Final SSA 0172 Clean

SUPPORTING STATEMENT A

MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT

APPLICATION/ANNUAL REPORT GUIDANCE

OMB Control No. 0915-0172 Revision

We are requesting the OMB Number of this Information Collection is 0906-0172

A. Justification

1. Circumstances Making the Collection of Information Necessary

This submission is a request for Office of Management and Budget (OMB) continued approval of the updated Application/Annual Report Guidance for the Maternal and Child Health (MCH) Services Block Grant (hereafter referred to as the MCH Block Grant). This Guidance will be used by the 50 states and nine (9) jurisdictions (hereafter referred to as “states”) eligible for state formula grants, as authorized by Section 501 of Title V of the Social Security Act (the Act), PL 101-239. All sections of the Title V legislation can be viewed at: http://www.ssa.gov/OP_Home/ssact/title05/0500.htm. The current Application/Annual Report Guidance (OMB No. 0915-0172) will expire on

January 31, 2024. The attached updated edition is divided into four sections: Background and Administrative Information; Application/Annual Report Instructions; Reporting Forms; and Appendices. The Appendices include Reporting Definitions for the Forms and Assurances and Certifications needed from the states.

The Application and Annual Report fulfill the requirements of Section 505 and Section 506, respectively, of the Title V legislation. Consistent with previous editions, the updated Application/Annual Report Guidance is designed to allow states flexibility in meeting the unique needs of their MCH populations while enabling the Maternal and Child Health Bureau (MCHB) to meet the Title V legislative requirements, collect and utilize comparative data for addressing national and state MCH priorities, and demonstrate accountability in the use of the Federal Title V funds. The MCHB, in the Health Resources and Services Administration (HRSA), serves as the Health and Human Services (HHS) Secretary’s delegate to collect this information and to review it prior to the award of approximately $581 million annually in state formula grants under the MCH Block Grant.

The attached updated edition builds on the transformative changes that were introduced with the release of the current Application/Annual Report Guidance in 2018. Full implementation of the MCH Block Grant transformation was achieved with the submission of the 59 state fiscal year (FY) 2018 Applications/FY 2016 Annual Reports in July 2017. While carrying forward the three aims of the MCH Block Grant transformation (i.e., reduce state burden; maintain state flexibility; and improve accountability), updates to the 2021 Application/Annual Report Guidance further refined the reporting structure and requirements. Updates to this edition of the Application/Annual Report Guidance build on the reporting refinements and seek to further advance the federal-state MCH partnership. Clarifying instructions and supportive background and resource information have been added to assist states in the development of an Application/Annual Report that provides an articulate and comprehensive description of their Title V program priorities, informs their action planning and demonstrates their leadership efforts.

The MCH Block Grant is a formula grant under which funds are awarded to 59 states and jurisdictions upon the submission of an acceptable plan that addresses the health services needs within a state for the target population of mothers, infants and children, which includes children with special health care needs (CSHCN). Through this process, each state and jurisdiction supports and promotes the development and coordination of systems of care for the MCH population, which are family-centered, community-based and culturally appropriate.

History

The purpose of the Title V MCH Services Block Grant is to create federal/state partnerships in all 59 states/jurisdictions that support service systems for addressing MCH challenges, such as:

• Significantly reducing infant mortality;

• Providing comprehensive care for women before, during, and after pregnancy and childbirth;

• Providing preventive and primary care services for infants, children, and adolescents;

• Providing comprehensive care for children and adolescents with special health care needs;

• Immunizing all children;

• Reducing adolescent pregnancy;

• Putting into community practice national standards and guidelines for prenatal care, for healthy and safe child care, and for the health supervision of infants, children, and adolescents;

• Assuring access to care for all mothers and children; and

• Meeting the nutritional and developmental needs of mothers, children, and families.

The state health programs for mothers and children date back to 1935, when these programs were first authorized under Title V of the original Social Security Act. In 1981, Title V was amended to create a single block grant program that consolidated seven related categorical health services programs for mothers and children into the MCH Services Block Grant. Programs folded into the MCH Block Grant included: Maternal and Child Health and Children with Special Needs Services; Supplemental Security Income for Children with Disabilities Program; Lead-Based Poisoning Prevention; Genetic Disease; Sudden Infant Death Syndrome (SIDS); the Hemophilia Treatment Centers; and Adolescent Pregnancy Grants. In 1996, PL 104-193 created a new section in Title V, section 510, which established a separate program for abstinence education. More recently, in 2010, the Patient Protection and Affordable Care Act (ACA) added a new section 511 to Title V of the Social Security Act, which created the Maternal, Infant and Early Childhood Home Visiting Program.

