Introduction The Health Resources and Services Administration (HRSA), of the Department of Health and Human Services (HHS), is the federal agency charged with improving the nation's health safety net. HRSA provides access to health care services for those who are uninsured, isolated, or medically vulnerable, and educates health care providers on maternal and child health issues. HRSA's main role in maternal health is through its Maternal and Child Health Bureau (MCHB). The MCHB, in this context, encourages health promotion, promotes risk prevention, and disseminates information to health care professionals with the goal of reducing U.S. cases of severe maternal morbidity (SMM) and maternal mortality. According to the Centers for Disease Control and Prevention (CDC) of HHS S evere maternal morbidity refers to a medical condition such as eclampsia and health failure that adversely affects the maternal health outcome of labor and delivery, resulting in either short-term or long-term consequences for pregnant and postpartum women. U.S. maternal death refers to "the death of a woman while pregnant or within 42 days of termination of pregnancy, but excludes those from accidental or incidental causes." CDC estimates the U.S. rate of SMM by measuring U.S. cases of SMM per 10,000 delivery hospitalizations. According to the CDC, the overall U.S. SMM rate increased by 190.9% between 1993 and 2014, from 49.5 SMM to 144.0 SMM. The CDC estimates the prevalence of U.S. maternal deaths by calculating the U.S. maternal mortality ratio (MMR) , which is the number of U.S. maternal deaths per 100,000 live births. According to the CDC, the U.S. MMR increased by 32.8% from 13.1 maternal deaths per 100,000 live births in 2004 to 17.4 maternal deaths per 100,000 live births in 2018. To address U.S. cases of SMM and maternal mortality, the FY2019 appropriations report language for the Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019, and Continuing Appropriations Act, 2019 ( P.L. 115-245 ), among other things, reserved funds within the Special Projects of Regional and National Significance (SPRANS) for HRSA to administer maternal health programs. SPRANS is a competitive grant program for research and training programs and services related to maternal and child health and to children with special health care needs. The FY2019 appropriation provided $109.6 million to SPRANS, which explicitly included $26 million for HRSA to maintain and establish new maternal health programs. Using the SPRANS authority, HRSA allocated $3 million to the previously existing Alliance for Innovation on Maternal Health (AIM) program and for the establishment of the Alliance for Innovation on Maternal Health (AIM)âCommunity Care Initiative. Additionally, HRSA allocated $23 million to establish the State Maternal Health Innovation (MHI) program. In FY2019, HRSA also established the Rural Maternity and Obstetrics Management Strategies (RMOMS) program and the Supporting Maternal Health Innovation (MHI) program. The appropriations report language authorizes HRSA to use $1 million of the $23 million appropriated, for the purchase and implementation of telehealth and to support coordination of rural obstetric care. FY2020 Appropriations and FY2021 Budget Request The FY2020 appropriations report language explicitly provides $5 million to SPRANS for HRSA to carry out the activities through both of the AIM programs and $23 million for the State MHI program; the report language does not explicitly provide funding to the RMOMS program and Supporting MHI program. However, Congress appropriated $119.1 million to SPRANS for FY2020âincreasing the FY2019 appropriation level by $10.5 million. For FY2020, according to HRSA, the federal agency is providing $2 million to the RMOMS program, $5 million to carry out the activities through both of the AIM programs, and $23 million to the State MHI program. For FY2021, according to HRSA, the agency is requesting from Congress $12 million for the RMOMS program, $15 million to carry out the activities through both of the AIM programs, and $53 million for the State MHI program. HRSA's FY2021 budget documents do not provide information on either prior year or planned funding allocations for the Supporting MHI program. HRSA funds the five programs through cooperative agreements. According to HRSA, a cooperative agreement refers to "a financial assistance mechanism where substantial involvement is anticipated between HRSA and the recipient during performance of the contemplated project." Overview of the Five Maternal Health Programs Figure 1 provides an overview of and the coordination between the five maternal health programs. HRSA is administering the five maternal health programs under the agency's Improving Maternal Health in America initiative. Report Roadmap To assist Congress as it considers measures on U.S. maternal health programs, this report provides an overview of the previously existing AIM program and the four new maternal health programs that HRSA established in FY2019. For each of the five maternal health programs, the report provides an overview of the program, discusses the main core activities or functions of the program, provides the program's criteria of eligibility and reporting requirements, and discusses the program's funding allocations. Alliance for Innovation on Maternal Heath (AIM) The Alliance for Innovation on Maternal Health (AIM) program aims to improve U.S. maternal health outcomes, including maternal safety, by diminishing the number of preventable SMMs and maternal deaths. The initiative funds one cooperative agreement to support continuity of care for pregnant and postpartum women who receive maternal health care services at birthing facilities and hospitals. HRSA established the AIM program in 2014. Since 2014, The American College of Obstetricians and Gynecologists (ACOG), which is a medical professional organization for obstetricians and gynecologists, has been the sole grantee of the AIM program. During the AIM program's most recent four-year performance period. ACOG was responsible for engaging and building partnerships with national stakeholders, promoting the adoption and implementation of hospital-focused maternal safety bundles by state-based teams, and evaluating the delivery of provider education on interconception health. According to HRSA, a maternal safety bundle refers to "a set of small, straightforward evidence-based practices, that when implemented collectively and reliably in the delivery setting have improved patient outcomes and reduced maternal mortality and [SMM]." Hospital-focused maternal safety bundles are designed for health care providers in birthing facilities and hospitals. The best practices contained in the maternal safety bundles are grouped into four administrative activities: (1) readiness, (2) recognition and prevention, (3) response, and (4) reporting/systems learning. Listed below are the current eight hospital-focused maternal safety bundles. For example, the text box below describes the Maternal Mental Health: Depression and Anxiety safety bundle. The eight hospital-focused maternal safety bundles, according to HRSA, "include data metrics, are shown to be clinically effective, and are currently being adopted by states for inpatient use." As of January 2020, according to HRSA, an estimated 1,300 hospitals in 27 states participate in the initial AIM program. The current AIM program has a five-year period of performance of September 1, 2018, through August 31, 2023. Three Core Activities Under the AIM program, the award recipient performs three core activities: (1) facilitating multidisciplinary collaborations to reduce the number of preventable SMMs and maternal mortality, (2) guiding the national implementation and adoption of maternal safety bundles, and (3) collecting and analyzing data. The overall goal of the core activities is to achieve the program's outcomes. According to HRSA, the program objectives are to do the following: Maintain the existing 10 AIM state-based teams and accept 25 new state-based teams to expand the implementation of the current maternal safety bundles. Develop new maternal safety bundles and/or resources that aim to address the quality and safety of maternity care practices. Establish a national campaign on SMM and maternal mortality that demonstrates the impact of AIM and maternal safety bundles. Prevent 100,000 cases of SMM and 1,000 maternal deaths. Eligible Applicants Domestic public and private entities are eligible to apply for the AIM program. Eligibility extends to tribes, tribal organizations, community-based organizations, and faith-based organizations. Reporting Requirements and Performance Measures The AIM grant recipient is required to provide HRSA with annual progress reports, performances reports, and a final report narrative. The recipient is to submit annual reports on progress made toward achieving the program outcomes. The performance reports are to examine measures such as sustainability, depression screening, well-woman visit/preventive care, and health equity in maternal health outcomes, sustainability. According to HRSA, "the Project Officer will provide additional information about [the final report narrative] after HRSA makes the award." Program Funding HRSA may annually allocate no more than $2 million to the sole recipient of the AIMâCommunity Care Initiative. This funding is dependent upon the availability of appropriated funds, recipient's satisfactory progress in meeting program's objectives, and the interest of the federal government. The AIM program has no cost-sharing or matching requirements. On August 1, 2018, HRSA awarded $2 million to ACOG via a cooperative agreement to continue assisting state-based teams with implementing maternal safety bundles. Alliance for Innovation on Maternal Health (AIM)âCommunity Care Initiative The Alliance for Innovation on Maternal Health (AIM)âCommunity Care Initiative is a designed to improve U.S. maternal health and safety. The initiative funds one cooperative agreement to support continuity of care for pregnant and postpartum women who receive maternal health care services at medical facilities outside of birthing facilities and hospitals. The AIMâCommunity Care Initiative builds on the work of the initial AIM program. Together, both AIM programs aim to expand the implementation and adoption of maternal safety bundles to all 50 U.S. states, the District of Columbia, and U.S. territories, as well as tribal entities. The AIMâCommunity Care Initiative focuses on two priority areas: supporting the development and implementation of nonhospital maternal safety bundles for health care providers in outpatient settings and community-based organizations, and addressing preventable SMM and maternal deaths among pregnant and postpartum women who receive care outside of birthing facilities and hospitals. The initial AIM program, which focuses on hospital-based services, began developing two nonhospital maternal safety bundles: (1) Postpartum Care Basics for Maternal Safety: From Birth to the Comprehensive Postpartum Visit, and (2) Postpartum Care Basics for Maternal Safety: Transition from Maternity to Well-Woman Care. The AIMâCommunity Care Initiative is responsible for further developing these two maternal safety bundles. The award recipient is to aim to advance the two nonhospital maternal safety bundles by developing data metrics, testing the bundles' effectiveness in outpatient settings and community-based organizations, and implementing the bundles in medical facilities outside of birthing facilities and hospitals. The initiative recipient is to collaborate with key stakeholders, including other HRSA grant recipients that address maternal and child health issues, on ways to address preventable SMM and maternal deaths among pregnant and postpartum women who receive care outside of birthing facilities and hospitals. In addition, the awardee is to collaborate with the recipient of the Supporting Maternal Health Innovation Program (discussed in the " Supporting Maternal Health Innovation (MHI)Â Program " section of this report). The two recipients are to work in partnership to develop resource materials for nonhospital-focused maternal safety bundles. After developing the resources, the Supporting MHI recipient is to assist the AIMâCommunity Care Initiative recipient with disseminating resource materials and other evidence-informed strategies to communities that experience disparities in U.S. maternal morbidity and mortality. The AIMâCommunity Care Initiative has a five-year period of performance of September 30, 2019, through September 29, 2024. Three Core Activities Under this program, the recipient of the AIMâCommunity Care Initiative is to perform three core activities: (1) establishing and convening a maternal safety workgroup, (2) facilitating the national implementation of two maternal safety bundles, and (3) collecting and analyzing data. The overall goal of the core activities is to achieve the program's outcomes. According to HRSA, the program objectives are to do the following: Increase knowledge and awareness of nonhospital-focused maternal safety bundles, and identify how bundle contents are related to best practices among providers, community-based organizations, outpatient clinical settings, etc. Increase the capacity to implement and test nonhospital-focused maternal safety bundles. Increase the number of nonhospital-focused maternal safety bundles developed that address emerging topics in the provision of maternal care services. Increase implementation of the nonhospital-focused maternal safety bundles within nonclinical community-based organizations and outpatient clinical settings across states/communities. Increase awareness of staff and providers in both inpatient and outpatient clinical settings regarding the need to address racial/ethnic disparities when implementing all nonhospital-focused maternal safety bundles. Increase the evidence base on the implementation of nonhospital-focused maternal safety bundles. The first core activity requires the AIMâCommunity Care Initiative award recipient to establish a maternal safety workgroup to guide the activities of the program. Members of the maternal safety workgroup must include community-focused public health and clinical experts in the field of maternal health. The second core activity requires the award recipient to facilitate the national implementation of nonhospital maternal safety bundles at approximately five test sites. The test sites, which subrecipients will manage, are to be located at outpatient clinical settings and nonclinical organizations. The test sites must provide health care services to pregnant and postpartum women. The award recipient is to collaborate with the initial AIM program's state-based teams and other key stakeholders to determine how to best disseminate the nonhospital maternal safety bundles nationwide. Like the test sites, the nonhospital maternal safety bundles are to be adopted by outpatient clinical settings and community-based organizations that provide health care services to pregnant and postpartum women. HRSA expects the recipient of the AIMâCommunity Care Initiative to collaborate with the current AIM program award recipient. The AIM program is to maintain a public website containing materials on non-hospital focused maternal safety bundles. The website would be further developed and maintained by the AIMâCommunity Care Initiative recipient, who would also support the collaboration of the AIM website and the Supporting MHI program website. The third core activity requires the award recipient to collect and analyze structure, process, and outcome data. According to HRSA, the recipient will collect and analyze "quality improvement baseline, process, structure, and outcome data on the implementation of non-hospital focused maternal safety bundles, both within test sites and during national rollout." Eligible Applicants Domestic public and private entities are eligible to apply for the AIMâCommunity Care Initiative. Eligibility extends to tribes, tribal organizations, community-based organizations, and faith-based organizations. Reporting Requirements and Performance Measures The AIMâCommunity Care Initiative awardee is required to provide HRSA with annual progress reports, performance reports, and a final report narrative. The recipient is to submit annual reports on progress made toward achieving the program outcomes/objectives (as described in the " Three Core Activities " section above). The performance reports would examine measures such as quality improvement, health equity in maternal health outcomes, sustainability, and well-woman visit/preventive care. The final performance report must include the project's abstract, expenditure data for the final year of the performance period, and the final scores for the performance measures. According to HRSA, "the Project Officer will provide additional information about [the final report narrative] after HRSA makes the award." Program Funding HRSA may annually allocate approximately $1,830,000 to the sole recipient of the AIMâ Community Care Initiative. This funding is dependent upon the availability of appropriated funds, recipient's satisfactory progress in meeting program's objectives, and the interest of the federal government. The program has no cost-sharing or matching requirements. The recipient may use the funds for direct, indirect, facility, and administrative costs. Annually, approximately 40% to 50% of the award must cover the costs of subrecipients' test sites and travel/meeting compensation for members of the maternal safety workgroup. In FY2019, HRSA awarded $1.8 million to one recipient. Rural Maternity and Obstetrics Management Strategies (RMOMS) Program The Rural Maternity and Obstetrics Management Strategies (RMOMS) program is a maternal health care pilot program that funds up to three cooperative agreements for the development, implementation, and testing of models that aim to improve access to and continuity of maternal and obstetrics care in rural communities. RMOMS program recipients serve communities based on factors such as disparities in ethnicity/race, socioeconomic status, primary language, access to maternal health care, and coordinated/continuing maternal and obstetrics care. According to HRSA, the RMOMS program has four goals: 1. improve maternal and neonatal health care outcomes, 2. develop sustainable financing models, 3. develop a network whereby coordination of maternal and obstetric care is sustainable within a rural region, and 4. increase access to and the delivery of preconception, pregnancy, labor and delivery, and postpartum health care services. The FY2019 RMOMS program has a four-year performance period, September 1, 2019, through August 31, 2023. The program occurs in two phases. Phase one. The first phase occurs during the first year of the performance period. During