Rural Health Transformation Program Year 2 Awards: What Changed for FNP Students

The Rural Health Transformation Program paid out its second year on November 9, 2026. The Centers for Medicare & Medicaid Services awarded $10 billion across all 50 states, from $142.3 million for New Jersey to $282.0 million for Texas. If you're training to be a family nurse practitioner and picture yourself practicing outside a metro area, this program lets states spend on rural clinics, rural training sites and recruitment bonuses, among other permitted uses, over the next several years. Each state chooses which of those uses it funds. It also carries a scoring rule that rewards states for letting nurse practitioners practice without a physician's oversight, with a deadline at the end of 2027.

What CMS awarded for year 2

Congress created the Rural Health Transformation Program in Public Law 119-21 with $50 billion spread over five federal fiscal years, $10 billion a year from 2026 through 2030. Only the 50 states can receive it. Washington, D.C. and the territories aren't eligible, so an FNP student in D.C. or Puerto Rico won't see this money at home.

The year 2 awards are the fiscal year 2027 amounts. The smallest is New Jersey's $142,338,224 and the largest is Texas's $281,976,026. Alaska, at $272.7 million, and Montana, at $239.7 million, are next behind Texas. Land area and rural population size are both in the formula, and those three states are among the four largest in the country by area.

CMS's fact sheet says each award has two parts. Half of the $10 billion is split evenly, which gives every state $100 million. The other half, the workload funding, is divided by points. CMS's own description of what earns those points is the part a future nurse practitioner should read closely, because one of the factors is about you.

Key dates in the Rural Health Transformation Program

Which states gained and lost money from year 1

CMS published both award tables, so the change is simple subtraction. Twenty-five states got more in year 2 than in year 1 and 25 got less. No state's award moved by as much as 4%.

Award amounts from CMS's year 1 release and HHS's year 2 release. Changes are our subtraction. CMS said the year 2 figures reflect, in part, each state's progress on its approved plan and on state policy actions. It didn't publish a factor-by-factor score for each state, so nobody outside CMS can say exactly why North Dakota went up and Florida went down.

How CMS turns state policy into dollars

The rules are in the program's notice of funding opportunity, CMS-RHT-26-001. Each state's share of the $5 billion workload pool is its total points divided by the sum of every state's points. Those points come from two groups of factors with fixed weights that don't change over the five years.

The first group, rural facility and population factors, carries half the weight: rural population size, the share of rural health facilities, uncompensated care, the percentage of residents in rural areas, frontier status, land area and hospitals receiving Medicaid disproportionate share payments. CMS scored these once, in late 2025.

The second group, the technical score factors, carries the other half and gets recalculated every year. Some reward a state's own initiatives, such as rural talent recruitment. Others reward state policy actions. One of those is factor D.3, scope of practice, which averages four scores: physician assistants, nurse practitioners, pharmacists and dental hygienists. For the NP part, CMS used AANP's State Practice Environment categories as of October 2024.

The weight is small. Table 3 of the NOFO gives scope of practice 1.75% of the total points, the same weight as licensure compacts and certificate of need, against 10% each for the three biggest population factors. The NOFO also says each factor carries 100 points in total across all 50 states. On that basis, our rough estimate is that about $87.5 million of each year's $5 billion workload pool moves through the scope of practice factor, and nurse practitioners are only one of the four professions averaged into it, so the NP piece is a fraction of that. You can read what each state's category actually means for your license on our FNP scope of practice by state page.

The December 31, 2027 deadline for scope of practice promises

A state didn't need full practice authority already in law to score well. The NOFO let it commit in its application to change the law, and paid partial credit for the promise. Here's how CMS scores a commitment over time, from the NOFO's own walkthrough:

• In the first budget period, a state got 50% of the full credit for a policy change it proposed.
• Once the state enacts the change, its points rise to full credit.
• If the change isn't finalized by the end of calendar year 2027, the points for that factor drop to zero, and CMS recovers the money it previously paid on them.

CMS's February 2026 rescoring webinar adds one more rule: a state can't get credit for a policy it didn't commit to in its original application. So a legislature that grants nurse practitioners full practice authority in 2027 without having promised it in 2025 doesn't pick up these points.

