Part B Allocation and Expenditure forms

RWHAP Part B Program Terms Report Instructions

FY 2016

FY 2016 RWHAP Part B Program Terms Report Instructions

This document provides instructions on submitting the FY 2016 RWHAP Part B Program Terms Report. If you have any questions regarding how to complete this report, please contact your Project Officer.

FY 2016 RWHAP Part B Program Terms Report

The FY 2016 RWHAP Part B Program Terms Report is a single report that all recipients are required to submit for the FY 2016 Ryan White HIV/AIDS Program (RWHAP) Part B Award. The report must include all of the required components and must be completed in this order:

1. FY 2016 RWHAP Part B Consolidated List of Contractors (CLC)

2. FY 2016 RWHAP Part B and Minority AIDS Initiative (MAI) Allocation Report

3. FY 2016 RWHAP Part B Revised SF424A and FY 2016 RWHAP Part B Revised Budget Narrative Spreadsheet

4. FY 2016 RWHAP Part B Revised Implementation Plan

5. FY 2016 RWHAP Part B Contract Review Certification (CRC)

The FY 2016 RWHAP Part B Program Terms Report, with all items listed above, must be submitted through the HRSA Electronic Handbook. The FY 2016 RWHAP Part B MAI Allocation Report, FY 2016 RWHAP Part B Revised Budget Narrative Spreadsheet, and FY 2016 RWHAP Part B CLC must be submitted as Excel spreadsheets.

The FY 2016 RWHAP Part B and MAI Allocations Table, FY 2016 RWHAP Part B Revised SF-424A, and FY 2016 RWHAP Part B Revised Budget Narrative Spreadsheetmust reflect the total amount received on the final Notice of Award (NoA). Only RWHAP Part B funds should be entered into these documents.

Please do not include State funds, rebate funds, program income, or other funding sources in these documents.

Please be advised that all of the individual report items listed above must be approved before the entire Program Terms Report can be approved by your Project Officer.

If revisions are required for individual report items, you must re-submit the entire report with the revisions. Failure to submit a complete FY 2016 RWHAP Part B Program Terms Report in a timely manner will result in a condition being added to the NoA and a possible restriction of all grant funds until all required information is received.

If you require assistance or have questions about the required FY 2016 RWHAP Part B Program Terms Report submission, please contact your DSHAP Project Officer.

FY 2016 RWHAP Part B Program Terms Report Components

Component 1: FY 2016 RWHAP Part B Consolidated List of Contracts (CLC)

All recipients must complete an FY 2016 RWHAP Part B CLC using the format provided in these instructions. The FY 2016 RWHAP Part B CLC must be submitted as an Excel spreadsheet.

A template has been provided for your convenience.

The FY 2016 RWHAP Part B CLC is the list of contracts and/or Fee for Service Memorandum of Understanding (MOU), Memorandum of Agreement (MAO) or Letter of Agreement (LOA) for all subrecipients receiving FY 2016 RWHAP Part B funding, including Emerging Communities and Minority AIDS Iniative (MAI) funding. The FY 2016 RWHAP Part B CLC must include the amounts for each service provided through contracts and/or Fee for Service MOU, MAO or LOA. Subrecipients funded for multiple services must be listed separately for each contracted service, including the funded amount for that specific service. Consortia/Lead Agencies must be included in the CLC.

The total direct Core Medical and Support service contracts and/or Fee for Service Memorandum of Understanding (MOU), Memorandum of Agreement (MAO) or Letter of Agreement (LOA) amount must reflect the total service dollars amounts as indicated in the Contract Review Certification (CRC).

Component 2: FY 2016 RWHAP Part B and MAI Allocation Report

The FY 2016 RWHAP Part B and MAI Allocation Report partially pre-populates based on the information provided for the CLC. The CLC must be completed and correct before completing the FY 2016 RWHAP Part B and MAI Allocation Report.

All recipients must complete the FY 2016 RWHAP Part B and MAI Allocation Report provided, indicating: 1) the priority areas established under the five eligible program components: HIV Care Consortia, Home and Community-Based Care, Health Insurance Programs, Provision of Treatments (including ADAP), and State Direct; and 2) the dollar amount of FY 2016 RWHAP Part B and MAI funds allocated to each prioritized service category related to RWHAP Part B eligible Core Medical and Support Services. All allocations must match the amounts provided in the FY 2016 RWHAP Part B Budget Narrative Spreadsheet and the FY 2016 RWHAP Part B SF424A.