Beginning in 1982, eligible states were required to submit a Report of Intended Expenditures annually to the HHS Secretary. This report outlined a state’s general plans for the use of its MCH Block Grant funds and an Annual Report (in an unspecified form and with unspecified content) that would inform the Secretary on how the block grant funds were being spent. The Omnibus Budget Reconciliation Act (OBRA) of 1989 tightened accountability of funds expended under the MCH Block Grant. Congress placed a 10 percent limit on administrative costs and mandated a minimum spending requirement of 30 percent for the following two categories: (1) children’s preventive and primary health services; and (2) services and service coordination for CSHCN. Special emphasis was placed on the provision of services for low-income individuals and the development of comprehensive plans for state systems of services, in accordance with a state’s Five-year Needs Assessment findings, which resulted in goals and objectives that were consistent with the Nation’s Healthy People 2000 objectives.

In 1993, the Government Performance and Results Act (GPRA), Public Law 103-62, was enacted which requires federal agencies to establish measurable goals that are to be reported as part of the budgetary process. In linking funding decisions with performance, GPRA calls for federal agencies to develop comprehensive strategic plans, annual performance plans that include measurable goals and objectives, and annual reports that compare actual performance with established performance goals. The MCHB effort to respond to the new GPRA requirements coincided with other planned improvements to the MCH Block Grant Application/Annual Report Guidance. In meeting its GPRA requirements, MCHB streamlined the 1997 edition of the Maternal and Child Health Services Title V Block Grant Program - Guidance and Forms for the Title V Application/Annual Report by combining into a single document the instructions to states for preparing and submitting an Annual Report, Application and Five-year Needs Assessment. The revised Guidance served to ensure that state grantees could clearly and concisely tell their MCH “stories”. The Application/Annual Report thus became the basis by which MCHB could meet its GPRA MCH Block Grant reporting requirements. Revisions to subsequent editions over the years have been based on changes in MCH priorities, the availability of new national data sources and a continuing effort within the MCHB to refine and streamline the Application/Annual Report preparation and submission process for states.

In partnership with the State Title V program leadership and other key stakeholders, the MCHB initiated a major transformative effort in 2013 for the MCH Block Grant to ensure its continued relevance in a changing health care environment and to maximize the program’s effectiveness in responding to current and future needs of the nation’s mothers and children, including CSHCN. During the three-year implementation period, states applied a new three-tiered performance framework (depicted on the following page) to the development of a five-year State Action Plan.

The performance measure framework was intended to increase program accountability by enabling states to demonstrate the impacts of Title V on health outcomes. Fifteen NPMs were identified across six domains. States selected eight of the 15 NPMs, based on the priority needs that were identified in the 2015 Five-Year Needs Assessment. In addition, States developed between three and five State Performance Measures (SPMs) to address priority needs not aligned with the selected NPMs.

In recognition of the varying needs and resources in the 59 states, MCHB modified the performance measure requirements in the 2018 Application/Annual Report Guidance to allow states added flexibility in determining the best combination of NPMs and SPMs to address their individual MCH priority needs. States were required to select a minimum of five NPMs, which included at least one NPM in each of the five population domains. A state could choose to develop one or more SPMs based on the extent to which the NPMs address the identified priority needs. Each priority need has to be addressed by either a NPM and/or SPM.

This updated edition of the Application/Annual Report Guidance maintains the performance measure framework that was established in the 2016 Application/Annual Report Guidance and further refines it. The NOMs and NPMs have been updated for this edition of the MCH Block Grant Application/Annual Report Guidance to reflect salient and emergent priorities at the state and national levels. In addition to being distributed within the five population health domains, the NPMs also represent three different measure domains of action which aim to improve the NOMs. The measure domains include: 1) clinical health systems; 2) health behaviors; and 3) social determinants of health. Within each MCH population health domain, there are at least three NPM options, with at least one NPM for each measure domain. The exception is for CSHCN where there is a greater focus on the need to improve clinical health systems. With this Guidance, there are now 20 NPMs, which provide a state more measurement options for selection in each domain.

