CMS-10249 Maintenance of Effort (MOE) Form

Maintenance of Effort (MOE) Form
Money Follows the Person Demonstration Grant Program
State:

(Rev. 12/15/2020)

Grant Number:

State FY (Jul 1 - Jun 30)
Calendar Year (Jan 1 - Dec 31)
Federal Fiscal Year (Oct 1 - Sept 30)

Reporting Year Type:
(please check one)

Total Expenditures for Home & Community-Based Services
Base Year
2007-Actuals

2008-Actuals

2009-Actuals

2010-Actuals

2011-Actuals

2012-Actuals

2013-Actuals

2014-Actuals

2015-Actuals

2016-Actuals

2017-Actuals

2018 - Actuals

2019 - Actuals

2020 - Actuals

2021 - Projected

2022 - Projected

2023 - Projected

2024 - Projected

2025 - Projected

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. Enter your State and Grant Number.
2. Select the type of reporting year that your State will use. You must report by either State FY, Federal FY or Calendar Year.
3. Enter the base year which will represent the baseline for your HCBS expenditures. Provide the base year, base year
expenditures, and expenditures for the first full year you began your grant through the latest reporting period. For all prior
years, enter actual expenditures. For future years, enter projected expenditures. Medicaid HCBS Expenditures include all noninstitutional 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.
4. 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.
Remarks: Provide any explanations deemed necessary.