| FY17 RWHAP Part A & MAI Allocations Report | ||||||
| Section A: Identifying Information | Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp | |||||
| ~ Enter Name of Recipient Here ~ | ||||||
| ~ Enter Preparer's Name Here ~ | ||||||
| ~ Enter Preparer's Phone Number Here ~ | ||||||
| ~ Enter Preparer's Email Address Here ~ | ||||||
| Section B: Reporting Year Award Information | ||||||
| 1. Part A Grant Formula Award Amount | ||||||
| 2. MAI Grant Award Amount | ||||||
| 3. Part A Supplemental Award Amount | ||||||
| 4. Total Part A Grant Funds | $0 | |||||
| Section C: Allocation Categories | 1. Part A1 Award | 2. MAI Award | 4. Combined Total | |||
| Amount | Percentage | Amount | Percentage | Amount | Percentage | |
| 1. Core Medical Services Subtotal | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% |
| a. AIDS Drug Assistance Program (ADAP) Treatments | - - | - - | $0 | - - | ||
| 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 (incl. 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 Subtotal | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% |
| 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 Service Allocations | $0 | - - | $0 | - - | $0 | - - |
| 4. Non-services Subtotal | $0 | - - | $0 | - - | $0 | - - |
| a. Clinical Quality Management2 (see CHECKLIST) | - - | - - | $0 | - - | ||
| b. Recipient Administration 3 (see CHECKLIST) | - - | - - | $0 | - - | ||
| 5. Total Allocations (Service + Non-service)4 (see CHECKLIST) | $0 | - - | $0 | - - | $0 | - - |
| o Recipient received waiver for 75% core medical services requirement. | ||||||
| Footnotes: (1) This amount must equal the recipient's total Part A formula and supplemental award. (2) Clinical Quality Management may not exceed 5% of the Part A award, or 3 million, whichever amount is smaller. (3) Recipient Administration may not exceed 10% of the Part A award. (4) This amount must equal the recipient's total Part A Award. |
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| LEGISLATIVE REQUIREMENTS CHECKLIST | |||||
| INSTRUCTIONS: Recipients and Project Officers should use the following table to determine whether or not the following legislative requirements have been met. Unlike the Allocations Report which shows individual allocations as a percentage of total allocations, this table shows allocations as a percentage of award for specific categories as outlined in the Ryan White HIV/AIDS Treatment Extension Act of 2009. | |||||
| REQUIREMENT: At least 75% of your total award (less CQM and Recipient Administration) must be allocated to core medical services. | |||||
| When reporting Core Medical Services allocations, the Current FY totals in Section C, Row 1 of the Allocation Report for PART A AWARD and MAI AWARD and SUPPLEMENTAL AWARD columns do not necessarily need to be 75% of each individual award as long as the combined total meets the 75% minimum requirement. The exception to this requirement is only for those recipients that requested, and were approved by HRSA, for a Part A Core Medical Services Waiver. To the right in red, is the percentage of your Current Fiscal Year Core Medical Services allocations divided by your Total Part A Award less CQM and Recipient Administration allocations (F18 /F48). Please check to make sure this percentage is 75% or greater. |
0.0% | ||||
| REQUIREMENT: No more than 5% of your total award or $3 million (whichever is smaller) can be allocated to Clinical Quality Management. | |||||
| When reporting Clinical Quality Management allocations, the Current FY totals in Section C, Row 4a of the Allocations Report for PART A AWARD and MAI AWARD and SUPPLEMENTAL AWARD columns do not necessarily need to meet this requirement as long as the combined total meets the 5% or $3 million (whichever is smaller) requirement. To the right in red, is the maximum (Capped Amount) you can allocate on Clinical Quality Management (the lessor of B13 * .05 or $3 million) as well as the amount of Current Fiscal Year dollars allocated (CQM Allocations) on Clinical Quality Management (F50). Please check to make sure your Allocations do not exceed your Capped Amount. |
$0 | (Capped Amount) | |||
| $0 | (CQM Allocations) | ||||
| REQUIREMENT: No more than 10% of your total award can be allocated to Grantee Administration. | |||||
| When reporting Recipient Administration allocations, the Current FY totals in Section C, Row 4b of the Allocations Report for PART A AWARD and MAI AWARD and SUPPLEMENTAL AWARD columns do not necessarily need to meet this requirement as long as the combined total meets the 10% or less requirement. To the right in red, is the percentage of your Current Fiscal Year Recipient Administration allocations divided by your Total Part A Award (F51 / B13.) Please check to make sure this percentage is not greater than 10%. |
0.0% | ||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |