CMS-10249 Annual Financial Forms for Existing Grantees

CMS-10249
OMB 0938-1053 (Expires: TBD)
Protocol for Submitting Annual Financial Forms-Existing Grantees
January 2011
1) MFP Supplemental Budget Request
a. Modified SF-424a Supplemental Budget Request Information
- see worksheet tabs for template and instructions
b. Cover Letter
Send the cover letter and forms (3) by January 31, 2011 to:
Centers for Medicare and Medicaid Services
Office of Acquisition and Grants Management
Division of Research Contracts and Grants
Attention: Grants Office
Mail Stop: C2-21-15
7500 Security Blvd
Baltimore, MD 21244
Include the following in the cover letter:
_____
_____
_____
_____
_____

Award/Grant Number
The total amount of Federal Funds you are requesting for the 2011 request
The total amount of State Match Funds you are budgeting for the 2011 request
Signature of an authorized representative of the State
Name & address of Principal Investigator/Project Director to receive award letter also

2) Worksheet for Proposed Budget 2011-2016
- see worksheet tabs for template and instructions
Please note that what is projected on your Worksheet for Proposed Budget for 2011-2016, will
be the amounts that are committed to your MFP grant for future years.
Any remaining unobligated funds from prior years, must be expended before any new money
is expended.
3) Maintenance of Effort Form
- see worksheet tabs for template and instructions
Please note that a copy of all submitted documents must also be emailed to [email protected]
for Programmatic review and approval. Without the approval of your CMS Project Officer, your
supplemental award request will not be processed and approved by the CMS Grants Office.

MFP DEMONSTRATION GRANT SUPPLEMENTAL BUDGET REQUEST INFORMATION
STATE NAME:
AWARD NO. (Grant#):
SECTION A - BUDGET SUMMARY
Grant Program:
MFP
Demonstration
(a)
CY 2010 Funding
2011 Request

Federal Domestic
Assistance
Number
(b)
93.791
93.791

Estimated Unobligated Funds
Federal
State Match
(c)
(d)
$0
$0

New or Revised Budget
Federal
State Match
(e)
(f)
$0
$0

Total

Total
(g)
$0
$0
$0

$0
$0

SECTION B - BUDGET CATEGORIES
CY 2011 Federal Funds CY 2011 State Match Funds

Object Class Categories
a. Personnel
b. Fringe Benefits
c. Travel
d. Equipment
e. Supplies
f. Contractual
g. Construction
h. Service Dollars
i. Total Direct Charges (sum of a-h)
j. Indirect Charges
k. TOTALS (sum of i and j)

(1)

(2)

(3)

(4)

Total
(5)

$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0

$0
$0
$0

$0
$0
$0

$0
$0
$0

$0

$0

$0

MFP DEMONSTRATION GRANT SUPPLEMENTAL BUDGET REQUEST INFORMATION
STATE NAME: STEP ONE
AWARD NO. (Grant#): STEP TWO
SECTION A - BUDGET SUMMARY
MFP
Demonstration
Calendar Year
(a)
CY 2010 Funding
2011 Request
Total

Federal Domestic
Assistance
Number
(b)
93.791
93.791

Estimated Unobligated Funds
Federal
State Match
(c)
(d)
STEP FOUR
STEP THREE

New or Revised Budget
Federal
State Match
(e)
(f)
STEP FIVE

Tota
(g)

STEP SIX
$0

$0
SECTION B - BUDGET CATEGORIES

Object Class Categories
a. Personnel
b. Fringe Benefits
c. Travel
d. Equipment
e. Supplies
f. Contractual
g. Construction
h. Service Dollars
i. Total Direct Charges (sum of a-h)
j. Indirect Charges
k. TOTALS (sum of i and j)

(1)

(2)

CY 2011 Federal Funds

CY 2011 State Match Funds

(3)
STEP SEVEN
STEP SEVEN
STEP SEVEN
STEP SEVEN
STEP SEVEN
STEP SEVEN

(4)
STEP TEN
STEP TEN
STEP TEN
STEP TEN
STEP TEN
STEP TEN

STEP EIGHT

STEP ELEVEN
$0

STEP NINE

$0
STEP TWELVE

$0
TOTALS MUST MATCH

$0
TOTALS MUST MATCH

Tota
(5)

al
$0
$0
$0
al
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Step by Step Instructions for Completing the Modified SF-424a Budget Information Sheet for MFP Supplemental Budget Requests
Step
1
2
3
4
5
6

Action

Comments
SECTION A - BUDGET SUMMARY
Enter the State Organization
See section 11 of the most recent Notice of Award (NoA) from CMS
Enter the award/grant number
See section 3 of the most recent Notice of Award (NoA) from CMS
Enter the amount of estimated unexpended Federal funds from your
previous MFP grant award
This figure should include admin and services only
Enter the amount of estimated unexpended State match funds from your
previous grant award
Enter the 2011 new Federal Funds being requested
This figure comes from the Worksheet for Proposed Budget
Enter the 2011 State Match funds that you have budgeted
SECTION B - BUDGET CATEGORIES

7

Enter the 2011 new Federal Funds for your supplemental request in object
class categories a through f

8

Enter the 2011 new Federal Funds for services in object class category h .

9
10

Enter any Indirect charges if applicable
Enter the 2011 State Match for object class categories a through f

11

Enter the 2011 State Match for services in object class category h .

12

Enter any Indirect charges if applicable

Notes
All shaded gray areas are not to be completed
Construction costs are not allowed

Object class categories a through f come from your Administrative
Claims. Totals must match your submitted Worksheet for Proposed
Budget.

Object class category h comes from your Services Claims requirements
submitted with your protocol for the upcoming year less any funds unobligated
from the current year
Indirect charges should be submitted in accordance with the most recent
approved Indirect Cost Rate Agreement
These costs are based on the FMAP projected State share
Object class category h comes from your services claim State match
requirements for the upcoming calendar year less any unobligated funds from
the current year
Indirect charges should be submitted in accordance with the most recent
approved Indirect Cost Rate Agreement

Total Federal budget in Section A must match the total Federal budget in Section B
Total State Match in Section A must match the total State Match in Section B

Section A, column (g) and Section B, row (k) will calculate automatically

CY 2015 Money Follows the Per
Worksheet for P
Instructions: Please fill in only the cells highlighted in YELLOW. All other cells will auto po
Date of Report:
State:
Grant Number:
Original and ARRA Increased Federal Medicaid Assistance Percentages (FMAP) are prov
“Expenditures may vary slightly. States are responsible for keeping accurate records for auditing purpos
FMAP Table
Please express FMAP
as a decimal
(example: 68.32%=0.6832)

Column 1

Original State FMAP

Calendar Year Quarters
through 2020

Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar

2008
2009
2009
2009
2009
2010
2010
2010
2010
2011
2011
2011
2011
2012
2012
2012
2012
2013
2013
2013
2013
2014

FFY 2007
FFY 2008
FFY 2009 Q1
FFY 2009 Q2
FFY 2009 Q3
FFY 2009 Q4
FFY 2010 Q1
FFY 2010 Q2
FFY 2010 Q3
FFY 2010 Q4
FFY 2011 Q1
FFY 2011 Q2
FFY 2011 Q3
FFY 2011 Q4
FFY 2012 Q1
FFY 2012 Q2
FFY 2012 Q3
FFY 2012 Q4
FFY 2013 Q1
FFY 2013 Q2
FFY 2013 Q3
FFY 2013 Q4
FFY 2014 Q1
FFY 2014 Q2

Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec
Jan - Mar
Apr - Jun
Jul - Sept
Oct - Dec

