Form CMS-10477 Combined Administrative Cost Form - Informed Consent

Attachment 10a: MIPCD Administrative Costs Form, Years 1-3 with Informed
Consent
RTI International and its subcontractor, the National Academy for State Health Policy, were
selected by CMS to conduct an independent assessment of the Medicaid Incentives for
Prevention of Chronic Diseases (MIPCD) demonstration. To do so, we will use a mixed-methods
research design, combining both quantitative and qualitative data. One form of quantitative data
collected will be the administrative costs incurred by State agencies that are responsible for
administration of the MIPCD program. Evaluation of administrative cost data is required by the
legislation authorizing the MIPCD Demonstration.
RTI International is asking MIPCD demonstration state awardees to complete an administrative
costs form which will be used to collect administrative costs data from MIPCD demonstration
States.
Your involvement includes filling out a one-page form on costs for each year of your MIPCD
program to date (Year 1, 9/13/2011 to 9/12/2012; Year 2, 9/13/2012 to 9/12/2013; and Year 3,
9/13/2013 to date). Your participation is voluntary. We do not expect any risks to you from
being in this study. If you find discussing any of the fields on the form makes you
uncomfortable, you may skip them. You may stop participating at any time. If you decide not to
participate, it will not impact your MIPCD grant in any way.
There is no direct benefit to you for being part of this study except the satisfaction of helping us
learn more about the administrative costs of the MICPD programs.
Results of the Administrative Costs Form will be used to assess the following:
 How has the State been spending its administrative funds, and how does this compare
with the projected spending in its proposal?


Have administrative expenditures changed in the different phases of the initiative?



How do administrative costs vary by major structural differences, such as the type of
program, target group/health condition, type and amount of incentive, and scope of the
program (statewide vs. limited)?



What are the costs of the incentives that are paid by the program?



Were there additional financial costs of the program that were not covered by the
program?

If you have any questions about the study, you can call Tom Hoerger at RTI International at 1800-334-8571 x21746. If you have any questions about your rights as a study participant, you
can call RTI’s Office of research Protection at (919) 316-3358 in Durham, NC or 1-866-2142043 (a toll-free number).

Administrative Costs Form: Years 1-3
INSTRUCTIONS
STATE/YEAR:
Please record the relevant State name in the “State” field. For each cost category, please record
total costs incurred by your MIPCD program during Year 1 (9/13/2011 to 9/12/2012), Year 2
(9/13/2012 to 9/12/2013), and for Year 3 (9/13/2013 to date; i.e., through the most recent SF425
filing or quarterly report, whichever is latest). Please include all applicable costs for each
category and do not leave any cells blank. If the program has not incurred costs for a particular
category, please include $0 in the field. Finally, in the rightmost “Source of Data” column please
describe where/how you obtained the cost data for each category. For example, if you used the
SF425 filing form to report the incentives total, please write “SF425 filing” in the “Source of
Data” Column.
MIPCD COSTS FUNDED BY THE MIPCD GRANT
Incentives
Incentive costs are defined as the amount paid out of the MIPCD grant to fund MIPCD
incentives to beneficiaries. Examples might be the cost of cash incentives, flexible health
accounts, gift cards, or incentives vendor contracts. For states that give beneficiaries a flexible
health account, services purchased through the account should be counted as incentive payments.
For example, if a beneficiary in Texas uses his/her flexible spending account to purchase a gym
membership or weight watchers program, this would be counted as an incentive payment. As
noted in the services description, if the state directly purchases the gym membership or weight
watcher program, this would be counted as a service.
Services
Service costs are defined as the amount paid out of the MIPCD grant to fund MIPCD
programmatic services. Examples could include the cost of a quitline, NRT, breathalyzer testing,
gym memberships or weight watchers memberships (if these are paid directly by the state or its
agent and not through a flexible spending account), or transportation and child care during
programmatic events. If a staff member provides programmatic MIPCD services and does not
work directly for the MIPCD grantee (he/she is a contractor, or works for a partner organization),
this person’s salary and benefits can be included in the Services category. Examples of staff in
this category include health mentors, patient navigators, or peer counselors. If a staff member
works for the MIPCD grantee his/her salary and benefits should be included in the administrative
costs personnel category.
Administrative Costs
Personnel
Personnel costs are defined as the amount paid out of the MIPCD grant to an MIPCD grantee
employee in return for work done on the MIPCD project. Examples of personnel costs are
the salaries and fringe benefits of MIPCD grantee staff. Please include the salaries and

