| FY 2017 RWHAP Part B (X07) and MAI Allocations Report | ||||||||
| Instructions are located in EHB: https://grants.hrsa.gov/webexternal/Login.asp | Section B: Reporting Year Award Information | |||||||
| 1. Part B Base Award | ||||||||
| 2. Part B ADAP Earmark Award | ||||||||
| Section A: Identifying Information | 3. Part B ADAP Supplemental Award | |||||||
| ~ Enter Name of Recipient Here ~ | 4. Total ADAP Award (ADAP Base + Supplemental) | $0 | ||||||
| ~ Enter Preparer's Name Here ~ | 5. Part B Emerging Communities Award | |||||||
| ~ Enter Preparer's Phone Number Here ~ | 6. Total Part B X07 Funds | $0 | ||||||
| ~ Enter Preparer's Email Address Here ~ | 7. Part B MAI Award | |||||||
| 8. Total Part B X07 Award | $0 | |||||||
| Section C: Part B Allocations by Program Component | 1. Base Award | 2. ADAP + ADAP Supplemental Award | 3. Emerging Communities Award (EC) | 4. Total | ||||
| Amount | Percentage | Amount | Percentage | Amount | Percentage | Amount | Percentage | |
| 1. Part B AIDS Drug Assistance Program Subtotal | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| a. ADAP Services | - - | - - | - - | $0 | - - | |||
| b. Health Insurance to Provide Medications | - - | - - | - - | $0 | - - | |||
| c. ADAP Access/Adherence/Monitoring Services | - - | - - | - - | $0 | - - | |||
| 2. Part B Health Insurance Premium & Cost Sharing Assistance | - - | - - | $0 | - - | ||||
| 3. Part B Home and Community-based Health Services | - - | - - | $0 | - - | ||||
| 4a. Part B HIV Care Consortia/EC services (Provide detail in Section D, Column 1 or 3)1 | $0 | - - | $0 | - - | $0 | - - | ||
| 4b. Part B HIV Care Consortia Administration2 | - - | - - | $0 | - - | ||||
| 5. Part B State Direct Services (Provide detail in Section D, Column 2)1 | $0 | - - | - - | $0 | - - | |||
| 6. Part B Clinical Quality Management3 | - - | - - | - - | $0 | - - | |||
| 7. Part B Recipient Planning & Evaluation Activities4 | - - | - - | - - | $0 | - - | |||
| 8. Recipient Administration 4 | - - | - - | - - | $0 | - - | |||
| 9. Column Totals | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | - - |
| 10.Total Part B X07 Allocations5 | $0 | |||||||
| Section D: Breakdown for Consortia, State Direct Services and Emerging Communities | 1. Consortia7 | 2. Direct Services | 3. Emerging Communities | 4. Total | ||||
| Amount | Percentage | Amount | Percentage | Amount | Percentage | Amount | Percentage | |
| 1. Core Medical Services Sub-total | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| a. AIDS Drug Assistance Program (ADAP) Treatments | ||||||||
| b. AIDS Pharmaceutical Assistance (LPAP) | - - | - - | $0 | - - | ||||
| c. Early Intervention Services | - - | - - | - - | $0 | - - | |||
| d. Health Insurance Premium & Cost Sharing Assistance | - - | - - | $0 | - - | ||||
| e. Home and Community-based Health Services | - - | $0 | - - | |||||
| f. Home Health Care | - - | - - | - - | $0 | - - | |||
| g. Hospice | - - | - - | - - | $0 | - - | |||
| h. Medical Case Management (including Treatment Adherence Services) | - - | - - | - - | $0 | - - | |||
| i. Medical Nutrition Therapy | - - | - - | - - | $0 | - - | |||
| j. Mental Health Services | - - | - - | - - | $0 | - - | |||
| k. Oral Health Care | - - | - - | - - | $0 | - - | |||
| l. Outpatient /Ambulatory Health Services | - - | - - | - - | $0 | - - | |||
| m. Substance Abuse Outpatient Care | - - | - - | - - | $0 | - - | |||
| 2. Support Services Sub-total | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| a. Child Care Services | - - | - - | - - | $0 | - - | |||
| b. Emergency Financial Assistance | - - | - - | - - | $0 | - - | |||