2014
2014
2014
2015
2015
2015
2015
2016
2016
2016
2016
2017
2017
2017
2017
2018
2018
2018
2018
2019
2019
2019
2019
2020
2020
2020
2020

FFY 2014 Q3
FFY 2014 Q4
FFY 2015 Q1
FFY 2015 Q2
FFY 2015 Q3
FFY 2015 Q4
FFY 2016 Q1
FFY 2016 Q2
FFY 2016 Q3
FFY 2016 Q4
FFY 2017 Q1
FFY 2017 Q2
FFY 2017 Q3
FFY 2017 Q4
FFY 2018 Q1
FFY 2018 Q2
FFY 2018 Q3
FFY 2018 Q4
FFY 2019 Q1
FFY 2019 Q2
FFY 2019 Q3
FFY 2019 Q4
FFY 2020 Q1
FFY 2020 Q2
FFY 2020 Q3
FFY 2020 Q4
FFY 2021 Q1

Populations Transitions Chart (unduplicated count)
Unduplicated Count - Each individual is only counted once in the year that they physically trans
All population counts and budget estimates are based on the Calendar Year (CY) .
The State is held accountable for the current year populations to be transitioned and actual num
All prior year actuals must be updated accordingly to match what is reported on the semi-annual reports.

Elderly
CY 2007 (actuals)
CY 2008 (actuals)
CY 2009 (actuals)
CY 2010 (actuals)
CY 2011 (actuals)
CY 2012 (actuals)
CY 2013 (actuals)
CY 2014 (estimated actuals)
CY 2015 (projected)
CY 2016 (projected)

ID/DD

CY 2017 (projected)
CY 2018 (projected)*
Total Count

0

0

If a Grantee achieves less than the 85
See Policy Guidance Achieving and Amending Transition Benchmarks July 2014

Demonstration Budget Summary-All Years
* Qualified HCBS Services, Demonstration HCBS Services and Supplemental Services are de
* Administration - Normal - costs that adhere to CFR Title 42, Section 433(b)(7);
* Administrative - 75% - costs that adhere to CFR Title 42, Sections 433(b)(4) and 433(b)(10);
* Administrative - 90% - costs that adhere to CFR Title 42 Section 433(b)(3)
* Federal Evaluation Supports - costs related to administering the Quality of Life Survey (reimb
* Rebalancing Fund - estimates State's savings attributed to Enhanced FMAP Rate that could
* Other - Other costs reimbursed at a flat rate (to be determined by CMS)
Total Expenditures (2007 - 2017)
Qualified HCBS
Demonstration HCBS
Supplemental
Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation - 50%
ADRC Funding - 100%
AIAN Funding (Tribal) - 100%
Total

Total Costs (Fed & State)
$
$
$
$
$
$
$
$
$
$
$
$

Administrative 20% Cap Calculation Through CY 2017
Total Costs (Fed & State less Fed Eval, ADRC & AIAN) $
Total Administrative Costs (Fed & State) $
#DIV/0!
Admin. to Services Percentage (20% Max)
#DIV/0!
Administrative Cost CY 2018-2020
Total Administrative Costs (Fed & State) CY 2018 $
Total Administrative Costs (Fed & State) CY 2019 $
Total Administrative Costs (Fed & State) CY 2020 $

Total Costs (Fed & State) Per Capita
Service Costs
#DIV/0!
#DIV/0!
Admin Costs

-

-

-

Please update actual expendit
CY 2007
Qualified HCBS
Demonstration HCBS
Supplemental
Administrative - Normal
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports
Administrative (Other) - 100%
State Evaluation (if approved)
ADRC Funding
CY 2007 Actual Total

Rate
0.5000
0.5000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000

CY 2008 (including Partial Year Increased FMAP)