Required Reporting on Universal NPMs: Each year, every state is required to address and report on two Universal NPMs. These two Universal NPMs were selected for their focus on access and quality of primary and preventive care and will serve to accelerate progress to “provide and assure mothers and children (in particular those with low income or with limited availability of health services) access to quality maternal and child health services.” [Sec 501(a)(1)(A)]. The two Universal NPMs are:

• Postpartum Visit - A) Percent of women who attended a postpartum checkup within 12 weeks after giving birth and B) Percent of women who attended a postpartum checkup and received recommended care components; and

• Percent of children with and without special health care needs, ages 0 through 17, who have a medical home.

Addressing the maternal health crisis is a HRSA priority, as well as a state-level priority more broadly; therefore, for this Guidance, Postpartum Visit is the first Universal NPM. Addressing Postpartum Visit is intended to drive improvement in the maternal mortality rate. Untreated chronic conditions and pregnancy-related complications increase the risk of adverse health outcomes in the weeks and months following delivery. A comprehensive postpartum visit is an opportunity to improve maternal health by providing recommended clinical services, including screening, counseling, and management of health issues. These services can lead to identification, treatment, and prevention of adverse outcomes to optimize maternal health following pregnancy.

The second Universal NPM is Medical Home, selected in the CSHCN, Child, and Adolescent population health domains, which is intended to drive improvement in the core CSHCN outcome, Well-functioning system of care, as well as access to quality health care for all infants, children, and adolescents. The American Academy of Pediatrics (AAP) specifies seven qualities essential to medical home care, which include accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective. Providing comprehensive and coordinated care to children in a medical home is the standard of pediatric practice. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions.

A state will continue to report on a minimum of five (5) NPMs, which includes the two Universal NPMs, with at least one NPM for each of the five MCH population domains. States have the flexibility to select as many NPMs and SPMs as necessary to address each of its priority needs including the other NPMs within the Women/Maternal Health, Child Health, Adolescent Health, and CSHCN domains. There is no maximum for the number of NPMs that a state can select. See the Title V Block Grant Technical Assistance Resources at: https://mchb.tvisdata.hrsa.gov/Home/Resources for detailed information about the NPM Framework, NOMs, and NPMs.

 

In addition, the Application/Annual Report Guidance emphasizes the need for a state to demonstrate the value of family and community partnerships in improving health outcomes across all sectors of the MCH population. Title V MCH programs support access to quality services and service delivery for all MCH populations to achieve their full health potential. The focus on advancing health equity is at the center of Title V’s work and highlights efforts improving equity and promoting fairness of services for the MCH populations, as states address their health care priority needs. Advancing health equity requires valuing everyone equally; making meaningful progress on mitigating or eliminating systemic barriers, such as poverty, racism, ableism, gender discrimination, and geographic disparities; and aligning resources to eliminate health and health care inequities. Addressing health equity includes focusing on major upstream drivers of health for MCH populations and integrating and centering the lived experience of diverse individuals, families, and communities into policy and program planning, implementation, and monitoring. This Guidance communicates this principle throughout the sections of the document.

Since its development in 2002, the Title V Information System (TVIS) has contributed to numerous efficiencies in the Application/Annual Report Submission process. The TVIS is a web-based system, which consists of the TVIS Data Entry System and the TVIS Web Reports. The transformation of the MCH Block Grant mandated the development and deployment of a redesigned electronic data collection and web reports system in 2015. Specific enhancements made to the redesigned TVIS are described in Section 3.

2. Purpose and Use of Information Collection

The Application/Annual Report Guidance is used annually by the 50 states and nine (9) jurisdictions in applying for MCH Block Grants under Title V of the Social Security Act and in preparing the required Annual Report. Data requested in the updated edition of the MCH Block Grant Application/Annual Report Guidance are necessary to assist states in telling a coherent and compelling story about the impact of their Title V programs, both within the state and nationally. These data further help to demonstrate the Title V program’s return on investment in ensuring accountability for the ongoing monitoring of health status in women and children, in documenting the progress that has been achieved relative to established National and State performance measure targets and in supporting an effective and responsive public health system for the nation’s MCH population.

Consistent with the block grant concept, the attached updated edition of the Application/Annual Report Guidance retains the rights of each state to determine its own MCH priority needs, to develop tailored strategies for addressing its identified needs and to assume accountability in achieving measurable progress towards its stated program goals. The revised narrative reporting will also allow a State Title V program to reflect on its leadership role in the state and to demonstrate the program’s contributions to the state’s overall public health system in building improved and expanded systems of care for the MCH population that are positioned to address current and emerging MCH needs.