benefits of partner organization staff and contractor staff under the category of work they are
contracted to do. For example, if a contractor is hired to conduct evaluation for MIPCD, this
cost should be recorded under evaluation. If a contractor is hired to provide motivational
interviewing training, please record this cost under training.
Training
Training costs are defined as the amount paid out of the MIPCD grant to provide training on
a necessary skill, product, or service needed for the MIPCD program. Examples include
trainings on motivational interviewing or tobacco cessation counseling.
Outreach & Marketing
Outreach & Marketing costs are defined as the amount paid out of the MIPCD grant to
promote MIPCD products and services amongst its target population. Examples of outreach
& marketing costs may include the cost of patient recruitment materials, a telephone
recruitment service, or program advertisements. Outreach & Marketing costs do not include
incentives for retaining participants.
Data Systems
Data systems costs are defined as the amount paid out of the MIPCD grant to manage data
and data systems associated with the MIPCD program and evaluation. Examples include
developing a project database for data collection or developing a web portal for peer
navigators.
Evaluation
Evaluation costs are defined as the amount paid out of the MIPCD grant to evaluate the value
of the MIPCD program. Examples of evaluation costs might include the cost of an
evaluation contractor or survey administration. Please do not report costs attributable to a
satisfaction survey in this category. Please record these costs in the Satisfaction Survey
category.
Satisfaction Survey
Satisfaction survey costs are defined as the amount paid out of the MIPCD grant to evaluate
the value of the MIPCD program through a satisfaction survey. Some- but not all- MIPCD
State programs administer these surveys. If your program does administer this type of survey
please report these costs in this category separately from evaluation costs. Examples of
satisfaction survey costs incurred might include mailing, telephone, or survey design costs.
Other Administrative Costs
Other administrative costs are defined as the amount paid out of the MIPCD grant for any
type of administrative cost not yet described. Examples may include travel, IT infrastructure,
materials/supplies, quarterly reports, or indirect costs. In the Source of Data column, please
briefly describe each item you record in this category.

Total
Next to total please sum all MIPCD costs for the time period. This amount for Years 1 and 2
should correspond with the total reported on the SF425 form for this time period; if not, please
explain differences (see Frequently Asked Question #9 for how to handle costs incurred but not
yet processed in a period). For Year 3, the amount should correspond with the total reported on
the SF425 form or your latest quarterly report.
MIPCD COSTS FUNDED BY IN-KIND CONTRIBUTIONS
Personnel
In-Kind personnel contributions include the value of the time grantee staff spend on MIPCD
activities that is not paid for by the MIPCD grant. An example of this could be a Medicaid
Director who spends 5% of his/her time on the MIPCD program but is not paid out of MIPCD
grant funds. If you do not explicitly track these contributions, please provide your best estimates.
Other
Other In-Kind contributions are the value of administrative resources (for example training,
outreach & marketing, travel, IT, evaluation, materials/supplies, indirect costs) used for MIPCD
program activities but not paid for directly by the MIPCD grant. If you do not explicitly track
these contributions, please provide your best estimates. In addition, if the program receives
donations of gym memberships or memberships in a weight loss program please include them
here.
For questions, comments, or technical assistance about the data categories and/or the cost form,
please contact Tom Hoerger by email ([email protected]) or telephone (919-541-7146). Feel free to
attach additional budget information as clarification.

FREQUENTLY ASKED QUESTIONS
1. Our MIPCD program health educators are hired through an independent contractor. In
which category should their salaries and fringe benefits be recorded?
Please report the salaries and fringe benefits of staff providing programmatic MIPCD
services who do not work directly for the MIPCD grantee (he/she is a contractor or
works for a partner organization) in the “Services” category.
2. Our MIPCD program evaluators are hired through an independent contractor. In which
category should their salaries and fringe benefits be recorded?
Please report the salaries and fringe benefits of staff providing evaluation services who
do not work directly for the MIPCD grantee (he/she is a contractor or works for a
partner organization) in the “Administrative Costs: Evaluation” category.

3. Our MIPCD program hired an incentives vendor to distribute incentives as needed to
MIPCD participants. Should the cost of the incentive vendor be recorded under
“Incentives” or an Administrative Costs category?
Please record amounts paid to incentives vendors in the “Incentives” category.
4. I’m not sure where to report a cost, or one of my costs does not fit cleanly into one of the
cost categories (it seems to fit into more than one and I’m not sure how best to split it up).
What should I do?
Please reach out to Tom Hoerger at RTI International by email ([email protected]) or
telephone (919-541-7146). We are happy to provide assistance to help you complete the
form easily and accurately. You may also provide a comment in the Source of Data
column to communicate your uncertainty.
5. MIPCD participants in my state’s program can purchase Weight Watchers and/or gym
memberships with their flexible health account provided by the MIPCD program. How
should I report the costs of paying for these Weight Watchers and/or gym memberships
through the flexible health account?
For states that give beneficiaries a flexible health account, services purchased through
the account should be counted as incentive payments.
6. My state’s MIPCD program pays Weight Watchers directly to provide free/subsidized
Weight Watchers memberships to MIPCD participants. In what category should I report
this cost?
Please report this cost in the “Services” category.
7. Should MIPCD personnel be categorized under Administrative Costs: Personnel, or
Administrative Costs: Evaluation?
If a staff member is conducting evaluation for MIPCD, this cost should be recorded
under evaluation. Otherwise, please put this under Administrative Costs: Personnel.
8. My state’s MIPCD program provides a tool kit for physicians with information on the
MIPCD program, how to provide smoking cessation information, and how to conduct
outreach/marketing and enrollment for MIPCD. This tool kit is this used to train
physicians about MIPCD outreach and enrollment, but is also used to market MIPCD.
Should these costs be put into training or marketing/outreach?
If costs contribute to both Outreach & Marketing and Training, please report these costs
under Outreach & Marketing. If costs clearly fall predominantly under training, please
report them under training.
9. How do I accurately reconcile expenditures with what was reported on the SF 425 forms,
specifically when the SF 425 reflects a lower amount than the actual expenditures
because expenditures have not yet been processed for those periods?
Because the SF 425 only includes the expenditures that have been processed by the time
that the form is filled out you may have some true expenditures that are not included on
the SF 425 for the current year, but these will be included in next year’s SF 425. You can

report these as (a) current expenditures (so that reported expenditures exceed SF 425
expenditures) or (b) report these in the following period. Please choose whichever
method is easiest for your accounting system. If you choose (a), please add a note
explaining the difference between the reported and SF 425 expenditures, and reconcile
differences in subsequent years. Ideally, you would be able to tell us which line items
differed, but if not, we can understand. If you choose (b), no note will be necessary.

ADMINISTRATIVE COSTS FORM: Years 1-3 to date
State:
________________________
MIPCD COSTS FUNDED BY THE MIPCD GRANT
YEAR 1 (9/13/2011 YEAR 2 (9/13/2012
to 9/12/2012)
to 9/12/13)
$
$
Incentives

YEAR 3 (9/13/2013
to date)
$

Services

$

$

$

Personnel

$

$

$

Training

$

$

$

Outreach & Marketing

$

$

$

Data Systems

$

$

$

Evaluation

$

$

$

Satisfaction Survey

$

$

$

$

$

$

$

$

$

Administrative Costs

Other (please describe
cost in source)
Total*
*This amount should match the
total on the SF425 form;if not,
please explain differences.

SOURCE OF
DATA

MIPCD COSTS FUNDED BY IN-KIND CONTRIBUTIONS
YEAR 1 (9/13/2011 YEAR 2 (9/13/2012
to 9/12/2012)
to 9/12/13)
$
$
Personnel

YEAR 3 (9/13/2013
to date)
$

Other

$

$

$

Total

$

$

$

SOURCE OF
DATA