Rate

Qualified HCBS (Jan - Sept)
Qualified HCBS (Oct - Dec increased FMAP)
Demonstration HCBS (Jan - Sept)
Demonstration HCBS (Oct - Dec increased FMAP)
Supplemental (Jan - Sept)
Supplemental (Oct - Dec increased FMAP)
Administrative - Normal
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports
Administrative (Other) - 100%
State Evaluation (if approved)
ADRC Funding
CY 2008 Actual Total

0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000

CY 2009 (using Increased FMAP)
Qualified HCBS (Jan-Mar increased FMAP)
Qualified HCBS (Apr-Jun increased FMAP)
Qualified HCBS (Jul- Sep increased FMAP)
Qualified HCBS (Oct - Dec increased FMAP)
Demonstration HCBS (Jan-Mar increased FMAP)
Demonstration HCBS (Apr-Jun increased FMAP)
Demonstration HCBS (Jul- Sep increased FMAP)
Demonstration HCBS (Oct - Dec increased FMAP)
Supplemental (Jan-Mar increased FMAP)

Rate
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.0000

Supplemental (Apr-Jun increased FMAP)
Supplemental (Jul- Sep increased FMAP)
Supplemental (Oct - Dec increased FMAP)
Administrative - Normal
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports
Administrative (Other) - 100%
State Evaluation (if approved)
ADRC Funding
CY 2009 Actual Total

CY 2010 (using increased FMAP)
Qualified HCBS (Jan-Mar increased FMAP)
Qualified HCBS (Apr-Jun increased FMAP)
Qualified HCBS (Jul- Sep increased FMAP)
Qualified HCBS (Oct - Dec increased FMAP)
Demonstration HCBS (Jan-Mar increased FMAP)
Demonstration HCBS (Apr-Jun increased FMAP)
Demonstration HCBS (Jul- Sep increased FMAP)
Demonstration HCBS (Oct - Dec increased FMAP)
Supplemental (Jan-Mar increased FMAP)
Supplemental (Apr-Jun increased FMAP)
Supplemental (Jul- Sep increased FMAP)
Supplemental (Oct - Dec increased FMAP)
Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding
CY 2010 Actual Total

CY 2011 (using partial year increased FMAP)
Qualified HCBS (Jan-Mar increased FMAP)
Qualified HCBS (Apr-Jun increased FMAP)
Qualified HCBS (Jul-Sept)
Qualified HCBS (Oct-Dec)
Demonstration HCBS (Jan-Mar increased FMAP)
Demonstration HCBS (Apr-Jun increased FMAP)
Demonstration HCBS (Jul-Sept)

0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000

Rate
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000

Rate
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000

Demonstration HCBS (Oct-Dec)
Supplemental (Jan-Mar increased FMAP)
Supplemental (Apr-Jun increased FMAP)
Supplemental (Jul-Sept)
Supplemental (Oct-Dec)
Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding - 100%
CY 2011 Actual Totals

CY 2012
Qualified HCBS (Jan-Mar)
Qualified HCBS (Apr-Jun)
Qualified HCBS (Jul-Sept)
Qualified HCBS (Oct-Dec)
Demonstration HCBS (Jan-Mar)
Demonstration HCBS (Apr-Jun)
Demonstration HCBS (Jul-Sept)
Demonstration HCBS (Oct-Dec)
Supplemental (Jan-Mar)
Supplemental (Apr-Jun)
Supplemental (Jul-Sept)
Supplemental (Oct-Dec)
Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding - 100%
CY 2012 Actual Totals

CY 2013
Qualified HCBS (Jan-Mar)
Qualified HCBS (Apr-Jun)
Qualified HCBS (Jul-Sept)
Qualified HCBS (Oct-Dec)
Demonstration HCBS (Jan-Mar)

0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000

Rate
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000

Rate
0.5000
0.5000
0.5000
0.5000
0.5000

Demonstration HCBS (Apr-Jun)
Demonstration HCBS (Jul-Sept)
Demonstration HCBS (Oct-Dec)
Supplemental (Jan-Mar)
Supplemental (Apr-Jun)
Supplemental (Jul-Sept)
Supplemental (Oct-Dec)
Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding - 100%
CY 2013 Actual Totals