This updated Application/Annual Report Guidance adheres to the specific statutory requirements contained in Sections 501 and 503-509 of the Title V legislation and promotes the use of evidence-based or -informed public health practices by states in developing a Five-year Action Plan that responds to the unique MCH population and program needs of each individual state. In addition, the updated Guidance continues to affirm the mission of Title V as “to improve the health and well-being of all of America’s mothers, children, and families.”

Uses of Information

The data and attendant information that will be collected by the MCHB from the 59 states and jurisdictions through the Application/Annual Report offer utility to both HRSA, MCHB, and to the individual states and jurisdictions.

Federal

The information collected from State Title V agencies in the Application/Annual Report will be used to comply with statutory requirements for MCH Block Grant funds. HRSA’s MCHB will use the information to take two administrative actions:

• Acceptance of Annual Report submitted in accordance with standard format and requirements of Section 506 of the Act; and

• Acceptance of a complete State Application submitted in accordance with the standard format and requirements of Section 505 of the Act.

Additionally, as mandated by Section 506, information provided through the Annual Report and other sources of state data gathered by HRSA’s MCHB will be aggregated and made publicly available through the TVIS Web Reports. Such reporting by the states on their performance relative to the National performance and outcome measures is used by the MCHB to assess national progress in key MCH priority areas and to facilitate the Bureau’s annual GPRA reporting. In addition, the MCHB will use these data to identify current and emerging national MCH priority areas, guide strategic planning efforts and inform the allocation of resources.

State

States will use the national and state-specific data to establish priorities for their individual MCH populations; support ongoing assessment of MCH population needs; determine effectiveness of current Title V program strategies; respond to other federal, state, and local performance requirements/requests; and develop and justify efforts for advancing MCH-related agendas with the legislatures and/or Governor’s offices.

Information Collection and Proposed Changes

The combined Application/Annual Report will be completed and submitted to HRSA’s MCHB on an annual basis. This reporting supports states in their data-driven MCH programming and quality improvement efforts by reflecting on a state’s MCH priority needs, health status of its MCH population, established systems of care, existing gaps in health care delivery, available funding/resources and data trends relative to its selected National/State performance and outcome measures.

The updated edition of the Application/Annual Report Guidance contains data collection and reporting requirements that are consistent with GPRA and the established Title V MCH federal/state partnership. Through such reporting, HRSA’s MCHB and the states demonstrate accountability in the use of federal Title V funds and the required state matching funds for meeting the legislative intent.

Major proposed changes to this edition are listed below:

• Revised Approach for Interim-Year Reporting: states will decide whether updates are needed to numerous sections of the guidance during interim years two through five, following submission of the five-year Needs Assessment in year one.

• Streamlining and Reorganizing of the Guidance: the requirements for state narrative reporting are streamlined and reorganized in order to eliminate duplication.

• Family and Community Partnership: Expectations around state Title V reporting on family and community partnerships are clarified, such as reporting on partnership with HRSA’s Family-to-Family Health Information Centers, discussion on the impact these partnerships have on the MCH population, and their value in improving outcomes.

• Health Equity: There is a stronger emphasis on health equity, including it being a guiding principle of the Title V Program. Discussion on this principle is incorporated in the needs assessment sections and the state action plan for each MCH population. States have the option to identify and set annual targets for priority populations under each National Performance Measure (NPM) and use prepopulated, stratified data to report annual progress.

• Children and Youth with Special Health Care Needs: The instructions for describing the CSHCN system of care and the Annual Report and Application narrative for the CSHCN population domain have clarified.

• Reporting on Stillbirth: HRSA will add an NOM for stillbirth rate defined as, “number of fetal deaths at 20 or more weeks gestation per 1,000 live births plus fetal deaths.” In addition, HRSA will update the narrative in the tenth edition of the Guidance to revise the last sentence of III.B.3.a System of Care for Mothers, Children, and Families to include bereavement and stillbirth, as follows: "In describing the state's system of care for mothers, infants, and children, the role of the Title V program in addressing key MCH issues, which may include access to quality services, prenatal and postpartum care, maternal morbidity and mortality, stillbirth, newborn screening, infant mortality, preventive and primary care services for children and adolescents, immunizations, injury prevention, oral health, behavioral and mental health, bereavement, and/or substance use, should be clearly identified.” HRSA also added an example for Form 5b, pregnant women, around health promotion campaigns that address stillbirth and postpartum depression.

