Public Health Service System FAQs

What is the Lead Entity’s responsibility when a local public health agency in their district isn’t carrying out the core services?  Is the Lead Entity responsible for delivering the service or ensuring that another provider does? 

• Yes, the Lead Entity will be responsible for ensuring the services are being provided in all counties within the district served by that Lead Entity.

How will the relationship between lead and local provider entities work? Will there be any shared liability between the lead agency and local providers?

• The Lead Entity will be filling a roll of accountability for service provision across the district, and more importantly convening and collaborating efforts across each district. Iowa HHS is unable to speak to the question of shared liability without greater specificity. Please provide more details in the feedback survey referenced during the April district visits. The survey is available through Friday, May 15, 2026.

What if there is local provider non-compliance with a district? Will the lead entity or the state will be required to monitor, enforce or correct issues, and how will those be handled? Does this differ from contract requirements vs code requirements?

• Iowa HHS is exploring contractual terms to manage expectations of the Lead Entity and local providers. If local providers have recommendations on how best to manage this accountability, you are encouraged to respond to the feedback survey following the April district meetings. This survey is open through Friday, May 15, 2026.

Since the Lead Entity will likely be a public health department, who will the lead entity be accountable to for their own public health work for compliance?

• The Local Board of Health of the Lead Entity and/or the Contracting Agency will be accountable for compliance.

If a local county fails to deliver core services or violates compliance terms, what timeline and process will Iowa HHS grant the Lead Entity to correct the issue before the Lead Entity is held in breach of the contract?

• HHS will follow standard contract compliance procedures, which include, but are not limited to, notifying contractors of performance concerns, offering technical assistance to improve performance, implementing corrective action plans as necessary, and working closely with the Lead Entity to improve outcomes. HHS is committed to supporting the contractor through challenges when feasible. As long as the Lead Entity demonstrates reasonable effort to address performance concerns of a district partner, HHS will provide support and guidance as it deems appropriate.

Will the standard Iowa HHS contract template include indemnification clauses that protect the Lead Entity from lawsuits or financial clawbacks resulting directly from the negligence, malfeasance, or non-compliance of a local county provider?

• HHS does not extend indemnification protections to Lead Entities for actions taken by separately contracted local providers. Instead, each contracted entity is solely responsible for its own compliance and liabilities under its respective contract. Lead Entities should ensure their own agreements with local providers include appropriate protections if needed, as this responsibility does not shift to HHS under the contract.

How will Iowans continue to receive the full scope of services and programs they need when local public health agencies already operate with reductions to funding and local budgets?

• This question highlights the importance of district assessment and planning for year one of the lead entity model. The statewide system, due to budget and capacity limits, may not be able to support the needs of every single community. Our challenge, as a statewide system, will be to prioritize the most significant health needs for the entire state and then allow for flexibility of individual communities to identify and support their own unique needs.

Can rural public health services remain robust, sustainable and responsive to community needs under the proposed alignment structure without additional funding and resources?

• Rural models of district-level sharing have demonstrated that high quality, sustainable public health service provision can be accomplished under a shared responsibility structure. Funding challenges will likely persist in the future. Taking action now to establish district-level plans and collaboration provides the best opportunity for local partners to establish a level of sustainability and service provision for their communities.

Will Boards of Supervisors be responsible for covering a local public health agency’s costs if that agency is a lead entity? 

• County tax dollars will not be required to support the lead entity roles. Iowa HHS will establish clear requirements of the lead entity within the RFP and subsequent contract.

With an added layer of governance (the Lead Entity), will non-lead agencies experience a delay in the payment of grant funds?

• Iowa HHS is unable to make projections on this question and would like to hear more about this concern. Please provide more details in the feedback survey referenced during the April district visits. The survey is available through Friday, May 15, 2026.

The current funding to local public health agencies is insufficient to do the necessary work. How will the core services be funded with an additional layer of district administration? 