If your state promised a scope change, its legislature has until December 31, 2027 to finish it. Start an FNP program in 2026 and you may still be in clinicals on that date, so the law you get licensed under could be different from the one in force when you applied. Our guide to NP collaborative agreements explains what you'd sign in a reduced or restricted state today.

Does full practice authority line up with bigger awards?

Not in any way you could see from the totals. Three of the four largest gains went to states AANP lists as full practice: North Dakota, Iowa and Montana. But the fourth, Virginia, is restricted. On the other side, Florida, a restricted state, had the largest dollar drop, while Vermont, a full practice state, had the second largest, and New Jersey, a reduced practice state, had the largest percentage drop.

Across all 50 states, the averages point the same way. We grouped every state by its current AANP category and averaged the change in its award from year 1 to year 2:

Changes are our arithmetic from the two CMS award tables. Categories are AANP's as of July 2026, while CMS scored states on AANP's October 2024 map, so a state that changed its law in between sits in a different row here than in CMS's formula. Full practice states, as a group, came out flat. If you're choosing where to train or work based on practice authority, choose on the law itself, not on how much rural money a state received.

What the workforce money can pay for

For an FNP student, the scoring rule is the background. The workforce spending is what could reach you directly. The NOFO's model rural talent recruitment initiative names nurse practitioners among the clinicians states should recruit, and lists these as possible uses of the money:

• Developing or expanding education programs based at or rotating through rural facilities, including nurse practitioner residencies.
• Short-term housing for students and trainees on rural rotations, under six months.
• Distance learning so rural students can study without moving away.
• Support with licensure and clinical supervision in rural areas.

There's a catch on incentive money. The program's uses of funds limit recruitment and retention spending to clinicians who commit to serving rural communities for at least five years, and the NOFO says any financial incentive should carry that same five-year requirement. Treat a rural signing bonus or scholarship paid from this program as a contract, not a gift.

The abstracts states sent CMS in December 2025 show how some of them plan to use it:

Preceptor development matters to you because many FNP programs leave students to find their own clinical sites, and a state paying rural clinicians to precept could open sites that don't exist now. Our guide on how to find an NP preceptor covers what to ask a program before you enroll. If you want structured training after graduation, the FNP residency programs list shows where postgraduate programs already run.

What to watch before year 3

CMS's fact sheet says states begin more detailed quarterly reporting in November 2026. On CMS's draft timeline, the next annual progress report is due in late August 2027 and CMS rescores states in September and October, and the NOFO says year 3 amounts are set by October 31, 2027. That's two months before the scope of practice deadline, so the year 3 awards will be decided before CMS knows which promised laws actually passed.

The money also doesn't sit around. CMS's fact sheet says states must obligate each year's award within its budget period, and money obligated in time generally stays available until the end of the following fiscal year. Every dollar of the $50 billion must be spent by September 30, 2032. A rural training program you see announced in 2026 or 2027 is real money now, but it isn't guaranteed past the program's last year. Ask any employer or program offering an incentive where the money comes from after 2030.

What this means if you’re studying to be an FNP

If you plan to practice in a rural area, three things are worth doing now. First, find your state's transformation plan. CMS's year 2 fact sheet links state program snapshots, and your state health or Medicaid agency posts its own plan. Look for the workforce initiative. That's where scholarships, rotation housing and recruitment bonuses would show up, and any financial incentive from the program is supposed to carry a five-year rural service commitment.

Second, check your state's practice category and whether it promised a change. CMS hasn't published a list of which states committed to expanding NP scope, so you'd have to read your state's application or ask its program office. For a state that did commit, December 31, 2027 is the point where it either finalizes the change or loses those points. A legislature can still change NP practice law later, so the deadline doesn't settle whether you'll practice under a collaborative agreement after graduation. Our FNP programs by state pages pair each state's programs with its practice authority.

Third, ask programs about rural clinical sites. A program in a state funding rural preceptors may be able to place you in a rural clinic it couldn't offer before. Ask how many students it placed in rural sites last year and whether that number is growing. Don't count on any of this money when budgeting tuition, though. Rural Health Transformation Program funds go to states and their partners, not to students as a grant you apply for directly.