0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000

For CY 2014, Report ESTIMATED
CY 2014
Qualified HCBS (Jan-Mar)
Qualified HCBS (Apr-Jun)
Qualified HCBS (Jul-Sept)
Qualified HCBS (Oct-Dec)
Demonstration HCBS (Jan-Mar)
Demonstration HCBS (Apr-Jun)
Demonstration HCBS (Jul-Sept)
Demonstration HCBS (Oct-Dec)
Supplemental (Jan-Mar)
Supplemental (Apr-Jun)
Supplemental (Jul-Sept)
Supplemental (Oct-Dec)
Administrative - Normal
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding - 100%
AIAN Funding (Tribal) - 100%
CY 2014 Estimated Actual Totals

Rate
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000
1.0000

For CY 2015, Report PROJE

CY 2015
Qualified HCBS (Jan-Mar)
Qualified HCBS (Apr-Jun)
Qualified HCBS (Jul-Sept)
Qualified HCBS (Oct-Dec)
Demonstration HCBS (Jan-Mar)
Demonstration HCBS (Apr-Jun)
Demonstration HCBS (Jul-Sept)
Demonstration HCBS (Oct-Dec)
Supplemental (Jan-Mar)
Supplemental (Apr-Jun)
Supplemental (Jul-Sept)
Supplemental (Oct-Dec)
Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding -100%
AIAN Funding - 100%
CY 2015 Projected Totals
Less Unobligated Balance from Prior Years
Final CY 2015 Projected Totals
CY 2015 Federal Supplemental Request Amount

CY 2016
Qualified HCBS (Jan-Mar)
Qualified HCBS (Apr-Jun)
Qualified HCBS (Jul-Sept)
Qualified HCBS (Oct-Dec)
Demonstration HCBS (Jan-Mar)
Demonstration HCBS (Apr-Jun)
Demonstration HCBS (Jul-Sept)
Demonstration HCBS (Oct-Dec)
Supplemental (Jan-Mar)
Supplemental (Apr-Jun)
Supplemental (Jul-Sept)
Supplemental (Oct-Dec)

Rate*
(assume FFY 2014 rate if FFY
2015 is unknown)
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000
1.0000

For CY 2016, Report PROJE
Rate*
(assume most recent
known rate)
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000

Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding -100%
AIAN Funding - 100%
CY 2016 Projected Totals

0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000
1.0000
CY 2016 WILL BE T

CY 2017
Qualified HCBS (Jan-Mar)
Qualified HCBS (Apr-Jun)
Qualified HCBS (Jul-Sept)
Qualified HCBS (Oct-Dec)
Demonstration HCBS (Jan-Mar)
Demonstration HCBS (Apr-Jun)
Demonstration HCBS (Jul-Sept)
Demonstration HCBS (Oct-Dec)
Supplemental (Jan-Mar)
Supplemental (Apr-Jun)
Supplemental (Jul-Sept)
Supplemental (Oct-Dec)
Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding -100%
AIAN Funding - 100%
CY 2017 Projected Totals

CY 2018
Qualified HCBS (Jan-Mar)
Qualified HCBS (Apr-Jun)
Qualified HCBS (Jul-Sept)

For CY 2017, Report PROJE
Rate*
(assume most recent
known rate)
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000
1.0000

For CY 2018, Report PROJE
Rate*
(assume most recent
known rate)
0.5000
0.5000
0.5000

Qualified HCBS (Oct-Dec)
Demonstration HCBS (Jan-Mar)
Demonstration HCBS (Apr-Jun)
Demonstration HCBS (Jul-Sept)
Demonstration HCBS (Oct-Dec)
Supplemental (Jan-Mar)
Supplemental (Apr-Jun)
Supplemental (Jul-Sept)
Supplemental (Oct-Dec)
Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding -100%
AIAN Funding - 100%
CY 2018 Projected Totals

