Proposed Change to FY 2022-2023 MHBG-SABG Application Table 2-State Agency Planned Expenditure for COVID-19 Relief Funds 04012021 FINAL

APPLICATION/PLAN (SABG/MHBG)

Plan Table 2: State Agency Planned Expenditures

States must project how the SMHA and/or the SSA will use available funds to provide authorized services for the planning period for state fiscal years FFY 2022/2023.

Plan Table 2 State Agency Planned Expenditures SABG – ONLY include funds expended by the executive branch agency administering the SABG MHBG: Include public mental health services provided by mental health providers or funded by the state mental health agency by source of funding)
Planning Period- From: To:
State Identifier:
Source of Funds
ACTIVITY (See instructions for using Row 1.)	A. SABG	B. MHBG	C. Medicaid (Federal, State, and local)	D. Other Federal Funds (e.g., ACF (TANF), CDC, CMS (Medicare), SAMHSA, etc.)	E. State funds	F. Local funds (excluding local Medicaid)	G. Other	H. COVID-19 Relief Funds (SABG)a	I. COVID-19 Relief Funds (MHBG)
Substance Abuse Prevention and Treatment
a. Pregnant Women and Women with Dependent Childrenb	$		$	$	$	$	$	$
b. All Other	$		$	$	$	$	$	$
Primary Prevention	$		$	$	$	$	$	$
a. Substance Abuse Primary Prevention	$		$	$	$	$	$	$
b. Mental Health Primary Prevention		$	$	$	$	$	$		$
Evidence-Based Practices for Early Serious Mental Illness including First Episode Psychosis (10 percent of total award MHBG)		$	$	$	$	$	$		$
Tuberculosis Services	$		$	$	$	$	$	$
Early Intervention Services for HIV	$		$	$	$	$	$	$
State Hospital			$	$	$	$	$
Other 24-Hour Care		$	$	$	$	$	$		$
Ambulatory/Community Non-24 Hour Care		$	$	$	$	$	$		$
Administration (excluding program / provider level) MHBG and SABG must be reported separately	$	$	$	$	$	$	$	$	$
Crisis Services								$	$
Subtotal (Rows 1, 2, 4, 5, and 9)	$	$	$	$	$	$	$	$	$
Subtotal (Rows 3, 6, 7, 8, 9, and 10)	$	$	$	$	$	$	$	$	$
Total	$	$	$	$	$	$	$	$	$

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