• Universal Measures: The two universal measures, Postpartum Visit and Medical Home, are selected as national priorities because of their focus on access and quality of essential primary and preventive care for mothers and children, including children with special health care needs. To help reduce burden, instructions will clarify that only one Evidence-based or -informed Strategy Measure (ESM) is required for Medical Home. HRSA has removed the requirement to discuss Medical Home in the Adolescent Health Domain, emphasizing reporting in the Child Health Domain. States may optionally report on Medical Home in the Adolescent Health Domain in addition to the required Child Health and CSHCN domains. HRSA did not receive specific comments on the Postpartum Visit universal measure.

• Standardized Measures: A new set of Standardized Measures are available to select as SPMs. Similar to NOMs and NPMs, annual performance data for these SPMs will be prepopulated by MCHB from national data sources, if available, and provided to the states for their use. States will be able to target priority populations for MCH outcomes. The Standardized Measures set contains measures that were NPMs in the previous Guidance as well as former NOMs that function better as performance measures.

• Form 7 Title V Program Workforce: Form 7 instructions will be clarified to better define what is a full-time employee (FTE), the relationship between the data fields, and the data being collected about positions lost over the past 12 months.

3. Use of Improved Information Technology and Burden Reduction

Since 1997, HRSA has made efforts to improve the use of information technology in data collection. In 2002, the MCHB developed the TVIS in order to better support its work in managing the Title V MCH Block Grant. TVIS was developed to provide an on-line mechanism for states to complete the required financial/program reporting forms and Application/Annual Report narrative discussion. It was also developed to provide a means to display the Application/Annual Report data to the general public. As such, TVIS consists of two components:

• TVIS Data Entry System - used by state Title V MCH Block grantees to submit their financial, program, and performance data as part of their yearly Application/Annual Report; and

• TVIS Web Reports - a web-based interface that allows public users to search, view and retrieve the finalized Title V data that is submitted by the 59 State Title V MCH Block grantees.

TVIS Data Entry System, which allows grantees to enter data into web-based forms and report sections, is derived from the Guidance and Forms for the Title V Application and Annual Report, Maternal and Child Health Services Title V Block Grant Program. State users electronically enter data and upload information as appropriate. The interface provides the “forms” of the Application that can be completed online, and those forms in turn submit data to a relational database that is developed to HRSA standards (e.g., SQL Server Relational Database) and is integrated with the larger and related agency grant management system known as the HRSA’s Electronic Handbooks (EHB). This system provides significant benefits, as users are permitted to complete the Application/Annual Report forms via the web and to submit the Application/Annual Report forms directly to the database. It should be noted that states are required to provide data only for the Application/Annual Reporting year, as other data cells are pre-populated from the previous years’ submissions.

TVIS Web Reports is a database that allows users to search and sort data on the health status of the nation’s mothers and children, as submitted by the 59 State MCH Block Grantees. This database assures that Title V program data on maternal and child health are uniformly available from all 50 states and nine (9) jurisdictions. Access to the data enables states, communities, policymakers, and health care professionals to make informed decisions about meeting the health care needs of women and children in the United States. Since the TVIS makes all information publicly accessible on the web, states have strong incentive to ensure the quality and accuracy of the data they submit.

Transformational changes made to the State MCH Block Grant program in 2016 brought new reporting requirements and a revised narrative format to the MCH Block Grant Application/Annual Report. The transformational changes mandated the redevelopment and deployment of TVIS.

Enhancements to TVIS Data Entry since 2016 include streamlined data entry, built-in checks and validations to ensure data quality, fewer data reporting forms, pre-populated National outcome and performance measure data (as available from national data sources), and intuitive Five-year State Action Plan Table.

TVIS Web Reports has been enhanced to feature a data dashboard presentation of the new performance measure framework (national and state-level data), interactive charts and maps, data downloads (images and Excel), updated narrative search feature, a National Snapshot and a State Snapshot for each of the 59 states and jurisdictions, which is updated annually and pulls data from various data reporting forms. The data reported annually by the states are available to the public on the enhanced TVIS Web Reports at: https://mchb.tvisdata.hrsa.gov.

In addition to the proposed changes in the updated Application/Annual Report Guidance, the MCHB continues to add increased functionality and other enhancements to the TVIS that serve to assist states in completing and submitting their online Applications/Annual Reports. In response to requests from numerous states, a Word upload feature was added in 2018. This functionality has been well received by state users and has contributed to burden reduction in submitting a MCH Block Grant Application/Annual Report in the TVIS.