CY 2019

0.5000
0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000
1.0000

For CY 2019, Report PROJE
Rate*
(assume most recent
known rate)
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000
1.0000

Qualified HCBS (Jan-Mar)*
Qualified HCBS (Apr-Jun)*
Qualified HCBS (Jul-Sept)*
Qualified HCBS (Oct-Dec)*
Demonstration HCBS (Jan-Mar)*
Demonstration HCBS (Apr-Jun)*
Demonstration HCBS (Jul-Sept)*
Demonstration HCBS (Oct-Dec)*
Supplemental (Jan-Mar)*
Supplemental (Apr-Jun)*
Supplemental (Jul-Sept)*
Supplemental (Oct-Dec)*
Administrative - Normal- 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding -100%
AIAN Funding - 100%
CY 2019 Projected Totals
* Cost should only be included if the state has a approved sustainability plan from CMS which in

CY 2020
Qualified HCBS (Jan-Mar)
Qualified HCBS (Apr-Jun)
Qualified HCBS (Jul-Sept)
Qualified HCBS (Oct-Dec)
Demonstration HCBS (Jan-Mar)
Demonstration HCBS (Apr-Jun)
Demonstration HCBS (Jul-Sept)
Demonstration HCBS (Oct-Dec)
Supplemental (Jan-Mar)
Supplemental (Apr-Jun)
Supplemental (Jul-Sept)
Supplemental (Oct-Dec)
Administrative - Normal - 50%
Administrative - 75%
Administrative - 90%
Federal Evaluation Supports - 100%
Administrative (Other) - 100%
State Evaluation (if approved) - 50%
ADRC Funding -100%
AIAN Funding - 100%
CY 2020 Projected Totals

For CY 2020, Report PROJE
Rate*
(assume most recent
known rate)
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.0000
0.0000
0.0000
0.0000
0.5000
0.7500
0.9000
1.0000
1.0000
0.5000
1.0000
1.0000

rson Demonstration Supplemental Budget Request
roposed Budget (Updated Aug 8, 2014)
opulate and are locked.
Preparer Name:
Preparer Phone:
Preparer Email:
vided in the State FMAPs worksheet tab.
ses in accordance with OMB Circular A-133, Audits of States, Local Governments, and Non-Prof
Column 2

Column 3

Column 4

State Enhanced FMAP
with MFP
(1.00 - Reg FMAP /
2 + Reg FMAP)

State FMAP
with
ARRA Increase
(Oct 2008 - Jun 2011)

State Enhanced FMAP
with ARRA and MFP
(for Oct 2008 - Jun 2011)
Not to Exceed 90%

0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000

0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000

0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000

sition.
mbers should be consistent with semi-annual reports submitted in Jan/Feb for the previo
Physical Disability

Mental Illness

Other

0

0

5% of the established benchmark, an Action Plan will be required.

0

efined in the MFP Solicitation.

bursed @ about $100-$150 per survey).
be reinvested into rebalancing benchmarks. It is the State's responsibility to track Reba

Federal
$
$
$
$
$
$
$
$
$
$
$
$

State
-

$
$
$
$
$
$
$
$
$
$
$
$

Estimated Rebala
CY 2007
CY 2008
CY 2009
CY 2010
CY 2011
CY 2012
CY 2013
CY 2014
CY 2015
CY 2016
CY 2017
CY 2018
CY 2019
CY 2020
Estimated Total

tures for all past years.
Total Costs
(actual expenditures)

$

Federal
(actual expenditures)

-

$
$
$
$
$
$
$
$
$
$
$

Total Costs
(actual expenditures)

$

State
(actual expenditures)
-

$
$
$
$
$
$
$
$
$
$
$

Federal
(actual expenditures)

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$

Total Costs
(actual expenditures)

