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Case Management Agency CCM Stabilization ARPA 5.01 Grant Application and Statement of Assurance Form
The purpose of this grant is to support CMAs through CMRD and the multiple phases of the new CCM. This funding will provide support to CMAs for unexpected costs outside of previous funding opportunities or existing reimbursement structure during transitions to implement CMRD, to support staff retention, assist with data clean-up in the CCM, digitization and/or storage of documents and unexpected demands related to the Public Health Emergency Unwind.

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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 
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Required
How many members will your case management agency serve? 
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What is the total dollar amount of the funds requested? 
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What is your SAM number. If you have not yet completed this, please type “in process” 
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 Please explain in detail how the grant funds requested are supplementing and not supplanting existing dollars, including other ARPA HCBS funds that you have been awarded or received.
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CMA CCM User Staff Retention: 

 In addition to completing the budget workbook and your one page work plan, please answer the questions below.    

  1. CCM User Staff Retention: Case Management Agencies can apply for funding to retain and support staff as they acclimate to the new Care and Case Management (CCM) system.

What is the number of staff you are requesting retention funds for? (you will still be required to fill out this section of your workbooks) *
What is the bonus amount you are asking per CCM user? You can ask for up to $2000.00 per CCM user and CCM support staff.  *
CMA CCM Records Digitization, Cleanup and Temporary or New Staff Questions: 

 In addition to completing the budget workbook and your one page work plan, please answer the questions below.   

  1. HCPF is issuing the Case Management Agencies Request for Applications (RFA) to solicit grant applications from eligible organizations, as defined below, to support selected Case Management Agencies in one or more of the following areas of focus:

    1. Records Digitization: Case Management Agencies can apply for funding to use for contracts with vendors specializing in digitization, transporting records, renting storage for paper files during the digitization process, destroying old old paper files, and purchasing software licenses to support the digitization process (e.g. Adobe). 

    2. Temporary or New Staffing: Case Management Agencies apply for funding to use for contracts with temporary staffing agencies or to hire temporary/term limited staff to:

      1.  Assist with data clean up in the new CCM system,

      2.  Assist with increased workload attributed to the Public Health Emergency Unwind, PAR backlog attributed to PHE unwind or CCM implementation, 

      3. Provide IT assistance to support the  CCM implementation and/or to support their efforts of digitizing paper files into the new Care and Case Management (CCM) system.

      4. Case Management Agencies can also apply for funding to support new positions within the agency associated with data clean up and digitization efforts.  If hiring permanent staff, the Case Management Agency should be able to report how the position will be sustained post grant funding.

How will these funds provide continuity of care for HCBS members?  
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Has your organization been awarded Single Entry Point funding subject to subrecipient monitoring? 
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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.
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Software Questions:  
 In addition to completing the budget workbook and your one page work plan, please answer the questions below. 
Software Requests: Software licenses, upgrades or enhancements needed as a result of CCM implementation that were unexpected. Retrospective payments prior to Grant Agreement execution date or duplication of other funding opportunities will NOT be approved.  Requests under this section will be reviewed based on CCM implementation 
   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 software upgrades or enhancements? 
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2.  Approximately how long will this project take? 
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3.  Will the software be used for HCBS client data only or other lines of business at your agency?  
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5.  Other supporting information for a software 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 CCM Stabilization Grant Program and agrees to the following assurances: 

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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. 

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