Clinical Quality Management (CQM) allocations may not exceed 5% of the award amount or $3,000,000, whichever amount is smaller. Allocations for Health Insurance Premium and Cost Sharing Assistance using ADAP Earmark/ADAP Supplemental funds should be captured under Health Insurance to Provide Medications. Administrative Costs cannot exceed 10% of the award amount, which includes the RWHAP Base, ADAP Earmark, ADAP Supplemental, Emerging Communities, and MAI awards. Planning and Evaluation (P & E) Activities cannot not exceed 10% of the award amount. Additionally, the combined allocations of P & E and Administration activities cannot exceed 15% of the award.

Consortia funds are considered Support Services Allocations, even if funds are allocated for Core Medical Services.

MAI funds are considered Support Services and must follow the 75/25 rule accordingly. MAI allocations for outreach and education should correlate with the amounts indicated in the MAI award. Allocations for MAI Recipient Administration, P & E, and CQM must be factored into the Administration, P & E, and CQM allocations in Section C to ensure the administrative caps are not exceeded.

Per Title XXVI, Part B, Subpart 1, Section 2612 (b) (1), Core and Support Services Allocations must meet the 75/25 rule, unless the recipient has been approved for a Core Medical Services Waiver per the requirements stated in Federal Register Notice Volume 78, Number 207, Pages 63990-63993, Friday, October 25, 2013.

Component 3: FY 2016 RWHAP Part B Revised SF424A and FY 2016 RWHAP Part B Revised Budget Narrative Spreadsheet

All recipients must complete an FY 2016 RWHAP Part B Revised SF424A and FY 2016 RWHAP Part B Revised Budget Narrative Spreadsheet reflective of the actual award amount for FY 2016.

FY 2016 RWHAP Part B Revised SF424A

The revised FY 2016 RWHAP Part B SF424A must be completed and submitted using the OMB approved SF424A form. The SF424A form may be found here: http://apply07.grants.gov/apply/forms/sample/SF424A-V1.0.pdf.

Section A: Budget Summary:

Column (a) Grant Program Function or Activity:

Row 1: Enter Administration here. In this row, enter all RWHAP Part B funds allocated to recipient administration, planning and evaluation, and quality management under Federal (column e).

Row 2: Enter ADAP here. In this row, enter all funds allocated to ADAP services under Federal (column e).

Row 3: Enter Consortia/Emerging Communities here. In this row, enter all funds allocated to services provided via Consortia and to Emerging Communities under Federal (column e).

Row 4: Enter Direct Services here. In this row, enter all funds allocated to Direct Services, including MAI services under Federal (column e).

Section B: Budget Categories:

Row 6: Object Class Categories:

Column 1: Enter Administration here. In this column, enter all RWHAP Part B Administration funds allocated for Personnel, Fringe Benefits, Travel, Equipment, Supplies, Contractual, Construction, Other, and Indirect Charges.

Column 2: Enter ADAP here. In this column, enter all RWHAP Part B ADAP funds allocated for Personnel, Fringe Benefits, Travel, Equipment, Supplies, Contractual, Construction, Other, and Indirect Charges.

Column 3: Enter Consortia/Emerging Communities here. In this column, enter all RWHAP Part B Consortia/Emerging Communities funds allocated for Personnel, Fringe Benefits, Travel, Equipment, Supplies, Contractual, Construction, Other, and Indirect Charges.

Column 4: Enter Direct Services here. In this column, enter all RWHAP Part B Direct Services funds allocated for Personnel, Fringe Benefits, Travel, Equipment, Supplies, Contractual, Construction, Other, and Indirect Charges.

All contracts (including those for Administration, ADAP, Quality Management, Planning and Evaluation, and HIV Services), must be listed on the Contractual line (row f) on the SF424A and within the appropriate column heading.

Object Class Categories (a.) through (h.) and (j.) must reflect costs from the FY 2016 RWHAP Part B Revised Budget Narrative Spreadsheet.

Row 7: Program Income: Please do not enter any information into any of the cells on this line.

Section C: Non-Federal Resources: Please do not enter any information into any of the cells in this section.

Section D: Forecasted Cash Needs: Please do not enter any information into any of the cells in this section.