State
(actual expenditures)
-

$
$
$
$
$
$
$
$
$
$
$
$
$
$

Federal
(actual expenditures)
$
$
$
$
$
$
$
$
$

-

-

State
(actual expenditures)
-

$
$
$
$
$
$
$
$
$

-

$

-

$
$
$
$
$
$
$
$
$
$
$

Total Costs
(actual expenditures)

$

-

$
$
$
$
$
$
$
$
$
$
$

Federal
(actual expenditures)

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Total Costs
(actual expenditures)

State
(actual expenditures)
-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Federal
(actual expenditures)
$
$
$
$
$
$
$

-

-

State
(actual expenditures)
-

$
$
$
$
$
$
$

-

$

-

$
$
$
$
$
$
$
$
$
$
$
$
$

Total Costs
(actual expenditures)

$

-

$
$
$
$
$
$
$
$
$
$
$
$
$

Federal
(actual expenditures)

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Total Costs
(actual expenditures)

State
(actual expenditures)
-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Federal
(actual expenditures)
$
$
$
$
$

-

-

State
(actual expenditures)
-

$
$
$
$
$

-

$

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

D ACTUAL Expenditures
Total Costs
(estimated actual
expenditures)

$

ECTED Expenditures

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Federal
(estimated actual
expenditures)

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

State
(estimated actual
expenditures)
-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

Total Costs
(projected expenditures)

$
$
$

Federal
(projected expenditures)

-

State
(projected expenditures)

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

$
$

-

$

-

ECTED Expenditures
Total Costs
(projected expenditures)

Federal
(projected expenditures)
$
$
$
$
$
$
$
$
$
$
$
$

-

State
(projected expenditures)
$
$
$
$
$
$
$
$
$
$
$
$

-

$
$
$
$
$
$
$
$
$
- $
THE FINAL YEAR FUNDS WILL BE AWARDED.

-

$
$
$
$
$
$
$
$
$

-

ECTED Expenditures
Total Costs
(projected expenditures)

$

Federal
(projected expenditures)

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

State
(projected expenditures)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

ECTED Expenditures
Total Costs
(projected expenditures)

Federal
(projected expenditures)
$
$
$

-

State
(projected expenditures)
$
$
$

-

$

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

ECTED Expenditures
Total Costs
(projected expenditures)

$
ncludes transitions in 2018.

Federal
(projected expenditures)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

State
(projected expenditures)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

ECTED Expenditures
Total Costs
(projected expenditures)

$

Federal
(projected expenditures)

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

State
(projected expenditures)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

fit Organizations.”
Column 5
Calculated
Enhanced FMAP
(Oct 2008 - Jun 2011)
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000
0.5000

ous calendar year.
Total per CY
0
0
0
0
0
0
0
0
0
0

0
0
0
* Projections and cost

alancing Funds.

ancing Fund Calculation
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

Enter CY 2007
Comments Here

Enter CY 2008
Comments Here

Enter CY 2009
Comments Here

Enter CY 2010
Comments Here

Enter CY 2011
Comments Here

Enter CY 2012
Comments Here

Enter CY 2013
Comments Here

Enter CY 2014
Comments Here

Enter CY 2015
Comments Here

Enter unobligated balance in the
highlighted fields. Enter a positive
number. Do not enter a negative
number.

