No single eligible provider will receive less than 2 percent or more than 30 percent of the available funding for this grant.

Date: September 11, 2015 To: From: Administrators, Critical Access Dental Clinics, Other Interested Parties Will Wilson, Supervisor Primary Care and Financial Assistance Programs Office of Rural Health & Primary Care Phone: 651-201-3842 Email: Subject: will.wilson@state.mn.us FY 2016 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 14, 2015. Attached are the program s Grant Application and Guidelines. Applications for STEP 1 are due October 30, 2015. Budgets for STEP 2 are due November 20, 2015. The website address for application information and instructions is: www.health.state.mn.us/divs/orhpc/funding/index.html In 2014, the Legislature created this grant program in order to provide support 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 at least 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 dental patients under the age of 21 served by each eligible provider, compared with the number of uninsured dental patients under the age of 21 served by all eligible providers. No single eligible provider will receive less than 2 percent or more than 30 percent of the available funding for this grant. For the first time, MDH will solicit, award, and administer this grant program using our online grant 1

management system, WebGrants @ MDH, available at http://www.grants.health.mn.gov. All applications must be submitted in WebGrants, which will involve completing forms online, attaching documents where requested, and submitting electronic signatures. There are instructions within WebGrants for each step of the application. Please feel free to call me with any questions about this grant program, or while you are working on your application. 2

2016 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. Applications must be submitted using the WebGrants@MDH electronic grant management system, found at http://www.grants.health.mn.gov. 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. BACKGROUND Section I Dental Safety Net Grant Program Minnesota Statute 145.929 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 applicants, based on the total number of uninsured dental patients under the age of 21 served. 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; 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 at least 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 3

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 (explain) C. Total Available Funding The amount available for grants in Fiscal Year 2016 is approximately $100,000. 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 dental patients under the age of 21 served by each provider, as a portion of the total number of individual uninsured dental 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 funding available 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 dental patients served over the grant period. For eligible providers, the anticipated date contracts will be executed is January 4, 2016. E. Timeline RFP published September 14, 2015 Grant Application for STEP 1 due to MDH: October 30, 2015 Grant distribution announcement: November 6, 2015 Grant Budget for STEP 2 due to MDH: November 20, 2015 Grant Agreements begin (estimated): January 4, 2016 4

Section II - Preparing the Application: STEP 1 2016 Dental Safety Net Grant Program Minnesota Department of Health Office of Rural Health and Primary Care The following outline and instructions should be used to prepare STEP 1 the grant application. Proposals must be submitted using the WebGrants@MDH electronic grant management system, found at http://www.grants.health.mn.gov. (In the WebGrants@MDH system, due to software requirements, this step of the application will be referred to as the Pre-Application. ) All forms for STEP 1 are electronic and must be completed online. Some documents, for example the Organization Description, must be created separately and attached where required. Step-by-step instructions are available in the WebGrants@MDH system. Applicants are required to complete and submit the following forms and documents in STEP 1: Application Form (electronic form) Organization Description (document to be attached) Evidence of current Critical Access Dental provider status (document to be attached) Date to Determine Eligibility and Grant Award (document or spreadsheet to be attached) Signature Page (electronic form) The rest of this section will give details about the information required in the forms and documents listed above: A. Application Form Complete the electronic application form in the WebGrants@MDH system. The form requires basic information about the applicant organization and contact information for key personnel associated with the grant. B. Organization Description (5 pages maximum, double-spaced). Write and attach in WebGrants 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. Include information from the organization s most recent audited financial statement or 990 form. b) Brief description of the intended purpose and use of grant funds. A detailed description of the use of grant funds will be required in STEP 2, along with a budget and budget narrative. For STEP 1, only a broad description of how the funds will be spent is required. C. Evidence of Critical Access Dental provider status Attach documentation from the Department of Human Services demonstrating current Critical Access Dental provider status. D. Data to Determine Eligibility and Award Amount (5 pages maximum, in a spreadsheet or table) Write and attach in WebGrants two data reports, one which will be used to determine eligibility, and one which will be used to determine the award amount. 5

1. In order to determine eligibility, applicants must provide evidence that at least 80 percent of all dental encounters (i.e. visits) from October 1, 2014 to September 30, 2015 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 Signature Page (see below) to verify the accuracy of the data. 2. In order to determine the award amount, applicants must include a spreadsheet or table which contains the total number of uninsured dental patients (i.e. individuals) under the age of 21 served from October 1, 2014 to September 30, 2015. The spreadsheet or table must include the number of uninsured dental patients under the age of 21 served and the number of encounters per uninsured dental patient, and may also include HIPAA-compliant data on geography, demographics, gender and age. The CEO or CFO of the organization must sign the Signature Page (see below) to verify the accuracy of the data. 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. E. Signature Page WebGrants@MDH accepts electronic signatures. This form must be signed online by the CEO or CFO of the applicant organization, to verify the accuracy of the information and data submitted. 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 the award amount for this grant. Submission for STEP 1: All forms and documents must be entered into the WebGrants@MDH system no later than 4:00 p.m., October 30, 2015. WebGrants@MDH will not allow any changes or submissions after the designated time plan accordingly! 6