this year, RMOMS program recipients develop baseline data, models, and work plans. In addition, the program recipients participate in the development of network capacity building and infrastructure. RMOMS program recipients collaborate with HRSA to assess the program's impact using specific measures and data elements, including access, workforce proficiency, cost and cost-effectiveness, clinical outcomes, quality of care, and healthy behaviors. The models are designed to address the four RMOMS focus areas described below in the " Four RMOMS Focus Areas " section of this report. In addition, each model addresses payment and reimbursement options, workforce skills required of maternal health care providers, and women's access to maternal health care services, including telehealth . According to HRSA, telehealth refers to "the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration." Â (Of the $23 million that Congress provided to SPRANS for the establishment of new maternal health grants in FY2019, Congress reserved $1 million for the purchase and implementation of telehealth and to, support coordination of rural obstetric care.) RMOMS program award recipients are to develop and submit to HRSA three-year work plans, which include the baseline data and strategic plans to implement the model. Phase two. The second phase occurs during the remaining second through fourth years of the pilot program. During these years, RMOMS program award recipients implement the models based on the recipients' work plans. In addition, the recipients are to provide mothers and infants with case management and care coordination services. The recipients would collaborate with HRSA to identify the data elements to monitor and measure through the model. Four RMOMS Focus Areas Each RMOMS program award recipient creates strategies to address each of the four RMOMS focus areas: (1) rural hospital obstetric service aggregation, (2) network approach to coordinating a continuum of care, (3) leveraging telehealth and specialty care, and (4) financial sustainability. Eligible Applicants Domestic public or private and nonprofit or for-profit entities are eligible to apply for the RMOMS program. Eligibility extends to tribes, tribal organizations, community-based organizations, and faith-based organizations. Eligible entities, which HRSA refers to as "applicant organizations," are equipped with necessary staff and infrastructure to direct the administrative and programmatic activities of the program. The applicant organization may be located in either an urban or a rural area. However, the application organization must serve a population either in HRSA-designated rural counties or rural census tracts in urban counties. (The Office of Rural Health Policy within HRSA funded the development of Rural Urban Area Codes to classify areas within metropolitan areas as HRSA-designated rural counties and rural census tracts in urban counties.) An entity could have applied twice for the FY2019 RMOMS program: (1) as an applicant organization and (2) as part of a network organization under a different applicant organization. RMOMS applicant organizations must be part of either a formal or an established network. HRSA refers to a network as an organizational arrangement among three or more separately owned domestic public and/or private entities, including the applicant organization. For the purposes of this program, the applicant must have a network of composition that includes: (1) at least two rural hospitals or [critical access hospitals (CAHs)]; (2) at least one health center under section 330 of the Public Health Service Act (Federally Qualified Health Center [FQHC]) or FQHC look-alike; (3) state Home Visiting and Healthy Start Program if regionally available; and (4) the state Medicaid agency. A formal network is a RMOMS Network organization that has signed bylaws, a governing body, and either a memorandum of agreement, memorandum of understanding, or other formal collaborative agreements. HRSA identifies a formal network that has a history of working together as an established network. At least one entity, aside from the applicant organization, within the network must be located in an HRSA-designated rural county or rural census tract in an urban county. Each RMOMS applicant organization and the entities that are part of a network must have separate and different Employer Identification Numbers (EINs) from the Internal Revenue Service. Separate and different EINs are required in order to receive RMOMS program funds. Figure 2 illustrates an example of a RMOMS network. Reporting Requirements and Performance Measures RMOMS program award recipients are required to provide HRSA with annual progress reports, a performance measure report, a sustainability report, and a final closeout report. Recipients are to submit annual reports on progress in achieving the program's four goals (as described in the " Rural Maternity and Obstetrics Management Strategies (RMOMS) Program " section of this report). In addition, the annual reports must specifically include progress toward addressing the third RMOMS focus area, "leveraging telehealth and specialty care." After the end of each budget period, RMOMS program recipients are to submit reports on performance measures. HRSA is to inform the program recipients of the performance measures to report on, during the first year of performance. HRSA provides guidance to RMOMS program recipients on how to complete the sustainability report, which is due during the final year of the performance period. Each RMOMS program award recipient is to provide the MCHB with a final closeout report within 90 days after the end of the performance period. The final report must include information and data such as barriers encountered, core performance data, and the impact of the overall project. The Notice of Award provides program recipients with additional information about the final report. Program Funding HRSA uses two authorities to administer and fund the RMOMS program, according to the program's Notice of Funding Opportunity (see Table 1 ). Using its authority for SPRANS (SSA Section 501(a)(2)), HRSA may provide up to $150,000 to RMOMS program recipients to carry out activities under the RMOMS focus area "leveraging telehealth and specialty care" for each year of the pilot program. Using its authority for the Office of Rural Health Policy within HRSA (SSA Â§711(b)(5)), HRSA may provide up to $450,000 for recipients to carry out the activities under each of the four RMOMS focus areas for the first year of the pilot program. For each of the remaining years of the pilot program, RMOMS may award recipients receive up to $650,000 to carry those activities. Each RMOMS recipient may receive up to $1.8 million per year. This funding is dependent upon the availability of appropriated funds, satisfactory recipient performance, and the interest of the federal government. RMOMS program award recipients can use funds for direct and indirect costs. In addition, recipients may use funds to cover staff travel expenses to conferences and/or technical assistance workshops. HRSA expects RMOMS program recipients to set-aside funds each year for up to two program staff members to attend a two-and-a-half day technical workshop in Washington, DC. There are no cost-sharing or matching requirements for this program. According to HRSA, the total program costs incurred by the supporting MHI satisfies a cost-sharing or matching requirement. In FY2019, HRSA awarded $9 million to the RMOMS program. State Maternal Health Innovation (MHI) Program The State Maternal Health Innovation (MHI) program is a maternal health program that funds up to nine cooperative agreements for state-focused demonstration projects, with the goal of improving U.S. maternal health outcomes. State MHI award recipients are to establish demonstration projects within a state or group of states. The demonstration projects are responsible for converting recommendations on SMM and maternal mortality into actionable items that can be implemented by the states or groups of states. Recommendationsâsuch as providing maternal women with continuous team-based support, improving quality of maternity health care services, and engaging in productive collaborationsâderive from HRSA's Maternal Mortality Summit, held in June 2018. State MHI program recipients are required to collaborate with other HRSA program awardees of programs such as AIM, the Healthy Start Program (Healthy Start), and Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programs in their state. The FY2019 State MHI program has a five-year performance period, September 30, 2019, through September 29, 2024. Three Core Functions Each state-focused demonstration project undertakes three core functions: (1) establishing a state-focused Maternal Health Task Force, (2) improving state-level maternal health data and surveillance, and (3) promoting and executing innovation in maternal health service delivery. Maternal Health Task Force Each State MHI award recipient is responsible for establishing, and each state-focused demonstration project operates through, a state-focused Maternal Health Task Force (Task Force). The Task Force comprises multidisciplinary stakeholders, including representatives from the state legislature and local public health professionals from state and federal programs, such as the State Department of Health and MCH Services Block Grant Program (Title V). The Task