Enter CY 2016
Comments Here

Enter CY 2017
Comments Here

Enter CY 2018
Comments Here

Enter CY 2019
Comments Here

Enter CY 2020
Comments Here

Instructions for Completing the MFP Worksheet for Proposed Budget (WFPB) Revised Jan. 2014
Please refer to the most recent ABCD Forms for Actual Expenditures.
Please fill in the cells highlighted in YELLOW. All other cells will auto populate.
Step 1 – Fill in the following highlighted cells: (1) Date of Report, (2) State, (3) Award Number (your Award Number
Step 2 – In the FMAP Table, enter your Original FMAP rate for each quarter in column 1. Enter the ARRA Increased
FMAP rate for each quarter in column 3. Please use the appropriate rate for each year as published in the Federal
Step 3 – Fill in/update the Population Transitions Chart. For years 2007-2012, enter actual transitions for each
population, which should be the same numbers entered in your semi-annual progress reports submitted in Jan/Feb
2013. New Requirement: For CY 2013, enter both projected and actual transitions on the appropriate line to
calculate the percentage of transitions achieved during this period. Enter the projected transitions as listed on the
CY 2013 Worksheet for Proposed Budget submitted and approved for the 2013 Supplemental Budget Request.
Enter the actual transitions that occurred for CY 2013. For years 2014-2017, enter projected transitions for each
population. Please note all transitions should occur by Dec. 31, 2017 with services ending by Dec. 31, 2018. The
"Other" column includes any populations that do not fit one of the listed target populations. Once you complete
this table, proceed to Step 4. The Total Expenditures table, Estimated Rebalancing Fund Calculations, Benchmarks
Achived Percentage, and Per Capita Costs will auto populate after you fill in actual and projected expenditures for
all Calendar Years.
Step 4 – For CY 2007 - CY 2013, enter actual expenditures in the yellow highlighted cells which should reflect the
sum of the year's quarterly MFP Financial Reporting Forms (ABCD forms) submitted to CMS. The MFP Project
Officers are aware that for the last quarter of CY 2013, actual expenditures may not be available. If this is the case,
please provide best estimates and add a note in the comments section that indicates as such. CMS expects that CY
Step 5– For CY 2014, enter projected expenditures in the yellow highlighted cells. If you have a prior year(s)
unobligated balance for federal and/or state, enter those amounts separately in the respective high-lighted
columns. Do not enter a negative unobligated number. If you expended more funds than awarded in previous
years (which would result in a negative unobligated number), you should account (recover) for those funds in the
current year projections.

Step 6 – For CY 2014-2020, enter projected expenditures in the yellow highlighted cells. Please note that CY 2016 is

Maintenance of Effort (MOE) Form
Money Follows the Person Demonstration Grant Program (Nov 2010)
STATE:

Grant #:

Reporting Year Format:

State Fiscal Year (Fiscal Year Runs: July 1-June 30)
FEDERAL FISCAL YEAR
CALENDAR YEAR

Total State Expenditures for Home & Community-based Services
Base Year
2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

Attestation (required by Section 6071 of the Deficit Reduction Act of 2005)

I assert by my signature that the expenditure report above is accurate and follows the MFP MOE Form
instructions. I also assert that all qualified HCBS programs operating under a waiver under section
(d)in the case of a qualified HCB program operating under a waiver under subsection (c) or (d) of
section 1915 of the Social Security Act (42 U.S.C. 1396n), but for the amount awarded under a grant
under this section, the State program would continue to meet the cost-effectiveness requirements of
subsection (c)(2)(D) of such section or comparable requirements under subsection (d)(5) of such
section, respectively.
Signature :

Date:

Title/Position:
Instructions
1. Fill out your State and Official Grant Number.
2. Check off the Report year you will be using. If it is the State Fiscal Year, indicate the dates of the
year the report covers. You must report by either State FY, Federal FY or Calendar year.
3. Fill in each year's expenditures for HCBS starting with the base year which you will fill in. The base
year is the immediate previous full year of expenditures based on the reporting year format you have
chosen. For new applicants for 2011 provide only your base year. For existing grantees only provide
the base year and the first full year you began your grant through the latest reporting period.
4. Medicaid HCBS Expenditures include all non-institutional services and include waiver and HCBS
State plan services such as personal care services, rehab services and other State plan services you
cover that are non-institutional.
5. The State authorized signatory must sign and date as well as identify their Title or position as
indicated. The second element to attest to is the continuation of meeting cost neutrality in the
waivers your State provides.