions.

      1. 1. To qualify for distribution of awarded funds, the grantee

must submit verification to the department annually that they have filled the new residency positions by the date(s) specified in the NGO.

1. 2. If a grantee fails to verify to the department that they

filled the awarded residency positions, then the grantee shall forfeit the award for any unverified positions.

1. 3. If a grantee verifies to the department that they filled

an awarded residency position, but the resident resigns, is terminated, or otherwise fails to remain qualified prior to completion of the program, the grantee will not forfeit that slot in subsequent years of the agreement period.

1. (B) Funds Distribution.

   1. 1. Payments. Grantees must follow any instructions

specified in the NGO for registering as a vendor with the State of Missouri prior to any payments becoming due.

1. 2. Retraction or reduction of payments. The department is

not bound by any award estimates in the NGO. After making a finding that a grantee has failed to perform or failed to conform to grant conditions, the department may retract the grant amount for the grantee. This retraction shall be prorated in relation to the earliest date for which there is evidence that the grantee failed to perform or conform to grant conditions as specified in the NGO. If that date is the start of the grant commitment period, then the entire grant award shall be retracted. If funds have been disbursed, the grantee shall issue reimbursement to the department.

1. 3. Grantees shall return any unexpended balance of the

award at the end of the grant commitment period to the department.

1. 4. Return of prorated funds.

   1. A. If the grantee is awarded funding for a residency

position, but fails to fill the residency position, the grantee is required to return the funds awarded for that slot for that academic year.

1. B. If the grantee is awarded funding for a residency

position and fills the residency position for any portion of the academic year, the grantee will not be required to return the funds awarded for that slot for the academic year or for the following academic year if the following academic year is the third year of a three- (3-) year residency program or the fourth year of a four- (4-) year residency program.

1. (9) Reporting Requirements.

   1. (A) Grantee shall submit reports to the department by the deadlines set and in the format specified in the NGO or as communicated to the grantee by the department.

   2. (B) Annual Program Report. Grantees shall submit an annual report to the department. The report will include but not be limited to—

      1. 1. Current residents—

         1. A. Number of total residents in the program, by post-

graduate year;

1. B. Number of resident slots funded by the GME Grant

Program, by post-graduate year;

1. C. Were there any residents in the class(es) funded by the

GME Grant Program who left the program as of the date of the report? If yes, enumerate and explain;

1. D. Registry of all current residents of all years in training,

organized by post-graduate year, including—

1. (I) Resident name;
2. (II) Post-graduate year;
3. (III) NPI;
4. (IV) Physician license number;
5. (V) Resident age;
6. (VI) Resident gender;
7. (VII) Resident race; (VIII) Resident trainee;
8. (IX) Attended high school in Missouri (yes/no);
9. (X) Attended college or any other non-medical school

graduate training in Missouri (yes/no);

1. (XI) Graduated from a Missouri medical school (yes/

no); and

1. (XII) Passed Step 3 exam (yes/no);
2. E. Curriculum/training over the entire course of residen-

cy, including—

1. (I) Training site name;
2. (II) Training site street address;
3. (III) Training site city;
4. (IV) Training site state;
5. (V) Training site zip code;
6. (VI) Training site percent training time;
7. (VII) Rural county (yes/no); (VIII) Training site type (FQHC, Health Center Program

Look-Alike, rural health center, AHEC, outpatient communitybased clinic in a rural setting, hospital); and

1. (IX) HPSA score (if psychiatry residency program,

use mental health HPSA score; other residency programs, use primary care HPSA score); and

1. F. Residency graduate outcomes during calendar year of

report and four (4) previous calendar years—

1. (I) Total number or residents who graduated;
2. (II) Number of graduates who currently practice in the

same field as their residency training;

1. (III) Number of graduates who currently practice in

Missouri;

1. (IV) Number of graduates who are currently practicing

in a rural setting; and

1. (V) Number of graduates who are currently practicing

in an underserved urban setting.

1. (C) Financial Deliverables.

   1. 1. Annual financial report. Grantees shall submit financial

reports to the department annually or when otherwise requested by the department. This report shall detail the—

1. A. Amount received from this funding opportunity;
2. B. Actual expenditures for the grant duration by purpose

and amount;

1. C. Remaining projected expenditures;
2. D. Unexpended balance of the GME Grant Program funds

as of the date specified by the department;

1. E. Amount owed back to the department, if applicable;
2. F. Total cost for the additionally funded residence

positions;

1. G. Grantee’s out-of-pocket expense; and
2. H. Total amount of funding from all sources.
3. 2. Each financial report shall include a statement

of certification by the program director or authorized representative of the sponsoring institution.

1. (D) Final Program Report. A final program report will be due by August 31 in the last year of the grant commitment period. This report will include similar content to the annual reports, but with outcome information limited to those residents funded by the GME Grant Program, including where the residents have or will be establishing practice, whether located in an underserved area, whether they remained in the prioritized specialty previously reported. This will also include a final financial report containing the same information as the annual financial report.
2. (E) Delinquent Reports. Medical residency programs with any required reports deemed to be delinquent may be ineligible for funding for the remainder of the grant agreement period or for participation in future funding cycles or expansion of this grant program.

1. (10) Additional Contractual Requirements. In order to receive funding under this grant program, grantees shall agree to abide by all contract terms and conditions as set forth in the grant agreement.

AUTHORITY: section 191.592, RSMo Supp. 2023.* Emergency rule filed Sept. 1, 2023, effective Sept. 18, 2023, expired March 15, 2024. Original rule filed Sept. 1, 2023, effective Feb. 29, 2024.

*Original authority: 191.592, RSMo 2023.