Force is responsible for carrying out two main objectives. First, the Task Force is responsible for identifying maternal health-related gaps at the state level. Examples of such gaps include a state's limited ability to monitor maternal health outcomes and the access barriers that women experience when accessing quality prenatal and maternity care services. Second, the Task Force is responsible for creating and implementing a maternal health strategic plan. The strategic plan must include the maternal health care activities outlined in the most recent State Title V Needs Assessment of each state or group of states. However, state-focused demonstration projects are encouraged not to duplicate the maternal mortality-related activities of the MCH Services Block Grant program. State MHI award recipients must develop their strategic plans by September 29, 2020, and update the plans by including additional actionable recommendations by September 29, 2021. Although not a core function, the Task Force is required to participate in the community of learners' sessions, which are convened by the recipient of the Supporting MHI Program. The goal of convening the community is to encourage peer-to-peer learning, including collective problem-solving and brainstorming sessions on ways the State MHI program recipients can effectively implement their program activities. Maternal Health Data and Surveillance Each State MHI award recipient is to aim to improve state-level data on maternal health data and surveillance through the state-focused demonstration project. To do so, the award recipient is to identify the leading factors of maternal deaths in the respective state or groups of states. A state-focused demonstration project can address the state or group of states' need for maternal health data and surveillance by conducting at least one of three activities. The demonstration project can coordinate with another state-focused initiative to collect, analyze, and report maternal morbidity and mortality data. The demonstration project may also coordinate with a multidisciplinary state-focused maternal mortality review committee (MMRC). An MMRC is a multidisciplinary team composed of maternal clinical health experts. Generally, an MMRC team researches and makes recommendations on maternal mortality-related issues such as racial maternal health disparities. In addition, the demonstration project can analyze valid and reliable data on U.S. maternal health outcomes. For example, the goal of the analysis is to determine the preventability of certain maternal deaths and to establish best practices on how to prevent future deaths. The demonstration project can also publish an annual report on maternal death that includes a discussion on how to prevent such deaths from a policy standpoint. Maternal Health Service Delivery Each State MHI award recipient is to promote and execute innovation in maternal health service delivery, for example, by implementing strategies to address gaps in the delivery of maternal health care. State-focused demonstration projects can implement innovative strategies by conducting at least one of the following three activities: (1) identifying critical gaps in access to comprehensive, continuous, and high-quality maternal health care services; (2) identifying critical gaps in maternal health workforce needs; and (3) identifying critical gaps in comprehensive postpartum and interconception care interventions. For example, a state-focused demonstration project can assist state birthing facilities with implementing and adopting AIM maternal safety bundles, address access to maternal health care by convening a state advisory panel on innovation payment models for maternal care, address maternal health workforce needs by identifying legislative mandates that affect maternal women accessing maternal health care services, and address comprehensive postpartum and interconception care intervention by disseminating patient educational information on preventing obstetric emergencies. HRSA encourages award recipients to include the use of telehealth as a component of their demonstration projects. The Supporting MHI program recipient hosts the web-based platform, which the State MHI program recipients use to consolidate their work. In addition, the Supporting MHI recipient plans, hosts, and facilitates the annual in-person meetings for State MHI award recipients. Eligible Applicants Domestic public and private entities are eligible to apply for the State MHI Program. Eligibility extends to tribes, tribal organizations, community-based organizations, and faith-based organizations. Reporting Requirements and Performance Measures State MHI Program award recipients are required to provide HRSA with annual progress reports, performance reports, and a final report narrative. By September 29, 2020, award recipients must submit annual reports on the maternal deaths and ways to prevent future maternal deaths in the state. Award recipients must include data in their reports that HRSA can measure under the State Title V Needs Assessment. By that same date, according to HRSA, the award recipients must report the following two sets of performance data to the agency: 1. Increases within the state from baseline on September 30, 2019, for the following: percentage of women covered by health insurance, percentage of women who receive an annual well-woman visit, percentage of pregnant women who receive prenatal care, percentage of pregnant women who receive prenatal care in the first trimester, percentage of pregnant women who receive a postpartum visit, and percentage of women screened for perinatal depression. 2. Decreases within the state from baseline on September 30, 2019, for the following: rate of pregnancy-related deaths, and racial, ethnic, and/or geographic disparities in pregnancy-related mortality rates. The Supporting MHI award recipient is required to help the State MHI award recipients achieve their performance milestones. The performance reports examine measures such as quality improvement, state capacity for advancing the health of maternal and child health populations, prenatal care, well-woman visit/preventive care, and adequate health insurance coverage. The final performance report must include the project's abstract, expenditure data for the final year of the period of performance, and the final scores for the performance measures. Each State MHI award recipient must submit its final report narrative to HRSA at the end of the project. Program Funding HRSA may annually allocate approximately $18,650,000 to fund up to nine cooperative agreements under the State MHI program. This funding is dependent upon the availability of appropriated funds, satisfactory recipient performance, and the interest of the federal government. In FY2019, the awards ranged from $1.9 million to $2.1 million. State MHI program award recipients can use funds to address state and local priorities. There are no cost-sharing or matching requirements for this program. Supporting Maternal Health Innovation (MHI)Â Program The Supporting Maternal Health Innovation (MHI) program funds up to one cooperative agreement to help states, stakeholders, and recipients of HRSA-administered awards reduce and prevent U.S. cases of SMM and maternal mortality, and improve U.S. maternal health outcomes. States and stakeholders include state health agencies, community-based organizations, and pregnant and postpartum women and their families. HRSA recipients include those of the initial AIM program, AIMâCommunity Care Initiative, Healthy Start, and MCH Services Block Grant program. Supporting MHI program award recipients aim to achieve the following three program objectives by calendar year 2024: Ensure that 75% of HRSA award recipients report improvement in their ability to implement evidence-informed strategies, with the goal of reducing and preventing maternal morbidity and mortality. Support the State MHI program by ensuring that 75% of HRSA award recipients that aim to improve maternal health outcomes can access the peer-to-peer learning opportunities and resources available through the State MHI program. Support the AIMâCommunity Care Initiative by (1) increasing the dissemination of resource materials to support the adoption of nonhospital-focused maternal safety bundles, and (2) increasing the dissemination of evidence-informed strategies in communities that experience disparities in U.S. maternal morbidity and mortality. The FY2019 Supporting MHI program has a five-year performance period, September 30, 2019, through September 29, 2024. Two Core Functions The State MHI program funds a single project that undertakes two core functions: (1) providing capacity-building assistance, and (2) establishing a national resource center. Capacity-Building Assistance The Supporting MHI project provides capacity-building assistance to the state-focused demonstration projects under the State MHI program and to the recipients under the RMOMS program. In this context, capacity-building assistance refers to technical assistance, training, and dissemination of information. The Supporting MHI program grantee provides the State MHI program and the RMOMS program with technical assistance in the form of programmatic, scientific, and mentoring support. Both programs receive training assistance to develop and deliver curricula. The programs also receive support to disseminate evidence-informed strategies to communities that experience