| c. Food Bank/Home-Delivered Meals | - - | - - | - - | $0 | - - | |||
| d. Health Education/Risk Reduction | - - | - - | - - | $0 | - - | |||
| e. Housing | - - | - - | - - | $0 | - - | |||
| f. Linguistics Services | - - | - - | - - | $0 | - - | |||
| g. Medical Transportation | - - | - - | - - | $0 | - - | |||
| h. Non-Medical Case Management Services | - - | - - | - - | $0 | - - | |||
| i. Other Professional Services | - - | - - | - - | $0 | - - | |||
| j. Outreach Services | - - | - - | - - | $0 | - - | |||
| k. Psychosocial Support Services | - - | - - | - - | $0 | - - | |||
| l. Referral for Health Care and Support Services | - - | - - | - - | $0 | - - | |||
| m. Rehabilitation Services | - - | - - | - - | $0 | - - | |||
| n. Respite Care | - - | - - | - - | $0 | - - | |||
| o. Substance Abuse Services - residential | - - | - - | - - | $0 | - - | |||
| 3. Total Services Allocations | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| MAI Award | Footnotes: (1) The total services amounts will automatically be calculated based on the details you provide in Section D, column 1 or 2 or 3. (2) Consortia/Emerging Communities Administration, Planning and Evaluation costs may not exceed 10% of their respective total funds. (3) Clinical Quality Management may not exceed 5% of the Part B X07 award, or 3 million, whichever amount is smaller. (4) Planning & Evaluation or Recipient Administration may not exceed 10% of the Part B X07 award. Additionally, the combined costs for these two categories may not exceed 15% of the Part B X07 award. (5) This amount must equal the recipient's total Part B X07 Award. (7) All services in this column are considered Support Services. |
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| Section E: MAI Allocations by Program Component | Amount | Percentage | ||||||
| 1. Education to increase minority participation in ADAP | - - | |||||||
| 2. Outreach to increase minority participation in ADAP | - - | |||||||
| 3. Clinical Quality Management 3 | - - | |||||||
| 4. Recipient Planning & Evaluation Activities 4 | - - | |||||||
| 5. Recipient Administration 4 | - - | |||||||
| 6. Total MAI Allocations | $0 | 0.00% | ||||||
| FOR OFFICE USE ONLY: | ||||||||
| o Recipient received waiver for 75% core medical services requirement. | ||||||||
| PUBLIC BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number. The OMB control number for this project is 0915-0318. Public reporting burden for this collection of information is estimated to be 12 hours per response. These estimates include the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments to HRSA Reports Clearance Officer, Health Resources and Services Administration, Room 10-33, 5600 Fishers Lane, Rockville, MD. 20857. | ||||||||
| LEGISLATIVE REQUIREMENTS CHECKLIST | |||||
| INSTRUCTIONS: Recipients and Project Officers should use the following table to help determine whether or not the various Part B legislative spending requirements have been met. For more information on each of these requirements, please refer to the Ryan White HIV/AIDS Treatment Extension Act of 2009. | |||||
| CORE MEDICAL SERVICES | Amount | Percentage (Amount / Total Service Allocations) |
|||
| ADAP (H16) | $0 | - - | |||
| Home-and Community-based Health Services (H21) | $0 | - - | |||
| Health Insurance Premium & Cost Sharing Assistance (H20) | $0 | - - | |||
| State-Direct Services: Core Medical Services (D33) | $0 | - - | |||
| Emerging Communities: Core Medical Services (F33) | $0 | - - | |||
| Total Core Medical Services Allocations | $0 | - - | |||
| Support Services Allocations | Amount | Percent | |||
| Consortia Services (B22) + Consortia Administration (B23) | $0 | - - | |||
