Case Management Agency Transition Support Start Up Grant Application and Statement of Assurance Form

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The purpose of the start up grant payments being offered are to provide support to CMAs to implement CMRD, transition, change management, strategic and organizational planning, capacity and ensuring member access to a CMA, including developing an infrastructure for a learning collaborative so that CMAs have access to individual resources relevant to their change management needs.

Email *

General Application Questions

Please carefully review the instructions in the Request for Application (RFA) document found on the ARPA HCBS Grants, Incentives, Pilots, and Community Funding web page before completing this application. Also, please note that you will be asked to attach a budget worksheet (template in RFA document) and project workplan (instructions in RFA document).

Legal Business Name: *

Authorized Representatives Name and Title: *

FULL Business Address & Phone Number: *

Name the Counties Served? *

Please identify if your organization fits one or more of the following categories
*

Small business (500 or fewer employees)

Minority-owned business

Woman-owned business

Veteran-owned business

Business that employs people with disabilities (employs any Home and Community-Based Services Waiver member in Competitive Integrated Employment (CIE))

Other if other please describe in your work plan.

Required

How many members will your case management agency serve?
*

What is the total dollar amount of the funds requested?
*

What is your SAM number. If you have not yet completed this, please type “in process”
*

Please explain in detail how the grant funds requested are supplementing and not supplanting existing dollars.
*

CMA Start Up Costs ARPA 5.01 Questions:

CMA transition start up costs maximum are capped at $200,000 per CMA. Please note, agencies may request for up to $200,000 but award amounts will vary by individual CMA application review.
The following list of items are eligible for this portion of the application:

Operational transition costs to include set up and first month costs, not to include any ongoing service costs
Renting work space
Utilities
Phone Service
Internet and cable
Paper record transfer costs such as moving truck rental or other transportation support
Internet and cable
Paper record transfer costs such as moving truck rental or other transportation support
Marketing costs
Costs for advertising of positions
Website design
Digital advertising
Promotional supplies including mailers, brochures, and flyers
Postage
Booth rentals at conventions/fairs/festivals for community engagement etc.
Training facilitator/strategic planner fee
Technology fee
Venue fee
Office set up costs
Office phones, headsets, or cell phones
Desks/desk mats
Chairs/ chair mats
Shredders
Cubicles
Tables, refrigerator, microwave, coffee maker, plates, cups, cutlery, etc
Chairs or couches, end tables, brochure holders, TV etc. in reception areas and common areas so that the office is welcoming and comfortable
General Office Supplies/Operating Supplies
Copy Machines (Rental) set up or first month
Construction build outs of office space including signage

In addition to completing the "Start Up Costs" portion of the budget workbook, please answer the questions below. For each of the responses, please respond in no more than one paragraph. (4-6 sentences)

Has your organization applied for any other ARPA funding, if yes, what project (name/number) and for what type of expenditure?
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How will these funds provide continuity of care for members?
*

Has your organization been awarded Single Entry Point funding subject to subrecipient monitoring?
*

Do you currently have any unexpended or deferred revenue that is subject to subrecipient monitoring? If so please explain the amount, source and how this grant will not supplant the use of those funds.
*

Device ARPA 6.08 Questions:

Care and Case Management Compatible Devices maximum award: variable; refer to Exhibit B in the RFA document for per-Designated Service Area maximums. In addition to completing the "Devices" portion of the budget workbook, please answer the questions below. For each of the responses, please respond in no more than one paragraph (4-6 sentences).

1. Please refer to Exhibit B or C in the RFA. Describe how your agency will use the purchased devices (including peripherals) to support the person-centered roll out of the Care and Case Management System? What business needs will be met and who will use the devices?
*

2. Please refer to Exhibit B or C in the RFA. Should the devices your CMA qualifies for not be sufficient to meet your agency’s needs as described in Question 1, please identify the number of additional devices needed along with a justification for their purchase in the workbook. Go to the linked WORKBOOK under 'Devices Budget' tab to enter in those details.
*

I DO need additional devices and included the details in the workbook.

I DO NOT need additional devices.

Required

3. While the grant is designed to provide devices to case managers, the Department is also willing to consider reimbursement of up to $300.00 per device for the costs of peripherals and accessories to expand the ability of and help protect and maintain the device. This allotment of funds is displayed in Exhibit A Supplanting vs. Supplementing below. *

I DO need additional devices and included the details in the workbook.

I DO NOT need additional devices.

Required

4. If your agency is requesting funding for leased devices, please explain how you plan to sustain these costs following the use of the grant funds. *

EHR ARPA 6.06 Questions:

Upgrade or adopt a new Electronic Health Record (EHR) maximum award: $100,000 per CMA (up to $2,000,000 total for 20 redesigned CMAs). In addition to completing the "EHR" portion of the budget workbook, please answer the questions below. For each of the responses, please respond in no more than one paragraph (4-6 sentences):

1. Why is your CMA agency requesting funding for an Electronic Health Record (EHR) upgrade or new implementation?
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2. Approximately how long will this EHR project take? (Please note this information is also required in your project work plan).
*

3. Will the EHR be used for HCBS client data only or other lines of business at your agency?
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4. How will your agency balance an EHR upgrade at the same time as implementing the Care and Case Management tool?
*

5. Other supporting information for an EHR upgrade
*

ATTESTATION STATEMENT:

Please check/mark each statement of assurance below to be considered for ARPA grant funding.

The applicant organization listed above hereby accepts the conditions of the Case Management Retention grant program and agrees to the following assurances:

The startup grant funds requested in the application will be administered and distributed in accordance with all applicable statutes, regulations, program plans, and requirements delineated in this application.

The applicant meets all eligibility requirements of the grant as outlined in the Case Management Agencies Start Up Request for Applications (RFA).

Applicants must have this form approved by the Department to be eligible for reimbursement.

Applicant understands that the funds requested in this application are likely the maximum amount that can be paid, the Department will not have additional funds available for costs invoiced above the requested amount.

The applicant will cooperate with any examination of records with respect to such Colorado Department of Healthcare Policy and Financing (the Department), the Office of eHealth Innovation (OeHI), the State of Colorado, or any auditors on its behalf; or (ii) any other state agency, commission, or department in the lawful exercise of its jurisdiction and authority.

All information contained in this application is true and accurate.

The applicant attests that no funds will be used to supplant their organizations existing costs.

Required

End of application:

By adding your name on this Statement of Assurances document, the applicant attests that all information indicated in this document is accurate and true. The applicant agrees and acknowledges that by printing their name here it represents their signature in order for the application to be valid.

A copy of your responses will be emailed to the address you provided.

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