disparities in U.S. maternal morbidity and mortality. The Supporting MHI recipient is to provide capacity-building assistance on 10 topic areas, listed below. The Supporting MHI program award recipient is to gather the community of learners for the State MHI program recipients. The goal of convening the community of learners is to encourage peer-to-peer learning, including collective problem-solving and brainstorming sessions on ways the State MHI program recipients can effectively implement program activities. In addition, the Supporting MHI program recipient is to help the State MHI program recipients assess their progress in meeting program goals and planning and facilitating annual in-person meetings for the recipients. National Resource Center The Supporting MHI program recipient is responsible for establishing a national resource center where states, HRSA award recipients, and key stakeholders can access guidance on reducing and preventing U.S. cases of SMM and maternal mortality. The resource center offers assistance with trainings/technical issues, partnership building, policy analysis, and dissemination of information. Trainings and technical assistance are provided to stakeholders and HRSA award recipients on topic areas similar to the 10 topic areas described above. HRSA award recipients under this program may include grantees of Healthy Start, the MIECHV program, and the MCH Services Block Grant program. The Supporting MHI program recipient, through the resource center, would collaborate with stakeholders that serve underserved populations to encourage partnership building. Key stakeholders and HRSA award recipients may reach out to the resource center for assistance with developing partnerships with national maternal health organizations (e.g., ACOG, the Association of Women's Health, Black Mamas Matter Alliance, Society for Maternal Fetal Medicine, and Telehealth Resource Centers). The resource center offers policy analysis assistance to stakeholders and HRSA award recipients. For example, the AIMâCommunity Care Initiative award recipient can receive assistance in determining whether any of the nonhospital maternal safety bundles are evidence-informed and could reduce U.S. cases of SMM and maternal mortality. In addition, the resource center develops and maintain a public-facing web-based clearinghouse where key stakeholders can access pertinent resources, such as training materials and evidence-informed practices. The website must have the capability to host the State MHI program recipient's online platform. The Supporting MHI program is also responsible for creating and implementing national guidance on reducing U.S. cases of maternal morbidity and mortality. Education and training are the foci of the national guidance. The national guidance provides learning opportunities to key stakeholders on the following nine topic areas: The national guidance is intended to help key stakeholders with related activities, such as creating tools for collaborations, disseminating information about the project, and providing culturally competent technical assistance to key stakeholders that provide maternal health services to populations that experience disparities in U.S. maternal morbidity and mortality. Eligible Applicants Domestic public and private entities are eligible to apply for the Supporting MHI Program. Eligibility extends to tribes, tribal organizations, community-based organizations, and faith-based organizations. Eligible applicants must be aware of the different HRSA award recipients that address U.S. maternal health outcomes. Reporting Requirements and Performance Measures The Supporting MHI Program awardee is required to provide HRSA with annual progress reports, performance reports, and a final report narrative. By 2024, according to HRSA, the award recipient must submit annual reports on progress made toward achieving the three program objectives listed under the " Supporting Maternal Health Innovation (MHI)Â Program " section in this report. The performance reports must examine measures such as technical assistance, health equity in maternal health outcomes, state capacity for advancing the health of maternal and child health populations, perinatal and postpartum care, depression screening, and adequate health insurance coverage. The final performance report must include the project's abstract, expenditure data for the final year of the performance period, and the final scores for the performance measures. Each State MHI awardee must submit its final report narrative to HRSA within 90 days from the end of the performance period. Program Funding HRSA may annually award approximately $2.6 million to the sole recipient, as the agency did in FY2019. This funding is dependent upon the availability of appropriated funds, satisfactory recipient performance, and the interest of the federal government. The Supporting MHI program recipient can use the funds for administrative and facility costs. There are no cost-sharing or matching requirements for this program. According to HRSA, the total program costs incurred by the Supporting MHI satisfies a cost-sharing or matching requirement.


Introduction The Higher Education Act of 1965 (HEA; P.L. 89-329, as amended) authorizes the operation of three federal s tudent loan programs: the William D. Ford Federal Direct Loan (Direct Loan) program, the Federal Family Education Loan (FFEL) program, and the Federal Perkins Loan program. While new loans are authorized to be made only through the Direct Loan program, FFEL and Perkins Loan program loans remain outstanding and borrowers of such loans remain responsible for repaying them. As of December 31, 2019, $1.5 trillion in these loans, borrowed by or on behalf of 42.8 million individuals, remained outstanding. Direct Loan program loans are owned by the U.S. Department of Education (ED). As of December 31, 2019, approximately 35.3 million borrowers owed about $1.3 trillion in Direct Loan debt. FFEL program loans may be held by private lenders, guaranty agencies, or ED. As of December 31, 2019, approximately 11.8 million borrowers owed about $257.2 billion in FFEL program debt. Of that, approximately $87.7 billion was held by ED, representing between 3.3 million and 6 million borrowers, and $169.3 billion was held by private lenders or guaranty agencies, representing debt for between 6.0 million and 7.2 million borrowers. Perkins Loan program loans may be held by institutions of higher education (IHEs) that made the loans or by ED. As of December 31, 2019, about 1.9 million borrowers owed approximately $5.9 billion in Perkins Loans. In response to the current coronavirus disease 2019 (COVID-19) pandemic, numerous questions have arisen regarding student loan repayment flexibilities and debt relief that may be available to individuals to alleviate potential financial effects related to COVID-19. The HEA generally authorizes several options for qualifying individuals. Recent administrative and congressional action, including the enactment of the Coronavirus Aid, Relief, and Economic Security (CARES) Act ( P.L. 116-136 ), provide additional student loan relief measures. This report provides an overview of student loan repayment flexibilities and debt relief provisions that may be available to borrowers facing financial difficulties resulting from the pandemic. It first lists some pre-existing loan terms and conditions (authorized through statute and regulations) that may be available to individuals. It then discusses specific administrative and congressional actions taken to address student loan debt in the context of COVID-19. The report concludes with a brief description of additional existing authorities that could be utilized to address other aspects of student loan relief. Pre-existing Loan Terms and Conditions Several loan terms and conditions that offer forms of repayment relief to borrowers were authorized in statute and regulations prior to the onset of the COVID-19 pandemic. These include periods of deferment and forbearance, which offer borrowers temporary relief from the obligation to make monthly payments; and the availability of income-driven repayment (IDR) plans (e.g., income-based repayment, Pay As You Earn [PAYE]), which afford borrowers the opportunity to make payments in amounts that are capped at a specified share or proportion of their discretionary income, for a maximum repayment period of 20 or 25 years. Deferment A deferment is a temporary period during which a borrower's obligation to make regular monthly payments of principal or interest is suspended, and during which an interest subsidy (i.e., interest does not accrue) may be provided. Where an interest subsidy is not provided, unpaid interest that has accrued on a borrower's loan during a deferment is capitalized (i.e., added to the principal) at the expiration of the deferment period. Periods of deferment do not count toward the 120 monthly payments required to qualify for Public Service Loan Forgiveness (PSLF), and most are not included in a borrower's repayment period (e.g., periods of unemployment deferment do not count toward the maximum repayment periods of 20 or 25 years under the IDR plans). In most instances, a borrower must proactively apply for and request a deferment. A deferment may be granted for a variety of reasons. Unemployment deferment and economic hardship deferment (described below) may be especially relevant to individuals facing financial difficulties