Section E: Budget Estimates of Federal Funds Needed for Balance of the Project: Please do not enter any information into any of the cells in this section.

Section F: Other Budget Information:

Row 21: Direct Charges: Please enter the total of all RWHAP Part B funds allocated for Direct Services.

Row 22: Indirect Charges: Please enter the total of all RWHAP Part B funds allocated for Indirect Services. Note: Recipients claiming Indirect Charges should submit an Indirect Cost Rate Agreement.

Row 23: Remarks: Please do not enter any information into this cell.

FY 2016 RWHAP Part B Revised Budget Narrative Spreadsheet

The FY 2016 RWHAP Part B Revised Budget Narrative Spreadsheet must be submitted as an Excel spreadsheet. A template has been provided for your convenience.

The FY 2016 RWHAP Part B Revised Budget Narrative preadsheet must explain the amounts requested for the following: RWHAP Part B Base, ADAP and ADAP Supplemental, Consortia, Emerging Communities, and Minority AIDS Initiative (MAI), and the relevant RWHAP Part B Budget Categories.

The line items provided must explain how they support the overall service delivery system and must also include a detailed justification for any applicable Object Class Categories: Personnel, Fringe Benefits, Travel, Equipment, Supplies, Contractual, Construction, Other and Indirect Charges.

For employees who are less than 1-Full-Time Equivalent (FTE) on the grant, the recipient must enter the percentage of RWHAP Part B funds used to pay for the employee’s salary, identify the full salary amount, and identify all funding sources outside of RWHAP Part B funding for Personnel and Fringe Benefits costs.

For travel costs, the recipient must provide separate costs of In-State and Out-of-State travel.

For additional guidance on completing a revised budget, refer to The Ryan White HIV/AIDS Program Part B Sample Budget Narrative.

Note: Each recipient will incur cost at its own risk until a budget has been approved by HRSA. RWHAP budgets are subject to requirements detailed in the U.S. Department of Health and Human Services Grants Policy Statement and applicable OMB Circulars.

Component 4: FY 2016 RWHAP Part B Revised Implementation Plan

A template has been provided for your convenience.

All recipients must complete an FY 2016 RWHAP Part B Revised Implementation Plan, using the format provided in the Forms section of these instructions, which reflects all the service categories and priorities established by the recipient.

Services funded from Base, ADAP , MAI, ADAP Supplemental, Emerging Community (EC), and MAI funds must be included in this plan, as applicable.

A separate FY 2016 RWHAP Part B Revised Implementation Plan must be submitted for each Core Medical, Support, and MAI service categories accounted for in the FY 2016 RWHAP Part B and MAI Allocation Report.

For additional guidance on completing the FY 2016 RWHAP Part B Revised Implementation Plan, refer to the FY 2016 Ryan White HIV/AIDS Program Part B Sample Implementation Plan Format below and please contact your Project Officer if you have any questions.

A separate table must be completed for each funded service category.

Allocation amounts provided in the FY 2016 RWHAP Part B Revised Implementation Plan must be reflected in the FY 2016 RWHAP Part B and MAI Allocations Report and in the FY 2016 RWHAP Part B Revised Budget Narrative Spreadsheet.

FY 2016 RWHAP Part B Revised Implementation Plan Instructions

The FY 2016 RWHAP Part B Revised Implementation Plan must reflect each Core Medical and Support service category funded for the relative fiscal year. NOTE: All information provided in the FY 2016 RWHAP Part B Revised Implementation Plan must be updated in the FY 2016 RWHAP Part B Annual Progress Report at the end of the grant period.

A separate table must be completed for each funded service category, including ADAP and MAI. The information provided in the MAI service category/categories must reflect the information provided in the FY 2016 RWHAP Part B MAI Plan.

For each funded service category complete the following:

Recipient: Enter the name of the recipient using the name provided in the NoA.

Fiscal Year: Enter FY 2016.

Service Category: Enter the name of the funded Core Medical or Support service. Service Categories must reflect the name of the funded service categories as indicated in the FY 2016 RWHAP Part B and MAI Allocation Report. The Service Category must support the specific goal(s) in the current Comprehensive Plan.

Total Allocation: Enter the total amount of RWHAP Part B funds (Part B Base, ADAP, ADAP Supplemental, Emerging Communities (where applicable) and Minority AIDS Initiative (MAI) (where applicable) allocated for this service category.

