Web Content Viewer

The Medicare Rural Hospital Flexibility Program (Flex)

Conceptual image of a stethoscope on a wooden background

Ohio’s Flex Program is administered through the Ohio Department of Health, State Office of Rural Health (SORH) and was established primarily to create and assist with the sustainability of Critical Access Hospitals (CAH).


The vision of the Ohio Flex Program is to support sustainability and development in quality improvement, financial and operational improvement, and health systems development and community engagement in all 33 Ohio CAHs.


The mission of the Flex Program is to help communities sustain the viability of small rural hospitals and health care services. 

Critical Access Hospitals

The Flex Program created the CAH Program to support small rural hospitals that were struggling to provide adequate care to their communities. Ohio’s Flex Program assists 33 CAHs that serve as rural health network hubs of improved access and health services.

CAHs are limited service hospitals (acute care with fewer than 25 acute and/or swing beds) designated to provide essential services. A CAH designation allows the hospital to be reimbursed on a “reasonable cost basis” for inpatient and outpatient services provided to Medicare patients. Our ultimate aim is to strengthen collaborative systems of care, and support CAHs to serve as the hub for improving access to quality health care services for Ohio’s rural residents.


The goals of the Flex Program include:

  • Aiding communities and hospitals as they work to improve access to needed health care services.
  • Supporting rural community hospitals that are converted to CAH status.

To achieve these goals, the Flex Program provides funding for the creation of rural health networks, promotes regionalization of rural health services and improves access to hospitals and other services for rural residents.


The Ohio Flex Program provides support for CAHs through the distribution of grant dollars and services. These hospitals received direct technical assistance on activities and programs related to the four Flex Program core areas:

  • Facilitate conversion of small rural hospitals to CAH status
    • Ohio began designating CAHs in 2001 and concluded designation in 2005 due to regulation changes.
  • Support for Quality Improvement
    • Access to benchmarking and assessment tools to provide infrastructure for improved data analysis and sharing of best practices.  
    • Technical assistance and workshops on data abstraction and reporting core measures provided specifically for CAHs.
    • Technical assistance related to reporting to Hospital Compare and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). 
  • Support for Financial and Operational Improvement
    • Benchmarking and assessment tools provided to encourage financial sustainability and evidence-based practices. 
    • Financial and operational assessments provided.
  • Support for Health System Development and Community Engagement
    • Funding opportunities for CAHs to conduct a health system and improvement project in collaboration with community providers.
    • Opportunities for CAHs to participate in regional community health needs assessments.
    • Collaborating and relationship-building with rural health stakeholders in order to leverage resources and support Ohio CAHs.

Creation of the Flex Program

The Federal Flex Program was established by the Balance Budget Act (BBA) of 1997. States with rural hospitals established their own Flex Programs by applying for federal funding through the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA).

Legislation surrounding the program has undergone many changes and updates such as the Balanced Budget Refinement Act (BBRA) in 1999; the Benefits Improvement Protection Act (BIPA) in 2000; and the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003.