Medicare Rural Hospital Flexibility Program (FLEX)

The Medicare Rural Hospital Flexibility Program (FLEX) is a federal funding program designed to improve and sustain access to appropriate and quality health care services in rural areas. Established by the Balanced Budget Act (BBA) of 1997:

  • Supports the conversion and designation of small rural hospitals to Critical Access Hospital (CAH) status;
  • Assists in developing and maintaining quality health care network systems;
  • Strengthens and further integrates Emergency Medical Services (EMS) in rural areas; and
  • Facilitates the development of state specific model community-based collaborative systems in rural areas.


HRSA Federal Office of Rural Health Policy Introduction:

The Flex Program supports Critical Access Hospitals (CAHs) to promote quality and performance improvement including:

  • Stabilizing finances;
  • Integrating emergency medical services into health care systems;
  • Incorporating population health; and
  • Fostering innovative models of health care.

Under the Flex Program, the Medicare Beneficiary Quality Improvement Project seeks to improve the quality of care provided in CAHs by voluntarily reporting measures not required by CMS.  States coordinate technical assistance based on the needs of hospitals in their state.


The Virginia FLEX Program

The Virginia FLEX Program exists to assist Virginia Critical Access Hospitals (CAHs) in moving toward a value-based payment model that provides high quality and appropriate care to all. The goal of the Virginia Flex program is to partner with Critical Access Hospitals to improve the quality of care, financial and operational performance, and population health needs of their communities. 

The Virginia Department of Health has managed this program since 1999. Accomplishments have included: 

  • Continuously increasing rural health partners;
  • Leveraging program funding to cost-effectively extend various Flex program services to include 7 CAH facilities and 17 other small rural hospital facilities;
  • Acquiring of $1.1 million in additional federal funds to pilot a health information technology project at one of Virginia’s CAH facilities;
  • Expand the use of technology, EMS and collaboration to improve healthcare in rural areas;
  • Provided over $100,000 to CAH facilities for health information technology upgrades.

Recent FLEX-funded projects:

  • Congregational Health Assessments
  • Incentives small rural hospitals to participate in a statewide assessment of the ability of emergency departments to treat pediatric patients
  • Multi-state Performance Improvement Project
  • Tele-health educational programs
  • Annual Virginia Rural Health Conference
  • Virginia State Rural Health Plan 2020 Our rural communities across Virginia have always been important in building the economy and the character of the Commonwealth, whether it be through coal, tobacco, textile, furniture, and timber industries; arts and education; or unmatched outdoor sports like hunting and fishing.The health and well-being of rural Virginia is important for all of us. A new Rural Health Plan will give us the opportunity to celebrate rural successes and to show that health is more than what happens at the doctor’s office or in a hospital or clinic.  Your voice matters, and the new health plan will be stronger with your participation. The State Office of Rural Health partnered with the Virginia Rural Health Association to host a series of Community Conversations throughout Virginia giving us the opportunity to hear about what health means to you.


Virginia Critical Access Hospitals (CAHs):


Virginia Critical Access Hospital (CAH) Application Materials:


Virginia FLEX Program Partners:


Virginia FLEX Program Resources:

Quality Improvement Resources:

Finance/Operational Improvement Resources:


Learn More

Federal Office of Rural Health Policy

Rural Health Resource Center

Technical Assistance and Services Center (TASC)

Flex Monitoring Team

Rural Health Information Hub

National Rural Recruitment and Retention Network (3RNet)

Technical Assistance and Services Center for the FLEX Program


For more information about the FLEX program, contact Brandon Rivenbark at

For more information about Virginia’s State Office of Rural Health contact Heather Anderson, Division Director of Primary Care and Rural Health.