due to COVID-19. These types of deferment are available to borrowers of loans made under the Direct Loan, FFEL, and Perkins Loan programs. Unemployment Deferment A borrower who is seeking to obtain full-time employment and is either not employed or employed less than full-time may be granted an unemployment deferment . To be eligible, a borrower must either be receiving unemployment benefits or document that he or she has registered with a public or private employment agency (if one is available within 50 miles) and is diligently seeking to obtain full-time employment. The deferment may be granted for an initial six-month period, and may be extended in six-month increments. A borrower may receive the deferment for a maximum cumulative period of three years, which may include one or more episodes of unemployment. During an unemployment deferment, an interest subsidy is provided on Direct Subsidized Loans, the subsidized component of Direct Consolidation Loans, FFEL Stafford (Subsidized) Loans, the subsidized component of FFEL Consolidation Loans, and Perkins Loans. Economic Hardship Deferment A borrower may qualify for a deferment during periods while he or she is experiencing an economic hardship. To qualify, a borrower must be (1) receiving payments under a federal or state public assistance program (e.g., Temporary Assistance for Needy Families [TANF], Supplemental Security Income [SSI], Supplemental Nutrition Assistance Program [SNAP], state general public assistance, other means-tested benefits), or (2) working full-time and have a monthly income that does not exceed an amount equal to 150% of the poverty line applicable to the borrower's family size, as calculated on a monthly basis. The deferment may be granted for periods of up to one year at a time, and may be extended up to a cumulative maximum of three years. Periods of up to three years while a borrower qualifies for an economic hardship deferment may be counted as part of the repayment period for each of the IDR plans. During an economic hardship deferment, an interest subsidy is provided on Direct Subsidized Loans, the subsidized component of Direct Consolidation Loans, FFEL Stafford Loans, the subsidized component of FFEL Consolidation Loans, and Perkins Loans. Forbearance Forbearance constitutes permission for a borrower to temporarily cease making monthly payments, to make payments in reduced amounts, or to make payments over an extended period of time. During periods of forbearance, no interest subsidies are provided (i.e., interest continues to accrue) and borrowers ultimately remain responsible for paying all of the interest that accrues on their loans. Borrowers may pay the interest as it accrues during forbearance. At the end of the forbearance period, any unpaid accrued interest is capitalized into the principal balance of Direct Loan program and FFEL program loans; it is not capitalized (but remains due) for Perkins Loan program loans. Periods of forbearance do not count toward the 120 monthly payments required to qualify for PSLF, and are not included in a borrower's repayment period (e.g., periods of student loan debt burden forbearance do not count toward the maximum repayment periods of 20 or 25 years under the IDR plans). Generally, borrowers must apply for forbearance. General forbearance and student loan debt burden forbearance (described below) may be especially relevant to individuals facing financial difficulties due to COVID-19. These types of forbearance are available to borrowers of loans made under the Direct Loan, FFEL, and Perkins Loan programs. General Forbearance A borrower may request a general forbearance (sometimes referred to as a discretionary forbearance) on the basis of experiencing a temporary hardship due to financial difficulties, a change in employment, medical expenses, or other reasons. General forbearance may be granted for an initial period of up to 12 months, renewed upon the borrower's request, and limited to a maximum of 36 months. At the end of the forbearance period, any unpaid interest that accrued during the period is capitalized. Student Loan Debt Burden Forbearance A borrower may receive a forbearance on the basis of having a federal student loan debt burden that equals or exceeds 20% of his or her total monthly taxable income. To qualify, a borrower must demonstrate that his or her required monthly payments on HEA Title IV federal student loans (e.g., loans made under the Direct Loan, FFEL, or Perkins Loan programs) equal or exceed that amount. Student loan debt burden forbearance may be granted for an initial period of up to 12 months, may be renewed upon the borrower's request, and is limited to a maximum of 36 months. Income-Driven Repayment Plans IDR plans afford borrowers the opportunity to make payments in amounts that are capped at a specified share or proportion of their discretionary income over a repayment period not to exceed 20 to 25 years, depending on the plan. At the end of the repayment period, the remaining balance of an individual's loans is forgiven. Under these plans, it is possible for a borrower's monthly payment to equal $0. There are several IDR plans currently available to borrowers: the Income-Contingent Repayment (ICR) plan, the Income-Based Repayment (IBR) plans (one version of which is available to individuals who qualify as a new borrower on or after July 1, 2014; and another which is available to individuals who do not qualify as a new borrower as of that date), the Pay As You Earn (PAYE) repayment plan, and the Revised Pay As You Earn (REPAYE) repayment plan. In general, Direct Loan borrowers (other than Parent PLUS Loan borrowers) are eligible for any of these plans. FFEL program borrowers (other than Parent PLUS loan borrowers) are only eligible for the IBR plans. Perkins Loan borrowers are not eligible for any IDR plan. Individuals must apply to repay their loans according to an IDR plan. In addition, they must annually provide documentation of their income and family size to remain eligible for IDR repayment. Borrowers may update their income and family size at any time if either changes. Upon submission of such information, a borrower's monthly payment amount will be recalculated accordingly. Administrative and Congressional Actions Taken in Response to COVID-19 Recently, ED and Congress have taken steps to provide additional forms of relief to federal student loan borrowers. This includes cancelling Direct Loans for payment periods during which qualifying individuals withdrew from their course of study due to COVID-19, waiving Direct Subsidized Loan limitations for students affected by COVID-19, temporarily setting interest rates to 0% on qualifying loans, expanding the instances under which a forbearance may be available to borrowers of qualifying loans, and temporarily ceasing collections on qualifying defaulted loans. Returning Direct Loans Under the HEA, a Direct Loan borrower may be required to return or repay all or part of the Direct Loans borrowed if the student does not complete a payment or enrollment period at an IHE for which the loan was received. Required procedures for such returns or repayments vary depending on whether a student did not begin attendance at an IHE or whether he or she withdrew. Failure to Begin Attendance If a student does not begin attendance at an IHE in a payment or enrollment period, Title IV funds (including Direct Loan funds) must be returned to ED by the IHE and/or the student according the regulatory provisions. For Direct Loan amounts required to be returned by the student, the IHE must immediately notify ED (or its loan servicers) when it becomes aware that the student will not begin or has not begun attendance. Loan servicers then issue a final demand letter to the borrower. The demand letter requires the borrower to repay any loan principal and accrued interest within 30 days from the date the letter is mailed. If the borrower fails to comply with the demand letter, he or she is considered in default on the loan. In March 2020, ED issued guidance to IHEs specifying some flexibilities that may be used to address the return of Direct Loans by recipients who did not begin attendance at an IHE due to COVID-19. ED stated that if a student was unable to begin attendance due to a COVID-19-related school closure, the IHE is not required to notify the loan servicer of the student's failure to begin attendance. By waiving this requirement, loan servicers would not issue demand letters, and borrowers would be able to repay any loans according to the terms of the promissory note, including receiving a six-month grace period prior to the start of repayment. Withdrawal HEA Section 484B specifies that when a Title IV aid recipient withdraws from an IHE before the end of the payment or enrollment period for which funds were disbursed, Title IV funds (including any Direct Loans received) must be returned to ED by the IHE and/or aid recipient according to statutorily prescribed rules (this is often referred to as Return of Title IV Aid). If an aid recipient is required to return any portion of a Direct Loan, he or she repays it in accordance with the terms of the loan. The CARES Act authorizes several waivers with respect to Return of Title IV Aid procedures. Specific to Direct Loan borrowers, the act requires ED to cancel a borrower's obligation to repay the entire portion of a Direct Loan associated with a payment period during which the student withdraws from an IHE as a