Do not include any other funding sources (e.g. medication rebates or state funds).

Service Goal: Enter the overall purpose of the funded service category. This goal should be broad in focus (e.g. To develop and implement medical case management treatment plans for clients that are not engaged in health care; To improve health outcomes of PLWH in the State/Territory.). The Service Goal must support the specific goal(s) in the current Comprehensive Plan.

Current Comprehensive Plan: Enter the specific goal in the current Comprehensive Plan that the Service Category and Objective(s) relates to.

Column 1: Objectives: Enter at least two SMART objectives that specifically describe how the Service Goal will be accomplished. SMART objectives are Specific—Identifying target population and activity, Measurable—Indicating how much or how many, Attainable—Must be realistically accomplished using resources provided, Realistic—Addressing and establishing reasonable programmatic steps, and Time-Sensitive—Indicating a timeline during which the objective will be accomplished. The SMART objective(s) in Column 1 must support the Service Goal. NOTE: For low-incidence states that may have only one objective for a specific Service Goal, please contact your Project Officer.  

For Example: During FY2016, 85% of people enrolled in RWHAP-funded outpatient/ambulatory health services in the jurisdiction will receive at least one medical visit in each six month period of the 24 month measurement period with a minimum of 60 days between medical visits.

Column 2: Service Unit Definition: Provide the name and definition of the unit of service to be provided. For Example: (e.g. one round-trip bus ride, one prescription, 15-minute visit).

Column 3: Quantity:

3a) Total Number of People to be Served: Provide the total number of people to be served during the grant year.

3b) Total Number of Service Units to be Provided Provide sthe total number of service units to be provided during the grant year. The number of people and units should be reasonable given the objective and allocated amount.

Column 4: Time Frame: Enter the estimated duration of the activity relating to the objective listed. Note: The timeframe cannot exceed the current budget period (April 1- March 31 of the current grant year).

Column 5: Funds: Provide the approximate amount of all RWHAP Part B funds to be used for each objective by funding source. RWHAP Part B funding sources include Part B Formula funding, AIDS Drug Assistance Program (ADAP) earmark, including ADAP Flexibility funds, ADAP Supplemental, and Emerging Communities. For applicable service categories, please indicate the approximate amount of Minority AIDS Initiative (MAI) funding used for outreach and education activities.

Block 6: Outcomes: From the objective(s) in Column 1, select a minimum of at least one client-level outcome/indicator to be tracked for the objective (using the HAB Standard Outcome Measures resource document); provide benchmark (baseline) data for each outcome/indicator to be tracked; and provide the data source for tracking progress of the outcome/indicatorCoordinating the chosen measures with the Clinical Quality Management program measures is encouraged as there does not need to be a separate set of measures. The Measures for Core Medical Services and Support Services document provides a list of measures that may be used for each funded service. Refer to the HAB HIV Performance Measures and the HHS HIV Common Indicators for additional guidance. The client-level outcome/indicator(s) in block 6 must relate to the SMART objective(s) in Column 1.

Block 7: Stage of the HIV Care Continuum related to this service category: Select at least one stage of the HIV Care Continuum that is related to this specific service category (i.e., Diagnosed, Linked to Care, Retained in Care, Prescribed Antiretroviral Therapy, or Virally Suppressed). NOTE: More than one Stage may be applicable to the service category.

Component 5: FY 2016 RWHAP Part B Contract Review Certification (CRC)

All recipients must complete a signed FY 2016 RWHAP Part B CRC using the format provided in these instructions. A template has been provided for your convenience.

Note: The total amount awarded for direct Core Medical and Support service contracts required at the top of the form must include all direct Core Medical and Support service contracts, MOU, MOA, and/or LOA for RWHAP Part B and MAI services. Applicable Office of Management and Budget Circulars for the certification are also included. The signatures of both the Recipient Project Director and the Recipient Budget (Fiscal) Officer must be provided. The Recipient Budget (Fiscal) Officer should be the fiscal point of contact at the state/territory level.

The Total RWHAP Part B amount awarded in Direct Core Medical and Support service Contracts for FY 2016 should reflect total direct Core Medical and Support service contract dollars for Core, Support, ADAP, and MAI as reflected on the the CLC.

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