• These are the difficult discussions and decisions facing public health. We need to be clear about whether we are going to prioritize a defined set of services and do them well, or continue trying to address every need without sufficient investment. Without additional funding, public health cannot fully meet all of the demands affecting the health and well-being of the public.

Can feedback be provided around the alignment funding model?

• The district meetings and the opportunities to provide feedback are the opportunity to discuss the funding model.

What is the total amount of funds for each district?

• Up to $4 Million will be available to support year one lead entity activities in all seven districts, approximately $570,000 per district. Funding for subsequent years will include funds to support basic lead entity operations and local implementation of district plan activities. Funding information will be outlined in the RFP. 

Will all funds be collected by the Lead Entity and the entity will be responsible for distributing the work/monies ? Or will the dollars have to be used by the Lead Entity and subcontracted out to each and every county to do the work within the district?

• Impacted funding will be pooled and contracted through the Lead Entity for distribution to local providers.

How will rural districts be funded? Has Iowa HHS determined a funding formula for each county to plan for county budgets?

• Up to $4 million will be available to support year one Lead Entity activities in all seven districts, approximately $570,000 per district. Funding for subsequent years will include funds to support basic lead entity operations and local implementation of district plan activities. Funding information will be outlined in the RFP.

Will there be a list of activities/services that can or cannot be performed using Iowa HHS funds?

• Yes, Iowa HHS will clearly identify funding eligibility for local Board of Health obligations

How will the additional layer of management (in the form of the Lead Entity) be funded? 

• Iowa HHS will continue to explore additional funding opportunities to support this work.

Is it correct to say that after alignment, state monies and any federal monies flowing through the state will no longer go to county boards of health for program implementation? Will those monies instead go to the lead entities, which will be responsible for implementation of programs and disbursement of monies throughout the region?

• Not entirely. Iowa HHS is prioritizing state and federal dollars that have the greatest amount of flexibility and of sufficient dollar amounts to support this future structure. Certain funding programs that target a very specific population or are such small amounts that cannot have impact by spreading the funding across seven lead entities will continue to be managed through direct contracts between HHS and a local provider. In these cases, the future contracts with local providers will include language to ensure collaboration with the lead entity.

Which program funding sources currently channeled through county health departments will be channeled through the lead entities?

• The tentative list of funding sources includes Local Public Health Services, Immunizations, Childhood Lead, and funding to support Healthy Eating and Active Living.

How will funding be distributed to districts? Will the distribution be the same for each program or be program specific? 

• Iowa HHS intends to use a funding formula consistent with current practices. Final decisions on the formula will not be made until after district assessments are completed during the first contract period.

Has there been any further consideration of whether Private Well Grant funds will be allowed to be used for the Environmental Health Core Function?

• No additional decisions have been made in this matter. 

Will the funding awarded to lead entities in year one be able to be carried over to year two? 

• Iowa HHS is currently exploring an extended initial contract period to ensure the greatest availability of initial funding. More details will be available at the time of RFP posting.

How does Iowa HHS anticipate they will sustain the funding for lead entities work beyond PHIG/the first-year funding?

• Lead entity work will be supported by the funding HHS intends to redirect through lead entities. See the question about the current funding sources that are being considered for this work.

Will Lead Entities received funding that will be contracted out within the service areas or will funds be provided by reimbursement?

• At this time, it is anticipated the lead entity contract will be reimbursement based.

Can Iowa HHS provide a by-district estimate of total dollars handled by the Lead Entity?

• Yes, HHS will provide this estimate of funding when the RFP is posted.

Will the funding awarded to Lead Entities in year one be awarded in one lump sum or will Lead Entities seek reimbursement from HHS as it’s used?  

• HHS is reviewing the funding strategies for the first contract period. The initial funding strategy will be outlined in the RFP.

What is the duration of the Public Health Emergency Planning funding? How would HHS respond should this funding end?