result of a qualifying emergency . Direct Subsidized Loan Limitations Since July 1, 2013, a student who is a first-time borrower may only borrow Direct Subsidized Loans for a period that may not exceed 150% of the published length of the academic program in which he or she is currently enrolled (e.g., six years for enrollment in a four-year bachelor's degree program). This is referred to as the Direct Subsidized Loan maximum eligibility period. If a Direct Subsidized Loan borrower subject to this provision remains enrolled beyond the applicable maximum eligibility period, he or she will lose the interest subsidy and will become responsible for paying the interest that accrues on his or her Direct Subsidized Loans after the date that the maximum eligibility period is exceeded. The CARES Act specifies that ED shall exclude from the maximum eligibility period any semester (or equivalent) that the student does not complete due to a qualifying emergency, if ED is "able to administer such policy in a manner that limits complexity and the burden on the student." Entering Repayment In general, borrowers of Direct Loan, FFEL, and Perkins Loan program loans are required to make payments on the loans during a repayment period. The repayment period for Direct Subsidized Loans, Direct Unsubsidized Loans, FFEL Stafford Loans, FFEL Unsubsidized Loans, and Perkins Loans begins after a grace period. The grace period begins after the borrower ceases to be enrolled in an eligible postsecondary program on at least a half-time basis (enrollment on at least a half-time basis is often referred to as in-school status for federal student loan purposes). The repayment period for Direct PLUS Loans (to graduate students and to parents of dependent undergraduate students), Direct Consolidation Loans, FFEL PLUS Loans, and FFEL Consolidation Loans is required to begin when the loan is fully disbursed. However, borrowers of these loans, along with borrowers of Direct Subsidized Loans, Direct Unsubsidized Loans, FFEL Stafford Loans, FFEL Unsubsidized Loans, and Perkins Loans, may qualify for a deferment on the basis of their in-school status (or the in-school status of the student on whose behalf a PLUS Loan was made to a parent borrower), during which time they are not required to make payments on their loans but interest may accrue. A borrower qualifies for such an in-school deferment if he or she, or the student on whose behalf a PLUS Loan is made, is enrolled on at least a half-time basis. ED has announced some flexibilities for borrowers of Direct Loan and FFEL program loans whose loan status was in-school on the date the student's attendance at an IHE was interrupted due to COVID-19. The loan status of such borrowers will continue to be reported as in-school until the IHE determines that the student has withdrawn from it. ED has permitted IHEs to defer reporting a student's withdrawn status if the IHE has a reasonable expectation that it will reopen at the start of a payment period that begins no later than 90 days following its COVID-19-related closure and that the student will resume attendance when the IHE reopens. ED guidance does not address Perkins Loans. Interest Accrual Interest is charged on loans made under the Direct Loan, FFEL, and Perkins Loan programs. Typically, under a limited set of circumstances the federal government subsidizes some or all of the interest that would otherwise accrue on certain Direct Subsidized Loans, FFEL Stafford Loans, and Perkins Loans. For March 13, 2020, through September 30, 2020, the Administration has set interest rates on federally held student loans (e.g., all Direct Loan program loans, and FFEL and Perkins Loan program loans held by ED) to 0%. The CARES Act specifies that during this time interest will not accrue. This means borrowers will not be responsible for paying interest on their ED-held loans for this period. This will permit borrowers to enter into a period of deferment or forbearance without concern for whether interest would accrue and capitalize. Borrowers who continue making payments on their loans during this time of 0% interest will not have decreased monthly payments. They will have the full amount of the payments applied toward loan principal. Borrowers who are eligible for this benefit need not apply for it; ED will automatically adjust their accounts to reflect the 0% interest. In addition, ED has authorized FFEL program lenders and institutions that hold Perkins Loans to provide the same 0% interest rate on these nonfederally held loans on a voluntary basis. Borrowers who are ineligible for the 0% interest rate benefit because their FFEL program loan holder or Perkins Loan program IHE is not providing it may take advantage of the 0% interest period by consolidating such loans into a Direct Consolidation Loan, which is eligible for the 0% interest rate. This 0% interest rate, coupled with the various options for temporary cessation of payments (e.g., forbearance, deferment) discussed throughout this report, means that qualifying borrowers may temporarily cease payments on their loans without interest accruing or being subject to capitalization when they begin to make payments again at a later point in time. Cessation of Payments In addition to the pre-existing deferment and forbearance options available to borrowers, ED and Congress have recently taken further steps to enable borrowers to temporarily cease making payments on their qualifying loans. For March 13, 2020, through September 30, 2020, federally held student loans (e.g., all Direct Loan program loans, and FFEL and Perkins Loan program loans held by ED) will be placed in an administrative forbearance. During this time, borrowers will not be required to make payments due on their loans. Borrowers who are eligible for this benefit need not apply for it; ED will automatically suspend payments. In implementing these provisions, ED has indicated that borrowers may opt out of this special administrative forbearance by contacting their loan servicer. In addition, any payments made on a borrower's account between March 13, 2020, and September 30, 2020, can be refunded to the borrower. A borrower must contact his or her loan servicer to request a refund. ED has also authorized FFEL program lenders and institutions that hold Perkins Loans to provide this special administrative forbearance to borrowers on a voluntary basis. Borrowers who are ineligible for this benefit because their FFEL program loan holder or Perkins Loan program IHE is not providing it may take advantage of the benefit by consolidating such loans into a Direct Consolidation Loan. Generally, periods of forbearance do not count toward the 120 monthly payments required to qualify for PSLF, and are not included in a borrower's repayment period (e.g., periods of unemployment deferment do not count toward the maximum repayment periods of 20 or 25 years under the IDR plans). However, the CARES Act specified that ED "shall consider each month for which a loan payment was suspended" under this special administrative forbearance "as if the borrower of the loan had made a payment for the purpose of any loan forgiveness program or loan rehabilitation program." Thus, for Direct Loan borrowers (the only borrowers eligible for PSLF) this special administrative forbearance will count toward the 120 monthly payments required to qualify for PSLF if the borrower was in a qualifying repayment plan prior to the payment suspension and also works full-time in qualifying employment during the suspension. For borrowers of federally held loans, the suspended payments will also count toward the 20- and 25-year repayment periods under the IDR plans, and toward the nine voluntary payments within 10 consecutive months required for individuals to rehabilitate their defaulted loans. It is unclear whether suspended payments on nonfederally held FFEL program loans whose lender has authorized this special administrative forbearance would count toward the 20- and 25-year repayment periods under applicable IDR plans. Perkins Loans, regardless of whether they are held by ED or an IHE, are ineligible for IDR plans. In addition, ED recently authorized institutions that hold Perkins Loans to grant a forbearance to borrowers who are in repayment and are unable to make payments due to COVID-19. Under this forbearance, interest would continue to accrue. The initial forbearance period may not exceed three months, but it may be extended upon a borrower providing supporting documentation. Borrowers must request the forbearance from the IHE. This period of forbearance counts toward the three-year maximum limit on the number of years of forbearance that may be granted to a Perkins Loan borrower. Loan Default and Collections Defaulting on a federal student loan can result in a number of adverse consequences for a borrower. Upon default, the borrower's obligation to repay the loan is accelerated (i.e., the entire unpaid balance of principal and interest becomes due in full). In addition, the borrower loses eligibility for certain borrower benefits (e.g., deferment, loan forgiveness), as well as eligibility to receive additional Title IV federal student aid. A defaulted borrower may have his or her student loan account transferred to an ED-contracted private collection agency (PCA) that will contact the borrower and offer him or her options for voluntary debt resolution, such as loan rehabilitation, consolidation out of default, or entry into a