4. Effort to Identify Duplication and Use of Similar Information

In establishing state reporting requirements, the MCHB considers the availability of national data from other federal agencies. As required by Section 509(a)(5) of the Act, every effort is made to not duplicate data collection efforts. Considerations for determining the required data reporting elements, as specified in the MCH Block Grant Application/Annual Report Guidance, include:

• Data are unique to the Title V program at both the state and national levels;

• Data are required by statute;

• Data are needed to address Departmental needs; and/or

• Data are not available from other sources.

The data requirements specified in Sections 505 and 506 have been discussed extensively with states in public meetings. Addressing them is part of the shared responsibility that exists through the program’s administrative structure of a federal/state partnership.

In addition to being one of the triple aims of the 2016 MCH Block Grant transformation, reduced duplication remains a priority for the MCHB. Ongoing feedback received from state partners on the Application/Annual Report submission process, along with feedback received in the annual TVIS User Satisfaction Survey (OMB Number: 0915-0212), help to guide burden reduction efforts. Efficiencies that have been incorporated into the updated Application/Annual Report Guidance include:

• Continued pre-population of the National performance and outcome data for states in the TVIS;

• Streamlined narrative reporting across the State Overview, Needs Assessment, and State Action Plan sections to allow for a more logical flow;

• Reduced duplication across the narrative sections of the Application/Annual Report;

• Clearer descriptions of expected content for individual narrative sections of the Application/Annual Report; and

• Continued incorporation of a Needs Assessment Summary into the Application; and

• Further clarification of reporting instructions and the use of consistent definitions across the Glossary and individual sections of the Application/Annual Report Guidance.

As discussed in Section 3, the MCHB continues to add increased functionality and other enhancements to the TVIS in an effort to reduce burden for states in submitting the yearly MCH Block Grant Application/Annual Report.

5. Impact on Small Businesses or Other Small Entities

No small business or other small entities are involved.

6. Consequences of Collecting the Information Less Frequently

Annual submission of an Application is required by law to entitle a state to receive MCH Block Grant funds (Sec.505). An Annual Report on the expenditure of the previous year’s funds is also required by Section 506 of Title V. Section 505(a) requires a state to conduct a statewide Needs Assessment every 5 years. The next Five-Year Needs Assessment reporting is due to be submitted in July 2025, as part of the FY 2026 Application/FY 2024 Annual Report.

7. Special Circumstances Relating to the Guidelines of CFR 1320.5

This data collection is consistent with the guidelines in 5 CRF 1320.5.

8. Comments in Response to the Federal Register Notice/ Outside Consultation

Section 8A:

A 60-day notice was published in the Federal Register on May 5th, 2023, vol. 88, No. 87; pp. 29135-37 (see attachment B). HRSA received 170 comments on the proposed updates to the tenth edition of the Guidance, from a variety of responders, including state Title V Programs, other state agencies, public health organizations, universities, members of the community, and other stakeholders. Of the 170 comments, 80 requested that stillbirth be addressed in the Guidance, and 71 requested that the oral health performance measures be retained as a national performance measure. The remainder of comments (19) included suggestions for clarifying instructions in certain sections of the Guidance, including examples of partnership with non-governmental organizations and family organizations, or responding to reporting burden on the universal performance measures. HRSA considered all public comments as part of its deliberative process in finalizing updates to the tenth edition of the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report.

A log of the public comments received is provided in Attachment C. which also includes the responses prepared by HRSA’s MCHB.

Section 8B:

By legislation, the MCH Block Grant is administered as a federal-state partnership. Throughout the development of the updated Application/Annual Report Guidance, the MCHB engaged a range of national and state MCH leaders and key stakeholders. The proposed updates to this edition (2023) of the Application/Annual Report Guidance reflect the recommendations of four internal MCHB workgroups (i.e., National Performance and Outcome Measures Workgroup; Children with Special Health Care Needs (CSHCN) and Family Engagement/Leadership Workgroup; Health Equity Workgroup, and Narrative Guidance/Reporting Forms Workgroup) and the input received from external partners. It should be noted that the CSHCN and Family Engagement/Leadership Workgroup solicited feedback from the Population Health Workgroup, which is comprised of federal and non-federal members,

Specific MCHB efforts to solicit stakeholder feedback included:

• Convening of a series of townhalls with states in region to examine the performance measure framework;

• Two virtual national Town Hall sessions with State Title V MCH programs, stakeholders, partners, community members, and families;

• Conducting an informational webinar on the proposed updates for State Title V MCH programs; and

• Soliciting input from the Association of Maternal and Child Health Programs.