• The current PH Emergency Preparedness project period runs through June 30, 2029. HHS acknowledges the uncertainty surrounding many federal funding sources, including this program. However, HHS is unable predict Congressional decisions on program funding. Funding uncertainties are a concern at all levels of the HHS system, including for HHS and a loss would impact HHS capacity to support local partners during emergency preparedness and response efforts. This is another example of the important need to collaborate and coordinate more effectively across all levels of the public health system.

Do you have a cap for facilities and administrative costs allowable for the Lead Entity?

• HHS has not yet made a decision on this question. Final guidance will be outlined in the RFP.

Will local boards of health no longer be able to look to the state to fund/help fund?

• HHS will continue to distribute funding to the local public health system through a combination of funding strategies including district lead entities, local boards of health/local public health agencies, and other service providers.

Will the current funding formula outlined in Chapter 80 remain in place with system alignment efforts and will those dollars still be directly allocated to local boards of health? 

• HHS will be reviewing Chapter 80 of our administrative rules and will consider adjustments to support the lead entity model. Because HHS does not intend to make changes to the allocation of these dollars before July 1, 2028, there will be time for review and feedback from system partners.

What is the anticipated turnaround time (e.g., 45, or 60 days) for Iowa HHS to process monthly expense reimbursements? Will any upfront working capital or advance payments be issued to mitigate cash-flow strain on the Lead Entity's local budget?

• The initial contract will be a deliverable based budget with 3-5 key deliverables spread across the contract period. The second contract period will transition to a line item budget with monthly billing. HHS will follow standard claims processing procedures.

If a localized outbreak exhausts one county's sub-allocated budget within the district, what contractual flexibility will exist to add or redistribute funding? 

• The Lead Entity will be responsible for managing and navigating subcontracting arrangements with local service providers. In a scenario of this nature, the Lead Entity should plan to coordinate closely with Iowa HHS and local providers to ensure appropriate coverage of outbreak response needs as well as the Lead Entity's contractual obligations.

Will the 6-year Emergency Response contracts fold into this funding allocation?

• No, at this time, the Emergency Response contracts issued to each local public health agency will remain as a stand-alone $0 base contracts.

What specific areas of improvement and processes will benefit from public health alignment?

Specific areas and processes that will benefit from public health alignment include the following:

• Communicable & infectious disease investigation and outbreak management, which is limited for most individual counties.
• Investigation of environmental exposures and risks, for which minimal to non-existent capacity exists at the local level
• Addressing Iowa’s leading health concerns related to chronic conditions and injury prevention, which account for a significant share of morbidity and mortality and require a more coordinated, upstream prevention approach.

What current redundancies exist throughout the current public health structure?

• The most prominent example of redundancies in the current public health structure was the delivery and payment of home health services. There are likely other redundancies within each district, including activities and services such as health messaging, screening/testing, contracting and others. District assessment and planning will help facilitate conversations between local providers to more clearly define and address redundancies locally.

Will the state mandate or provide any shared software for submitting claims, etc.?

• Iowa HHS is interested in hearing more about what shared software would be most valuable. Please provide more details in the feedback survey referenced during the April district visits. The survey is available through Friday, May 15, 2026.

Would the district plans be updated annually or will the same plans exist for the duration of the grant?

• District plans will be submitted annually throughout the duration of the Public Health Service System State Plan. A timeline of 3-5 years is anticipated but not yet finalized.

Will Lead Entities be able to review reports/records on how deliverables are either met/unmet within each district?

• Iowa HHS is willing to explore this request, however current contracting structures for the priority funding sources has not resulted in unmet deliverables from contractors.

Will lead entities have autonomy in conducting the planning phase in year 1, or will all entities follow the same process?

• A decision has not been finalized.

How will billing constraints be address as the proposed billing structure will change the billing practices currently in place for local public health agencies?