voluntary repayment agreement. If such voluntary debt resolution attempts do not succeed, involuntary collection practices may be utilized, which include administrative wage garnishment; offset of federal income tax returns, Social Security benefits, and certain other federal benefits; and civil litigation. Collection of Defaulted Loans For March 13, 2020, through September 30, 2020, ED will halt the above-described involuntary debt collection practices, and ED-contracted PCAs will stop proactive collection activities (i.e., stop making collection calls and sending letters or billing statements to defaulted borrowers) for all federally held student loans (e.g., all Direct Loan program loans, and FFEL and Perkins Loan program loans held by ED). However, borrowers may contact PCAs to continue repayment arrangements they had made prior to implementation of this policy or to consolidate their loans out of default. Borrowers of federally held loans whose federal tax refund or Social Security benefits were in the process of being withheld on or after March 13, 2020, and before September 30, 2020, will have any offset portion returned to them. Borrowers whose wages were garnished between March 13, 2020, and September 30, 2020, will have their wages refunded. In addition, ED has authorized institutions to stop collection activities on defaulted Perkins Loans that they hold through September 30, 2020, upon notification from a borrower, a member of the borrower's family, or another reliable source that the borrower has been affected by COVID-19. Satisfactory Repayment Arrangements, Loan Rehabilitation, and Consolidation Out of Default To regain Title IV student aid eligibility, a defaulted federal student loan borrower must make six on-time, voluntary monthly payments on a defaulted loan. In addition, loan rehabilitation offers defaulted borrowers an opportunity to have their loan(s) reinstated as active and to have other borrower benefits and privileges restored. To rehabilitate a loan, Direct Loan, FFEL, or Perkins Loan program borrowers must make nine on-time payments according to generally applicable procedures. Alternatively, a borrower may use the proceeds of a new Direct Consolidation Loan to pay off one or more defaulted Direct Loan, FFEL, and Perkins Loan program loans. To become eligible to do so, a borrower must make three consecutive, on-time, full monthly payments on a defaulted loan. ED has stated that for specified periods, if a borrower of a defaulted Direct Loan, FFEL, or Perkins Loan program loan fails to make any of the consecutive monthly payments required to re-establish eligibility for Title IV federal student aid, to rehabilitate such defaulted loans, or to consolidate such defaulted loans out of default, the borrower shall not be considered to have missed any of those payments. Reporting to Consumer Reporting Agencies Information about a borrower's federal student loans is reported to nationwide consumer reporting agencies on a regular basis. Information reported includes items such as loan amount and repayment status (e.g., whether a borrower is current on making payments). The CARES Act specifies that through September 30, 2020, ED shall ensure that any payment that has been suspended under the special administrative forbearance described above shall be reported to a consumer reporting agency as if it were a regularly scheduled payment made by the borrower. Teacher Loan Forgiveness The Teacher Loan Forgiveness program provides loan forgiveness benefits to borrowers of qualifying Direct Loan and FFEL program loans. To qualify for benefits, a borrower must serve as a full-time teacher for at least five consecutive complete academic years in a qualifying school or public education service agency that serves children from low-income families. The CARES Act specifies that ED shall waive the requirement that years of qualifying teaching service be consecutive if an individual's service was temporarily interrupted due to a qualifying emergency, and after such temporary disruption the borrower resumes teaching and ultimately completes a total of five years of qualifying service. Qualifying service may include service performed before, during, and after the qualifying emergency. Additional Flexibilities In addition to the above-described administrative and congressional actions that have been taken in response to COVID-19, further flexibility and authority is provided through the Higher Education Relief Opportunities for Students Act (HEROES Act). The HEROES Act can only be implemented, however, in connection with a war or other military action or a national emergency declared by the President. The HEROES Act provides the Secretary with authority to waive or modify statutory and regulatory requirements that apply to the HEA Title IV student aid programs in an effort to help affected individuals. There are three categories of affected individuals: 1. those who are serving on active duty or performing qualifying National Guard duty during a war or other military operation or national emergency; 2. those who reside or are employed in an area that is declared a disaster area by any federal, state, or local official in connection with a national emergency; and 3. those who suffered direct economic hardship as a direct result of a war or other military operation or national emergency. Examples of support that may be available to student loan borrowers under the HEROES Act include the following: For borrowers of loans made under the Direct Loan, FFEL, and Perkins Loan programs who are in the 1 st or 2 nd categories of affected individuals, the initial grace period excludes any period, not to exceed three years, during which a borrower is an affected individual. Borrowers of loans made under the Direct Loan, FFEL, and Perkins Loan programs who were in an "in-school" status but left school because they became a 1 st or 2 nd category affected individual may retain their in-school status for up to three years. During this period, the Secretary will pay any interest that accrues on a FFEL Stafford Loan. Borrowers of loans made under the Direct Loan, FFEL, and Perkins Loan programs who were in an "in-school" deferment or a graduate fellowship deferment but left school because they became a 1 st or 2 nd category affected individual may retain their deferment for a period of up to three years during which they are affected. During this period, the Secretary will pay any interest that accrues on a FFEL Stafford Loan. For borrowers of Perkins Loans who are in the 1 st or 2 nd categories of affected individuals, any forbearance granted on the basis of their status as an affected individual is excluded from the usual three-year limit on forbearance. Also, for these categories of affected individuals, borrowers of Perkins Loans may be granted forbearance based on an oral request and without written documentation for a one-year period and an additional three-month transition period. Borrowers of FFEL program loans who are in the 1 st or 2 nd categories of affected individuals may be granted forbearance based on an oral request and without written documentation for a one-year period and an additional three-month transition period. For borrowers that may qualify for Teacher Loan Forgiveness (Direct Loan and FFEL program borrowers) or Perkins Loan Cancellation (Perkins Loan program borrowers) on the basis of continuous or uninterrupted qualifying service, such service will not be considered interrupted by any period during which they are in the 1 st or 2 nd categories of affected individuals or during a three-month transition period. For borrowers who defaulted on Direct Loan, FFEL, or Perkins Loan program loans and are seeking to rehabilitate their loans by making nine on-time payments according to generally applicable procedures, any payments missed during periods when they are in the 1 st or 2 nd categories of affected individuals or during a three-month transition period shall not be considered an interruption in the series of payments required for loan rehabilitation. For borrowers who defaulted on Direct Loan, FFEL, or Perkins Loan program loans and are seeking to reestablish eligibility for Title IV federal student aid by making six consecutive on-time payments, any payments missed during periods when they are in the 1 st or 2 nd categories of affected individuals or during a three-month transition period shall not be considered an interruption in the series of payments required for purposes of reestablishing Title IV eligibility. For borrowers who defaulted on Direct Loan or FFEL program loans and are seeking to consolidate loans out of default, any payments missed during the period when they are in the 1 st or 2 nd category of affected individuals or during a three-month transition period shall not be considered an interruption in the series of payments required for purposes of reestablishing Title IV aid eligibility. Borrowers who are repaying their Direct Loan or FFEL program loans according to an IDR plan and because of their status as 1 st or 2 nd category affected individuals are unable to provide information normally required annually to document their income and family size may maintain their current payment amount for a period of up to three years, including a three-month transition period. This flexibility is made in lieu of having their payment amount adjusted to be based on a standard 10-year repayment plan or an alternative repayment plan, as applicable.