1 Part A Expenditures Report and Changes Summary

Ryan White HIV/AIDS Program Expenditure Forms

Part A Expenditures Report and Changes Summary

OMB: 0915-0390

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0390 can be found here:

2023-08-01 - No material or nonsubstantive change to a currently approved collection

Document [pdf]

Download: pdf | pdf

Changes Summary Table: Part A Expenditure Report Template
Current Reporting
Award Information
Carryover column appears before the Current FY
column
Carryover
2. RWHAP Part A MAI Award Amount appeared
before the 3.RWHAP Part A Supplemental Award
Amount.
RWHAP Part A Program Expenditure Totals
Previously, header title of the table was Part A
Program Total
RWHAP Part A Formula Award Amount and
RWHAP Part A Supplemental Award Amount
were presented in separate columns
RWHAP Part A MAI Award Amount
Aggregate Total
Previously, Prior FY Carryover column appeared
before Reporting FY column
Reporting FY
Non-services Subtotal
Total Service Expenditures
RWHAP Part A and MAI Service Category Expenditures
Previously, header title was Part A Expenditures
Categories
RWHAP Part A Formula Award Amount and
RWHAP Part A Supplemental Award Amount
were presented in separate columns
RWHAP Part A MAI Award Amount
Aggregate Total
Previously, Prior FY Carryover column appeared
before Reporting FY
Reporting FY

Proposed Change
-

Change column order to: Carryover appears after Current FY

Change text to: Prior FY Carryover
Change row order to: 2. RWHAP Part A Supplemental Award Amount
3. RWHAP Part A MAI Award Amount

Change text to: RWHAP Part A Program Expenditure Totals

Combined columns and update titles: RWHAP Part A Formula and RWHAP
Part A Supplemental Expenditure Amounts

Change text to: RWHAP Part A MAI Expenditure Amounts
Change text to: Total RWHAP Part A Expenditure Amounts
Change column order to: Prior FY Carryover appears after Reporting FY

Change text to: Current FY
Change text to: Non-services Expenditures Subtotal
Change text to: Service Expenditures Subtotal

Change text to: RWHAP Part A and MAI Service Category Expenditures

Combined columns and update title: RWHAP Part A Formula and RWHAP
Part A Supplemental Expenditure Amounts

Change text to: RWHAP Part A MAI Expenditure Amounts
Change text to: Total RWHAP Part A Expenditure Amounts
Change column order to: Prior FY Carryover appears after Reporting FY

Change text to: Current FY

FY2023 RWHAP Part A Expenditures Report Changes
The table below provides a summary of proposed changes to the RWHAP Part A Expenditures Report. A draft template of the report with is also provided below.
g. Hospice
1. Core Medical Services Total
2. Support Services Total
3. Total Service Expenditures
Balance
Previously, the order of the Award and
Expenditures rows:
3. RWHAP Part A MAI Award Amount
4. RWHAP Part A MAI Carryover Amount
5. RWHAP Part A Supplemental Award
Legislative Requirement Checklist
Previously, not available
-

Change text to: g. Hospice Services
Change text to: 1. Core Medical Services Expenditures Subtotal
Change text to: 2. Support Services Expenditures Subtotal
Change text to: 3. Service Expenditures Total
Change text to: Unobligated Balance
Change row order to:
3. RWHAP Part A Supplemental Award
4. RWHAP Part A MAI Award Amount
5. RWHAP Part A MAI Carryover Amount

Changes in language for clarity (please see attached document)
Added a requirement for Financial Officer/Designee signature to certify
subrecipient aggregated administrative expenditures
-

Note: Users will have to enter the amount and sign before moving forward;
otherwise, they will not be able to proceed to the next step.

Part A Expenditures Report
Expenditures Report
Budget Period: 3/1/2020 2/28/2021 11:59:59 PM
Last Modified
Date:

Grant Number and Name:
Report Status: Accepted
Contact Information of the Person Responsible
for This Submission
Preparer's Name:
Preparer's Phone:
Preparer's Email:
Award Information
Current
FY

Prior FY
Carryover

1. RWHAP
Part A
Formula
Award
Amount

2. RWHAP
Part A
Supplementa

Total

4. Total
RWHAP Part
A Funds

RWHAP Part A Program Expenditure Totals
RWHAP Part A Formula and Supplemental Expenditure
Amounts

Current FY
Amount

Percent

Prior FY Carryover
Amount

Percent

RWHAP Part A MAI Expenditure Amounts

Total
Amou
nt

Current FY

Percent

Amount

Percent

Prior FY Carryover
Amount

Percent

Non-Services
a. Clinical
Quality
Management

Total RWHAP
Part A
Expenditure
Amounts

Total
Amount

Percent

Amount

Percent

FY2023 RWHAP Part A Expenditures Report Changes
The table below provides a summary of proposed changes to the RWHAP Part A Expenditures Report. A draft template of the report with is also provided below.
b.Administrat
ion
Non-services
Expenditures
Subtotal
c. Core
Medical
Services
d. Support
Services
Service
Expenditures
Subtotal
Total
Expenditures
(Service +
Non-service)

-$0

RWHAP Part A and MAI Service Category Expenditures
RWHAP Part A Formula and Supplemental Expenditure
Amounts

Current FY
Amount

Percent

Prior FY Carryover
Amount

Percent

RWHAP Part A MAI Expenditure Amounts

Total
Amount

Total RWHAP
Part A
Expenditure
Amounts

Current FY

Percent

Core Medical Services
5

Amount

Percent

Prior FY Carryover
Amount

Percent

Total
Amount

Percent

Amount

Percent

FY2023 RWHAP Part A Expenditures Report Changes
The table below provides a summary of proposed changes to the RWHAP Part A Expenditures Report. A draft template of the report with is also provided below.
a. AIDS Drug
Assistance
Program
Treatments
b. AIDS
Pharmaceuti
cal
Assistance
c. Early
Intervention
Services (EIS)
d. Health
Insurance
Premium and
Cost Sharing
Assistance
for LowIncome
Individuals
e. Home and
CommunityBased Health
Services
f. Home
Health Care
g. Hospice
Services
h. Medical
Case
Management
, including
Treatment