While preliminary, proposed updates to the next edition (2023) of the Application/Annual Report Guidance were shared with the State Title V Directors and the MCH community in a webinar presentation in May 2023. Upon its publication on May 5, 2023, the MCHB provided State Title V Directors with a link to the Federal Register Notice that announced a 60-day public comment period for the draft updated Application/Annual Report Guidance. The public comments received prior to the release of the draft updated Guidance and the comments received following its release helped to inform the development of the attached updated Application/Annual Report Guidance.

9. Explanation of any Payment/ Gift to Respondents

Respondents will not be remunerated.

10. Assurance of Confidentiality Provided to Respondents

The Privacy Act does not apply in this data gathering effort because the information to be collected will not identify any individuals by name or collect any individual information.

All Annual Reports, Applications, and associated information submitted under Title V are public documents and available to the public on demand. Section 505 requires each state to have public disclosure through the MCH Block Grant Application process to facilitate public review and comment by interested persons or organizations during its development or transmittal.

11. Justification for Sensitive Questions

There are no questions of a sensitive nature associated with this data collection effort.

12. Estimated of Annualized Hour and Cost Burden

The annual burden estimate for this activity is based on previous burden estimates as well as consultations with eight selected State Title V MCH Directors (i.e., AK, LA, ME, MT, NV, NC, OK, and USVI) on the minimum number of hours needed by staff to complete an annual submission the application and report These states represented a range of population sizes, funding levels and urban/rural characteristics. Estimates for hours provided by states for reporting during the year of the needs assessment ranged from 100-410 hours. Estimates for interim year reporting (those years between needs assessments) ranged from 66-265. These hours were used as the basis for determining the minimum number of hours needed to submit an annual report in conjunction with estimates provided for previous versions of the Guidance.

HRSA’s MCHB recognizes that the full extent of the anticipated burden reduction will be realized over time, as states continue to become more familiar with the performance measure framework and reporting requirements. It is anticipated that the clarifying instructions, supplemental background information, and resources/tools provided in the updated edition of the Application/Annual Report Guidance will assist states in preparing the yearly MCH Block Grant Application/Annual Report, which will lead to further reductions in burden. The estimated average annual burden is presented below.

Section 12A:

Estimated Annualized Burden Hours

Form Name	Number of Respondents	Number of Responses per Respondent	Total Responses	Average Burden per Response (in hours)	Total Burden Hours
Application and Annual Report without Five-Year Needs Assessment Summary	59	1	59	115	6,785
Application and Annual Report with Five-Year Needs Assessment Summary	59	1	59	181	10,679
Total	59	……	59	……	17,464

Section 12B:

Estimated Annualized Burden Costs

As a Block Grant, states do not collect and report salary information or the working hour distribution of staff who are involved in administering the Title V program. In addition, the salary of staff supported under Title V will vary significantly across states. organizational capacity also varies, with the larger states typically utilizing more program staff than do smaller states. Each State Title V program has a unique organizational structure. Given its public health leadership role and the breadth of the services that are supported, the administration of a State Title V program requires multiple partners and health department units (e.g., MCH Director and staff, CSHCN Director and staff, Epidemiologist(s) and other supportive staff in Vital Statistics and Laboratory Services.)

Based on the Bureau of Labor Statistics, Occupational Employment and Wages for May 2022, the national mean wage estimate for 11-911 Medical and Health Services Managers in organizations that include public health agencies is $61.53 (https://www.bls.gov/oes/current/oes119111.htm). Wage has been doubled to account for overhead costs. The preparation and yearly submission of the Application/Annual Report and Five-Year Needs Assessment requires multiple levels of staff. As the Health Services Manager likely has one of the higher salaries, this rate was used to calculate the following annualized cost to the State Title V programs to account for costs nation-wide across the 59 states and jurisdictions. By using the mean hourly wage nationally, we have not adjusted for differences in locality.

Type of Respondent	Average Total Annual Burden Hours	Hourly Wage Rate	Total Respondent Costs1
Medical and Health Services Manager - Application and Annual Report without Five-Year Needs Assessment Summary	6,785	$61.35	$832,520
Medical and Health Services Manager - Application and Annual Report with Five-Year Needs Assessment Summary	10,679	$61.35	$1,310,314
Total	17,464		$2,142,834

13. Estimates of other Total Annual Cost Burden to Respondents or Recordkeepers/ Capital Costs

There is no capital, start-up costs, or operation and maintenance costs associated with this data collection.

14. Annualized Cost to the Federal Government

The level of federal staff effort associated with this activity is approximately 0.5 full-time equivalent (FTE) of one Federal staff (GS-15-10) based in HRSA Central Office in the Washington, DC area (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/DCB.pdf). This wage has been multiplied by 1.5 to account for overhead costs. The estimated annual salary cost of this level of effort is $137,625.

Federal Support	Base Pay Rate2	Response time in Hours	Number of Full Time Personnel	Total Annual Cost
Federal	$183,500 (GS-15, Step 10 in the Washington DC area)	.50	1	$137,625
Contractor support for Block Grant Reviews				$218,000
Total				$355,625

Subsequent editions of the Application/Annual Report Guidance will likely require less policy development and managerial oversight, which will result in further reductions of the level of required effort and grade level for Federal program staff who perform this work. In addition to federal program staff support, approximately $218,000 is needed annually to cover operational costs associated with conducting an annual review of each of the 59 State MCH Block Grant Applications/Annual Reports.

15. Explanation for Program Changes or Adjustments

The current inventory for this activity in a year in which States do not report on the findings of a Five-year Needs Assessment is 6,785 hours. In a year in which the state submits a Five-Year Needs Assessment Summary as part of its Application/Annual Report, the current estimate is 10,679 hours. The three-year period to be covered by the updated Application/Annual Report Guidance will include the submission of a Five-Year Needs Assessment Summary. Updates to the Application/Annual Report that contribute to the anticipated reduction in effort are:

• Streamlined narrative reporting for the State MCH Block Grant Application/Annual Report and the SSDI annual performance and progress reports;

• Clearer instructions for completing reporting forms;

• Development of a technical resource document that includes updated references, a complete glossary, added resources, tools, state examples and supportive background information; and

• Continued enhancements to the TVIS.

States have also indicated that having technical assistance support that provides resources, state examples and definitions are helpful and welcome. Continuing efforts to add functionality to the TVIS data entry system over the coming years should further serve to simplify and enhance the state user experience. It should be noted that the estimated burden hours reflect a minimum level of burden considered necessary to meeting the specified reporting requirements. Many states choose to engage in a more extensive process for conducting the Five-Year Needs Assessment and in preparing the yearly Application/Annual Report. For these states, the MCHB burden estimates may be low.

It should be noted that the operational costs to support the State MCH Block Grant reviews were lower in FY 2020-FY2022, as a result of the COVID-19 pandemic and the inability to conduct in-person reviews with the State Title V programs. Contract costs for the enhancement, operations and maintenance of the TVIS for FY 2020 were $1,600,000. On this basis, the estimated annual cost to the Federal government for the operations and maintenance of the TVIS (electronic data entry for states and the web reports), continued development of the TVIS to address changes in narrative and data reporting requirements and review of the State Applications/Annual Reports under the updated Application/Annual Report Guidance is $1,831,750.

16. Plans for Tabulation, Publication, and Project Time Schedule

During a regular submission year, the State MCH Block Grant Application/Annual Report document is usually submitted each year on July 15, with review of each submitted document completed between September and December. Announcements of funding decisions are usually made by October, or as soon as possible in the fiscal year after HRSA’s MCHB receives the appropriation.

Aggregation of data from the Annual Reports will begin each year in the Fall after receipt of the reports from states. Public web-based display of the states’ annual submission of the MCH Block Grant Applications/Annual Reports generally occurs by mid-November.

Data collected from each state’s MCH Block Grant Application/Annual Report provide key financial, programmatic, and performance measure data to assess a state’s progress in addressing its priority needs in assuring access to quality care of its MCH populations. Reporting on performance measures is used to assess national progress in key MCH priority areas and to facilitate the Bureau’s annual GPRA reporting. These data are made available for use by the public, researchers, universities, and other stakeholders interested in MCH populations.

17. Reasons(s) Display of OMB Exemption Date is Inappropriate

The expiration date will be displayed.

18. EXCEPTIONS TO CERTIFICATION FOR PAPERWORK REDUCTION ACT SUBMISSIONS

This project meets all of the requirements in 5 CFR 1320.9. The certifications are included in the package.

1 Hourly wage rate is from Bureau of Labor Statistics, Occupational Employment and Wages https://www.bls.gov/oes/current/oes119111.htm. Salaries have been doubled to account for overhead costs.

2 The rate used is a base rate according to the OPM salary table for 2023-DCB (annual rates and step) https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/DCB.pdf). Salaries have been multiplied by 1.5 to account for overhead costs.

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