Section III Preparing the Budget: STEP 2 2016 Dental Safety Net Grant Program Minnesota Department of Health Office of Rural Health and Primary Care The following outline and instructions should be used to prepare STEP 2 the grant application. Proposals must be submitted using the WebGrants@MDH electronic grant management system, found at http://www.grants.health.mn.gov. (In the WebGrants@MDH system, due to software requirements, this step of the application will be referred to as the Final Application. ) Grant Distribution Announcement a) After receipt of STEP 1 applications and verification of eligibility, MDH will calculate the grant distribution. b) On or before November 6, 2015, MDH will announce the results via email to the primary grant contact listed on the application form from STEP 1. c) Grant awardees will have roughly two weeks to finalize a detailed project narrative and budget explaining how state grant funds will be spent during the grant period. All forms for STEP 2 are electronic and must be completed online. Some documents, for example, the Grant Project Narrative, must be created separately and attached where required. Step-by-step instructions are available in the WebGrants@MDH system. Applicants are required to complete and submit the following forms and documents in STEP 2: Application Form (electronic form) Grant Project Narrative (document to be attached) Budget (electronic form) Budget Narrative (document to be attached) Signature Page (electronic form) The rest of this section will give details about the information required in the forms and documents listed above: A. Application Form Complete the electronic application form in the WebGrants@MDH system. The form requires basic information about the applicant organization and contact information for key personnel associated with the grant. 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. 7

B. Budget Complete the electronic form in WebGrants. Eligible applicants who receive awards must complete the Budget form detailing how grant funds will be spent, based on the Grant Project Description. The data entered into this form will become the basis for tracking grant payments please be as detailed and accurate as possible. Grant funds may be used for operating costs to defray underpayment for services provided to the uninsured, including: 1. Salaries and Fringe 2. Supplies 3. Travel 4. Equipment and Capital Improvements 5. Contracted Services 6. Other (explain in the Budget Narrative) C. Budget Narrative (3 pages Maximum) Attach the Budget Narrative document where required. For each of the cost items on the Budget form for which grant funds are requested, provide a rationale and details regarding how the cost items were calculated. 1. Salary and Fringe For these lines, describe all salaries and fringe to be paid to administrative and/or professional staff using grant funds. Include the number of staff to be paid using grant funds and the proportion of total salary and fringe to be paid out using grant funds. 2. Supplies Include a description of any supplies necessary for the grant project. 3. Travel Include a detailed description of the proposed travel as it relates to the grant project. 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. Equipment and Capital Improvements Include a description of any grant funding to be used to purchase equipment, or to make capital improvements. 5. Contracted Services Include any grant funding to be used for fees or costs associated with contracted services on this line. 6. 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 organization. If possible, include a separate line-item budget and budget narrative. Submission for STEP 2: All forms and documents must be entered into the WebGrants@MDH system no later than 4:00 p.m., November 20, 2015. WebGrants@MDH will not allow any changes or submissions after the designated time plan accordingly! 8

Section IV - Application Checklist 2016 Dental Safety Net Grant Program Minnesota Department of Health Office of Rural Health and Primary Care STEP 1 Due by October 30, 2015. I. Application Form (to be completed in WebGrants) II. III. IV. Program Description (5 pages max) Attach in WebGrants where required. This is a description of the applicant organization s history, clientele, budget, and geographic area. Also include a brief description of how grant funds will be spent. Documentation showing current Critical Access Dental provider status Attach documentation verifying eligibility. Data to Determine Eligibility and Award Amount (5 pages max) Attach spreadsheets or tables verifying that 80% of encounters in the last year were with public program recipients, and listing the number of uninsured dental patients under the age of 21 served from October 1, 2014 to September 30, 2015. V. Signature Page (to be completed in WebGrants) The Grant Distribution Announcement will be sent out on or before November 6, 2015. STEP 2 Due After the Grant Distribution Announcement, by November 20, 2015. I. Application Form (to be completed in WebGrants) II. III. IV. Grant Project Description (Maximum 5 pages) Attach in WebGrants where required. This is a detailed description of how grant funds will be spent Budget Form (to be completed in WebGrants) Budget Justification Narrative Attach in WebGrants where required. This is a detailed description of how grant funds will be used for each line of the budget. 9

One organization may submit an application on behalf of multiple eligible organizations. In this case, the primary applicant organization must complete the entire application. Sub-applicants must also complete the Data to Determine Eligibility and Award Amounts requirements in STEP 1, and, if eligible, the Project Narrative and Budget Narrative documents in STEP 2. 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 sub-applicants. All submitted grant application documents and data become public information once awards have been announced. Questions regarding these grant application guidelines, or the WebGrants@MDH system should be directed to Will Wilson at will.wilson@state.mn.us or 651-201-3842 or 800-366-5424. 10