| State-Direct Services: Support Services (D47) | $0 | - - | |||
| Emerging Communities: Support Services (F47) | $0 | - - | |||
| MAI Allocations for Education + Outreach Services (B67 + B68) | $0 | - - | |||
| Total Support Services Allocations | $0 | - - | |||
| Total Service Allocations | $0 | ||||
| CLINICAL QUALITY MANAGEMENT | |||||
| Total Clinical Quality Management allocations must be 5% of the total X07 award or $3 million (whichever is smaller.) To the right in red, is the maximum (Capped Amount) that may be allocated to Clinical Quality Management (the lessor of I11 * .05 or $3 million) as well as the amount of Current Fiscal Year dollars allocated (CQM Allocations) on Clinical Quality Management (H25+B69). Please check to make sure the Allocations do not exceed the Capped Amount. |
$0 | (Capped Amount) | |||
| $0 | (CQM Allocations) | ||||
| PLANNING AND EVALUATION / RECIPIENT ADMINISTRATION | |||||
| Total Part B X07 Planning and Evaluation allocations and total Recipient Administration allocations must each be 10% or less than the total X07 award. Planning and Evaluation and Recipient Administration do not necessarily need to be 10% of each funding stream as long as the combined total of each is 10% or less of the total X07 award. In addition, Planning and Evaluation and Recipient Administration allocations combined must not exceed 15% of the total X07 award. To the right in red, is the percentage of Planning and Evaluation allocations divided by the Total X07 award (H26 + B70) / I11 and Recipient Administration allocations divided by the Total X07 award (H27 + B71) / I11. Please check to make sure these percentage are not greater than 10%. Also shown is the percentage of the combined Planning and Evaluation and Recipient Administration allocations divided by the Total X07 Award (H26 + H27 + B70 + B71) / I11. Please check to make sure this percentage is not greater than 15%. |
$0 | 0.0% | (Planning & Evaluation) | ||
| $0 | 0.0% | (Recipient Administration) | |||
| $0 | 0.0% | (Planning & Evaluation + Recipient Administration) | |||
| CONSORTIA ADMINISTRATION | |||||
| Consortia administration allocations must be 10% or less than the total Consortia funds. To the right in red, is the percentage of consortia administration allocations divided by the consortia allocations (B23 / B22). Please check to make sure this percentage does not exceed 10%. |
|||||
| $0 | 0.0% | (Consortia Administration) | |||
| EC ADMINISTRATION | |||||
| EC administration allocations must be 10% or less than the total EC funds. To the right in red, is the percentage of EC administration allocations divided by the EC award (F27 / I8). Please check to make sure this percentage does not exceed 10%. |
|||||
| $0 | 0.0% | (EC Administration) | |||
| FY 2017 RWHAP PART B SUPPLEMENTAL EXPENDITURE REPORT INSTRUCTIONS | ||||||||
| Please print this sheet to review instructions. | ||||||||
| Recipients should complete the Suppl Expenditures Report (blue tab) to prepare the required "FY 2017 Ryan White HIV/AIDS Program (RWHAP) Part B Supplemental Expenditures Report". Complete steps 1-4 below and fill the areas or cells highlighted in light yellow with appropriate data. NOTE: Please do not enter any information into cells highlighted in gray, as these cells contain formulas. |
||||||||
| Identifying information (yellow section): Enter the name of the recipient, name of the preparer, and preparer's phone number. | ||||||||
| Award Amounts (gold and yellow sections): Enter the FY 2017 RWHAP Part B Supplemental award amount. | ||||||||
