State health officials described on Oct. 24 a major federal grant opportunity that could provide transformative funding for rural health infrastructure, workforce development, and payment reform.

Tricia Tilley said the Centers for Medicare & Medicaid Services has invited states to apply for a rural health transformation cooperative agreement that, for New Hampshire, was framed as up to $1 billion over five years (presented as a $200 million-per-year budget in the application). The department plans to file the application on Nov. 3 and the federal deadline is Nov. 5. "We have had six weeks to work on a really comprehensive plan for up to $1,000,000,000 over five years," Tilley said.

The proposal has defined allowable uses and requires states to show sustainability beyond the grant. Officials said their planning drew on more than 700 engagements with stakeholders and about 200 completed survey responses, and that they are working closely with critical access hospitals, federally qualified health centers (FQHCs), community mental health centers and EMS providers. Priorities described include improving quality of care in rural facilities, strengthening financial stability and exploring payment-reform approaches that better support rural providers.

Tilley said New Hampshire is budgeting to the $200 million-per-year figure required in the application but does not expect to receive that full amount; she described a baseline expectation of roughly $100 million per year with additional pots for geographic (rurality) weighting and policy incentives. The application gives extra scoring credit for policy changes the state can commit to (for example, expanded pharmacist scope or licensure compacts), and officials said they are coordinating with legislative partners on policy work that would increase competitiveness.

Workforce supports are central to the proposal but officials said some common workforce tools are not allowable under the grant: federal guidance excludes traditional loan repayment programs and straight scholarships but allows other investments such as awards or tuition reductions tied to a five-year service commitment. The department plans to invest in university and community college partnerships and to prioritize projects that can be sustained if federal funds decline after the grant period.

Committee members asked about prioritization if the award is smaller than requested; Tilley said the state is building a tiered plan that could operate at a $100 million baseline and scale up policy and program elements if additional funding is awarded. Officials said they anticipate feedback from CMS and expect negotiations over final award size and conditions.