• A similar model of "district" budgets exists for other programs such as the Preparedness Program. HHS is open to additional feedback on the constraints and will commit to work with local partners to minimize billing burdens. 

What criteria and process will be used to identify local contractors, performance metrics and funding amounts for each county or counties?

• Performance criteria will be established through contracting procedures between HHS and the Lead Entity or between the Lead Entity and local provider.

How will outcomes be assessed?

• The outcomes for the initial contract period will be deliverable based, focusing on the assessments and implementations plans. Outcomes in the second contract period will be linked directly to the implementation plans developed during the first contract period.

Will outcomes be tied to funding?

• Yes, funding will be tied to outcomes. 

What will happen to local boards of health as part of system alignment?

• The role of a local Board of Health (LBOH) is not impacted under this model. The Board of Health remains in Iowa Code and continues to have jurisdiction over public health matters in the county, maintaining autonomy for the local public health agency.
• HHS' model is about using the HHS district map to structure statewide funding/programs in a way that encourages and supports local coordination and collaboration in addressing state-wide priorities defined in the future Public Health Service System state plan.
• If there is any change for LBOH, it will be to understand the needs of their population within the district and across the geographical area and to use this information in guiding the local public health agency under this new district funding model. 

What is the Lead Entity’s responsibility to local Boards of Health throughout their district?

• Iowa HHS welcomes feedback on this topic. Counties are encouraged to provide responses to the survey questions presented during the April district visits. The survey is available through Friday, May 15, 2026.

Maintaining autonomy is extremely important to communities. Will alignment reduce the autonomy at the local level?

• Iowa HHS is working to find a balance between setting an overall direction for the public health system to address leading health priorities, while providing local flexibility to determine how best to organize and provide the priority services. While autonomy to use state funds in any way a local provider determines will be narrowed, the autonomy to determine how best to deliver services will remain. In addition, local providers will have full discretion to identify and support other locally identified needs that fall outside of statewide priorities.

Will local boards of health maintain authority over isolation, quarantine and public health orders? Or will that responsibility fall to the Lead Entity? 

• Local board of health authority and responsibility will not change under this model.

Will Iowa HHS take the lead on communicating with the Boards of Supervisors regarding their statutory obligations? If this responsibility falls solely to a lead entity, it may inadvertently strain the relationship-building efforts necessary for successful collaboration.

• HHS has engaged with the Iowa State Association of Counties and will remain engaged with the association to communicate the Public Health System Alignment expectations and impacts for local partners. HHS welcomes additional input and feedback on what we can do to support a Lead Entity is working with local elected officials.

How does a district model enable a ”well-coordinated system with clear access points for Iowans?”

• Iowa HHS is focusing on the broad HHS system, not just public health. In addition to public health, HHS is designing a system that more clearly links Public Health, Behavioral Health, Early Childhood & Family Services, Aging & Disability Services, and Community Access & Eligibility. This system design, through each system's "Lead Entity," should facilitate more clearly defined access points into each system, within each district.

How does Iowa HHS view collaboration at the local level? Public health agencies across the state, particularly in rural areas, are creating and maintaining collaborative relationships both within and outside our communities on a daily basis.  

• The transition to the Shared Responsibility Model with lead entities is intended to support existing successes in local collaboration, expand those successes across all 99 counties, and strengthen connections beyond public health to include other HHS service systems.

Has Iowa HHS obtained feedback from current, established program districts in terms of successes and challenges?  What are the “wins”? How will challenges be addressed in the PH System Alignment process?  

• Yes, Iowa HHS has visited with existing collaborative partnerships, hosted the April townhalls, and continues to receive feedback about the "wins", challenges, and concerns. Challenges are a routine part of the public health system and often best addressed by local collaboration. The Year 1 assessment and planning phase will be instrumental in identifying and developing a plan to navigate current and future challenges.

A five-year project period is a lot to consider taking on – what support will Iowa HHS provide, other than funding, to make this five-year project period successful?

• Iowa HHS is preparing a technical assistance and support plan that will be comprehensive. Your feedback is welcomed. Please respond to the feedback survey distributed following the April district visits. The survey is open until Friday, May 15, 2026.

How does Iowa HHS view collaboration at the local level? Public health agencies across the state, particularly in rural areas, are creating and maintaining collaborative relationships both within and outside our communities on a daily basis.  

• The transition to the Shared Responsibility Model with lead entities is intended to support existing successes in local collaboration, expand those successes across all 99 counties, and strengthen connections beyond public health to include other HHS service systems.

Has Iowa HHS obtained feedback from current, established program districts in terms of successes and challenges?  What are the “wins”? How will challenges be addressed in the PH System Alignment process?  

• Yes, Iowa HHS has visited with existing collaborative partnerships, hosted the April townhalls, and continues to receive feedback about the "wins", challenges, and concerns. Challenges are a routine part of the public health system and often best addressed by local collaboration. The Year 1 assessment and planning phase will be instrumental in identifying and developing a plan to navigate current and future challenges.

What role will county boards of health and directors play in advising the lead entities? 

• Lead entities, in partnership with local providers, will be encouraged to work collaboratively with key players within the district, including Local Boards of Health.

Can you describe the expectations for lead entities for the five core services?

• Iowa HHS will include this information in the RFP, and sooner if available.

Will there be a list of activities/services that can or cannot be performed using Iowa HHS funds?

• Yes, Iowa HHS will clearly identify funding eligibility for local Board of Health obligations.

What are the services local public health agencies will be required to provide utilizing Iowa HHS funds?

• Iowa HHS will clearly define these requirements as part of the RFP. These changes in funding eligibility will not take affect before July 1, 2027.

At the Townhalls it was said that Environmental Health under the District System will not include environmental activities regulated by DNR or DIAL.  What are some examples of activities that will be included under Environmental Public Health in the District System?

• To clarify, the regulatory activities carried out by local boards of health/local public health agencies will be maintained under the existing relationships local partners have with DIAL and DNR. HHS will be focusing on building the public health system's capacity to respond to identify, investigate, and provide interventions for environmental risks and exposures. Examples include responding to exposures such as heavy metals, groundwater contamination, carbon monoxide poisonings, pesticide poisonings, and infectious diseases such as Legionella. 

Is the map that has been created for the behavioral health services funding appropriate as a model for public health funded districts?

• The Iowa HHS map is primarily for administrative purposes and should not be viewed as a restrictive boundary for organizing and delivering HHS-funded public health services. Forcing the use of the map boundaries would highlight the limits of applying "one map for everything". Specific funding for the provision of HHS core public health services has yet to be determined, but funding formulas will take into account population as well as unique needs throughout the state.

Will the opportunity to become a Lead Entity be restricted to only public health agencies?

• Iowa HHS intends to limit eligible RFP applicants to designated local public health agencies. If a Lead Entity is not identified for a specific district, HHS will broaden the applicant pool for a subsequent Lead Entity funding opportunity.

The proposed districts are very large. Could there instead be a larger number of smaller-size districts or an opportunity to establish subdistricts during initial implementation? 

• The district map will not be reviewed except after each population census. However, to clarify, the proposed role of a lead entity and the formation of a district will not prohibit smaller groups of counties within or even across districts from forming and maintaining relationships that demonstrate the capacity to meet the core public health services.

Is it possible for local public health departments that are not the lead entity to assist with performing the work of the lead entity?

• Yes, there will be the possibility to assist.

What method was used in determining the Iowa HHS Service Systems map?

• In the summer of 2024, HHS worked with Health Management Associates (HMA) to identify districts that are adequately resourced to meet Iowans' needs. To determine Iowans' needs, an analysis was conducted using three categories of measures: Access - primary care physician ratios, dentist ratios, and mental health provider rates; Need - Medicaid rates; Risk - social vulnerability index. The analysis included creating a rank and score for each county. The state was then divided into zones that were spatially contiguous, approximately equal in area, and consistent in key statistical measures. This created balanced and compact districts that reflect the varied, data-driven needs of the population while considering existing administrative boundaries and potential future collaborations. 

Could one health department apply for multiple districts?

• Yes, one health department may apply for multiple districts.

Is it the expectation of the lead entity to provide technical assistance to the district when a local provider needs assistance on communicable disease response?

• At this time, HHS intends to maintain staff to provide this technical assistance to districts. Based on current funding and infectious disease trends, it will be more efficient and financially responsible to maintain centralized technical expertise at HHS to support all seven districts rather than attempting to fund FTEs in each district. HHS will continue to work with local partners to make adjustments in support and organizational structures that best support the future system.

Can the timeline for public health alignment be extended?

• There is no plan to extend the timeline. The year-long period of assessment and planning by districts will be essential to further inform prioritization for how Iowa HHS funding is used.

What are the services local public health agencies will be required to provide utilizing Iowa HHS funds?

• Iowa HHS will clearly define these requirements as part of the RFP. These changes in funding eligibility will not take affect before July 1, 2027.

Would Iowa HHS consider leading the planning efforts along with districts, or support contractual services for performing planning as the work for the Lead Entity in year 1 will be different from years 2-6?

• HHS is working to develop a technical assistance plan to support district lead entities and their partners. HHS welcomes input from our local partners on how to best support the initial year assessment and planning efforts.

What are the changes to the CHA/CHIP process, including requirements for completion and reporting, due to HHS system alignment? 

• Iowa HHS is discontinuing the local public health services grant requirement for completing county Community Health Assessment and Health Improvement Planning (CHA/CHIP) to reduce administrative burdens and allow local partners to prioritize planning efforts for district level coordination. This does not mean counties must stop conducting CHA/CHIP, counties who elect to conduct a county level CHA/CHIP maintain autonomy to complete these assessments. As HHS moves toward a statewide plan for investing state funding into district plans, a number of existing surveillance tools exist to inform the statewide plan. As stated during the April townhalls, local boards of health will retain autonomy to identify and support locally unique health needs that will complement the statewide and district plans. 

Can staff provide both lead entity services as well as local public health services in a county? Or are they required to be lead entity FTEs?

• Iowa HHS is open to a shared FTE concept that covers both lead entity responsibilities as well as Local Public Health services within the district/county.

What role will the regional epidemiologists have in alignment?

• Iowa HHS anticipates regional epidemiologists maintain a similar role and want to use this model for other technical assistance and support needs that HHS should provide.

Will staffing changes occur at the state level so dollars can be redirected to positions within the lead entities? What is the plan for funding the new layer of management represented by the lead entities? How will the additional layer of management (in the form of the Lead Entity) be funded? 

• No immediate staffing changes are planned at Iowa HHS. As lead entities work with districts to assess capacity and gaps, Iowa HHS will continue to work collaboratively with local partners on funding and staffing support needs. Iowa HHS will continue to explore additional funding opportunities to support this work.

What role with the Regional Community Health Consultants have in alignment?

• HHS will continue to hold a key role in providing technical assistance to lead entities and county health agencies. HHS will work with our local partners to assess the needs at the local, lead entity, and HHS levels and will evaluate those needs against the available financial resources to determine the best placement and allocation of resources.

Will Public Health Emergency Preparedness funds received from federal partners be added to the funding that the Lead Entity will receive in case of an emergent situation?

• No. As was discussed during the April townhalls, HHS intends to delay any actions on the PH Preparedness and Collaborative Service Area systems. In addition, HHS will continue to hold a key role in providing technical assistance to lead entities and county health agencies. HHS will work with our local partners to assess the needs at the local, lead entity and HHS levels and will evaluate those needs against the available financial resources to determine the best placement and allocation of resources.