| Section A - Expenditures by Program Component (sky blue section): Enter the amounts spent from the RWHAP Part B Supplemental award. For (Section A) rows 4a & 5 are automatically populated from (Section B) . | ||||||||
| Section B - Breakdown of Final Funding (light green section): This section provides details about funding amounts not captured in Section A. Use the columns provided to enter amounts spent by service category in relation to Consortia and State Direct Services final funding. The grantee should use the calculated amount of Total RWHAP Part B Program Supplemental final funding from Section A row 4a (RWHAP Part B Supplemental HIV Care Consortia) and row 5 (RWHAP Part B Supplemental State Direct Services) when you provide a detailed breakdown of final funding in Section B for Consortia and Direct Services respectively. Rows 10a-m are allowable Core Medical Services; rows 11a-o are allowable Support Services. Formulas will generate sub-totals for Core Medical (row 10) and Support Services (row 11); calculate column percentages; and sum column totals (row 12). | ||||||||
| Reminder: The legislation mandates that ALL Consortia Funding be considered 'Support Services.' Notes: (1) Row 10a is blocked for Consortia and Direct Services because those funding amounts are already accounted for in Section A. (2) Row 10b. (AIDS Pharmaceutical Assistance (local), or LPAP) is blocked for Direct Services, because only Consortia funds may be used to provide LPAP services. (3) Rows 10d ( Health Insurance Premium & Cost Sharing Assistance) and 10e (Home and Community-based Health Services) are blocked for Direct Services because these funding amounts are already accounted for in Section A. | ||||||||
| Core Medical Services Calculation (yellow tab worksheet): As amounts are entered in the Funding Table (blue-tab), formulas will automatically calculate the amount and percentage of total RWHAP Part B Supplemental service dollars that were spent for Core Medical Services and for Support Services in FY 2017. | ||||||||
| Reminder: Recipients are reminded that the 75% Core Medical Services Requirement is applicable to the RWHAP Part B Supplemental Award. |
| FY 2017 RWHAP Part B Supplemental Expenditures Report | ||||||||||
| Enter Recipient's Name | ||||||||||
| Enter Preparer's Name | ||||||||||
| Enter Preparer's Phone Number | ||||||||||
| Enter FY 2017 RWHAP Part B Supplemental Award | ||||||||||
| Section A: Expenditures by Program Component | Total FY 2017 RWHAP Part B Supplemental Award | |||||||||
| Amount | Percent | |||||||||
| 1. RWHAP Part B Supplemental AIDS Drug Assistance Program Subtotal | $0 | - - | ||||||||
| a. ADAP Services | - - | |||||||||
| b. Health Insurance to Provide Medications | - - | |||||||||
| c. ADAP Access/Adherence/Monitoring Services | - - | |||||||||
| 2. RWHAP Part B Supplemental Health Insurance Premium & Cost Sharing Assistance | - - | |||||||||
| 3. RWHAP Part B Supplemental Home and Community-based Health Services | - - | |||||||||
| 4a. RWHAP Part B Supplemental HIV Care Consortia (Provide detail in Section B) | $0 | - - | ||||||||
| 4b. RWHAP Part B Supplemental HIV Care Consortia/EC Administration | - - | |||||||||
| 5. RWHAP Part B Supplemental State Direct Services (Provide detail in Section B) | $0 | - - | ||||||||
| 6. RWHAP Part B Supplemental Clinical Quality ManagementFootnote 1 | - - | |||||||||
| 7. RWHAP Part B Supplemental Recipient Planning & Evaluation ActivitiesFootnote 2 | - - | |||||||||
| 8. Recipient AdministrationFootnote 2 | - - | |||||||||
| 9. Total RWHAP Part B Supplemental Funding Amounts | $0 | 0.00% | ||||||||
| Section B: Breakdown for Consortia, State Direct Services, and Emerging Communities Final Funding | Consortia Footnote 3 | Direct Services | ||||||||