FY2023 RWHAP Part A Expenditures Report Changes
The table below provides a summary of proposed changes to the RWHAP Part A Expenditures Report. A draft template of the report with is also provided below.
Adherence
Services
i. Medical
Nutrition
Therapy
j. Mental
Health
Services
k. Oral
Health Care
l. Outpatient
/Ambulatory
Health
Services
m. Substance
Abuse
Outpatient
Care
1. Core
Medical
Services
Expenditures
Subtotal

Support Services
a. Child Care
Services
b. Emergency
Financial
Assistance
c. Food
Bank/Home

-7

FY2023 RWHAP Part A Expenditures Report Changes
The table below provides a summary of proposed changes to the RWHAP Part A Expenditures Report. A draft template of the report with is also provided below.
Delivered
Meals
d. Health
Education/Ri
sk Reduction
e. Housing
f. Linguistic
Services
g. Medical
Transportatio
n
h. NonMedical Case
Management
Services
i. Other
Professional
Services
j. Outreach
Services
k.
Psychosocial
Support
Services
l. Referral for
Health Care
and Support
Services
m.
Rehabilitatio
n Services

FY2023 RWHAP Part A Expenditures Report Changes
The table below provides a summary of proposed changes to the RWHAP Part A Expenditures Report. A draft template of the report with is also provided below.
n. Respite
Care
o. Substance
Abuse
Services
(residential)
2. Support
Services
Expenditures
Subtotal
3. Service
Expenditures
Total

1. RWHAP
Part A
Formula
Award
Amount
2. RWHAP
Part A
Formula
Carryover
Amount
3. RWHAP
Part A
Supplementa
l Award

RWHAP
Part A
Award

Expendit
ures

UnObligated
Balance

Recipient received waiver for 75% core medical services requirement:

Legislative Requirement Checklist
Core Medical Services (CMS) Expenditure Requirement: At least 75% of your total service
expenditures must be spent on core medical services (unless a Core Medical Services waiver has
been approved).
When reporting CMS expenditures, the Total RWHAP Part A Expenditure Amounts
for CMS must be at least 75% of Total Service Expenditures unless a CMS waiver was
approved.
To the right is the percentage of your Current Fiscal Year (FY) CMS Expenditures
divided by your Total Part A Formula, Supplemental, and MAI expenditures.

Clinical Quality Management (CQM) Expenditure Requirement: No more than 5% of your total
award or $3 million (whichever is smaller) can be expended on CQM.

FY2023 RWHAP Part A Expenditures Report Changes
The table below provides a summary of proposed changes to the RWHAP Part A Expenditures Report. A draft template of the report with is also provided below.
When reporting CQM expenditures, the Total RWHAP Part A Expenditure Amounts for CQM must
not exceed 5% of the total award amount or $3 million (whichever is smaller).

Below is the maximum amount (Capped Amount) you can expend on CQM. The capped amount
will be 5% of the total award or $3 million, whichever is smaller. Please check to make sure your
CQM expenditures do not exceed your Capped Amount.

Recipient Clinical Quality Management Capped Amount

Recipient Clinical Quality Management Expenditure Amount

Administration Expenditure Requirement: No more than 10% of your total award can be
expended on recipient administration.
When reporting recipient administration expenditures, the Total RWHAP Part A Expenditure
Amounts for Administration must not exceed 10% of the total award amount.
Below is the percentage of your Current Fiscal Year recipient administration expenditures divided
by your Total Part A Award. Please check to make sure this percentage is not greater than 10%.
Recipient Administration Expenditure Amount

Certification of Subrecipient Aggregate Administrative Expenditures
Certification that the actual amount of funds expended on administrative costs by subrecipients
does not exceed 10% of the aggregate total of all HIV service dollars expended. The financial
officer responsible for the RWHAP Part A funds must attest that the aggregate administrative
expenditures is under the 10% administrative cap.
Final Certification of Subrecipient Aggregate Administrative
Expenditure Amount

FY2023 RWHAP Part A Expenditures Report Changes
The table below provides a summary of proposed changes to the RWHAP Part A Expenditures Report. A draft template of the report with is also provided below.
I certify to the best of my knowledge and belief that the report is true,
complete, and accurate, and the expenditures, disbursements and cash
receipts were for the purposes and objectives set forth in the terms
x
and conditions of the Federal award. I am aware that any false,
Financial Officer or Designee Signature
fictitious, or fraudulent information, or the omission of any material
fact, may subject me to criminal, civil or administrative penalties for
fraud, false statements, false claims or otherwise. (U.S. Code Title 18,
Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)

Public Burden Statement:
The purpose of this data collection system is to collect allocations/expenditures information regarding Ryan White HIV/AIDS Program
(RWHAP) Parts A, B, C, D grant funding. HAB will use these data to show the impact of RWHAP funding on the care and treatment of people
with HIV in the United States. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0318 and it is valid
until 09/30/2023. This information collection is mandatory (through increased Authority under the Public Health Service Act, Section 311(c)
(42 USC 243(c)) and title XXVI (42 U.S.C. §§ 300ff-11 et seq.). Public reporting burden for this collection of information is estimated to
average 4 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or
[email protected]

File Type	application/pdf
File Modified	2023-02-16
File Created	2023-02-16