| Amount | Percent | Amount | Percent | |||||||
| 10. Core Medical Services Sub-total | $0 | - - | $0 | - - | ||||||
| a. AIDS Drug Assistance Program (ADAP) Treatments | ||||||||||
| b. AIDS Pharmaceutical Assistance (LPAP) | - - | |||||||||
| c. Early Intervention Services | - - | - - | ||||||||
| d. Health Insurance Premium & Cost Sharing Assistance | - - | |||||||||
| e. Home and Community-based Health Services | - - | |||||||||
| f. Home Health Care | - - | - - | ||||||||
| g. Hospice | - - | - - | ||||||||
| h. Medical Case Management (including Treatment Adherence Services) | - - | - - | ||||||||
| i. Medical Nutrition Therapy | - - | - - | ||||||||
| j. Mental Health Services | - - | - - | ||||||||
| k. Oral Health Care | - - | - - | ||||||||
| l. Outpatient /Ambulatory Health Services | - - | - - | ||||||||
| m. Substance Abuse Outpatient Care | - - | - - | ||||||||
| 11. Support Services Sub-total | $0 | - - | $0 | - - | ||||||
| a. Child Care Services | - - | - - | ||||||||
| b. Emergency Financial Assistance | - - | - - | ||||||||
| c. Food Bank/Home-Delivered Meals | - - | - - | ||||||||
| d. Health Education/Risk Reduction | - - | - - | ||||||||
| e. Housing | - - | - - | ||||||||
| f. Linguistics Services | - - | - - | ||||||||
| g. Medical Transportation Services | - - | - - | ||||||||
| h. Non-Medical Case Management Services | - - | - - | ||||||||
| i. Other Professional Services | - - | - - | ||||||||
| j. Outreach Services | - - | - - | ||||||||
| k. Psychosocial Support Services | - - | - - | ||||||||
| l. Referral for Health Care and Support Services | - - | - - | ||||||||
| m. Rehabilitation Services | - - | - - | ||||||||
| n. Respite Care | - - | - - | ||||||||
| o. Substance Abuse Residential Services | - - | - - | ||||||||
| 12. Total Funding Amounts | $0 | - - | $0 | - - | ||||||
| (1) May not exceed 5% of the FY 2017 RWHAP Part B Supplemental award, or $3 million, whichever amount is smaller. | ||||||||||
| (2) May not use more than 10% of the FY 2017 RWHAP Program Part B Supplemental award for either Planning and Evaluation or Grantee Administration; | ||||||||||
| additionally, the combined costs for these two categories may not exceed 15% of the FY 2017 RWHAP Part B Supplemental award. | ||||||||||
| (3) All services in this column are considered Support Services. | ||||||||||
| Automatic Calculation of FY 2017 RWHAP Part B Supplemental Core Medical & Support Services Expenditures | |||||||
| Recipient Name: | |||||||
| This table is provided for grantees to automatically calculate their final Core Medical Service funding/percentages across all FY 2017 RWHAP Part B Supplemental Award service dollars. | |||||||
| The cell numbers referenced are shown in blue and come from Suppl Expenditures Report (blue tab). | |||||||
| Core Medical Services Expenditures | Amount | Percent Amount / Total Service Funding | |||||
| ADAP (B12) | $0 | - - | |||||
| Health Insurance Premium & Cost Sharing Assistance (B16) | $0 | - - | |||||
| Home-and Community-based Health Services (B17) | $0 | - - | |||||
| State-Direct Services: Core Medical Services (D29) | $0 | - - | |||||
| Total Core Medical Services Expenditure Amount | $0 | - - | |||||
| Support Services Expenditures | Amount | Percent | |||||
| Consortia Services (B18) | $0 | - - | |||||
| State-Direct Services: Support Services (D43) | $0 | - - | |||||
| Total Support Services Expenditure Amount | $0 | - - | |||||
| Total FY 2017 RWHAP Part B Supplemental Core Medical & Support Services Expenditure Amount | $0 | - - | |||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |