MFP-Work-Plan-Help-File

Money Follows the Person (MFP)
Work Plan Help File
CONTENTS
Detailed Content Guidance for Entering Recipient Program Data ....................................... 2
A. General Information ...........................................................................................2
B. Transition Benchmark ........................................................................................2
C. State or Territory-Specific Initiatives ................................................................. 4

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Detailed Content Guidance for Entering Recipient Program Data
Questions included in the Work Plan are numbered and listed below in black
text. Definitions of terms and guidance for reporting on specific questions are
indicated in this guide with a star () and teal text.

A. General Information
 Guidance: No information is collected in this section, which consists of a brief overview of
the Work Plan and its purpose.

B. Transition Benchmark
1. Provide the projected number of transitions for each target group during each quarter. This
number includes institutional residents who are discharged from an institution to a qualified
residence during the reporting period, enroll in MFP, and begin using Medicaid home and
community-based services (HCBS).
Select the target populations applicable to your MFP Demonstration project:
 Older adults
 Individuals with physical disabilities (PD)
 Individuals with intellectual and developmental disabilities (I/DD)
 Individuals with mental health and substance use disorders (MH/SUD)
 Other
 Specify other target population (e.g., HIV/AIDS, brain injury)
 Guidance: For the multiple-choice field, select the target populations for which your MFP
program will set transition benchmarks.
 To complete the transition benchmark table, project the number of transitions for each
target group per calendar year quarter.
 Note that transitions will be assigned to a quarter based on the discharge date.
2. Explain how you formulated your projected numbers, which should include descriptions of
the data sources used, the time period for the analysis, and the methods used to project
the number of transitions.
 Guidance: Recipients may use a variety of data sources, including previous years’ MFP
transitions, number of Medicaid-eligible residents in nursing facilities or other inpatient
facilities, administrative data from waiver programs, or other sources.
 Time period for the analysis refers to the years examined in the data sources to inform the
projection (e.g., using data from calendar year (CY) 2019–CY2023).
 Recipients may use a variety of methods to project the number of transitions, such as
applying a percentage increase or decrease to the previous period’s transitions, or
calculating the projected number as a percentage of the MFP eligible population.

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3. Provide additional detail on strategies or approaches the state or territory will use to
achieve transition targets here and through a required state or territory-specific initiative.
 Guidance: Responses should provide an overview of the approach the recipient will take to
meet projected transition benchmarks, particularly if the recipient projects an increase in
transitions or transitions in new target groups. For example, if the recipient calculated
benchmarks based on enrolling 5 percent more individuals with I/DD, the recipient may
describe plans to increase outreach within Intermediate Care Facilities.
 Additional information on strategies to achieve transition targets will be included in the state
or territory-specific initative on transitions and transition coordination services in the section
below.

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C. State or Territory-Specific Initiatives
 Guidance: Recipients should complete the questions in the State or Territory-Specific
Initiatives section (I–IV) separately for each proposed initiative. Please refer to the Work
Plan for the list of required and optional initiatives.
Answer the following questions regarding required initiative topics.
 Guidance: These questions are necessary in order to track completion of required
initiatives.
 States with a self-direction option specified in their Operational Protocol should select yes
for the first option.
 States with a tribal initiative grant should select yes for the second option.
•

Are self-directed initiatives applicable to your state or territory?
 Yes
 No

•

Are Tribal Initiatives applicable to your state or territory?
 Yes
 No

I. Initiative Description
1. Initiative name
2. Describe the initiative, including key activities.
 Guidance: Identify the gap, challenge, or opportunity the initiative aims to address
(reference information in section A.1.1, “Summary of state or territory LTSS system and
gap analysis” in the Operational Protocol (OP), if relevant). Describe how the initiative will
address this area, including key activities.
3. Work plan topic: [select one topic per initative]
 Transitions and transition coordination services
 Housing-related supports
 Quality measurement and improvement
 Self-direction
 Tribal Initiative
 Recruitment and enrollment
 Person-centered planning and services
 No Wrong Door systems
 Community transition support
 Direct service workforce and caregivers
 Employment support
 Convenient and accessible transportation options
 Data-based decision-making
 Financing approaches
 Stakeholder engagement
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 Equity and social determinants of health (SDOH)
 Other
 Please specify any other initiative topic addressed, if applicable.
 Guidance: Recipients must identify and describe required initiatives, and they have the
option to identify additional initiatives on other topics. Required initiatives are as follows:
transitions and transition coordination services; housing-related supports; quality
measurement and improvement; self-direction (if listed in the OP); and Tribal Initiative (if
listed in the OP). A single initiative cannot fulfill more than one requirement.
4. Target population(s): [select all that apply]
 Older adults
 Individuals with PD
 Individuals with I/DD
 Individuals with MH/SUD
 Other
 Guidance: Select one or more target populations based on the group(s) intended to benefit
from the initiative described. “Other” target populations identified in Section B will populate
as additional response options.
5. Start date: _________________________
 Guidance: For initiatives that have not yet begun, enter the projected month and year it will
start. The projected start month should allow at least 30 days for Centers for Medicare &
Medicaid Services (CMS) review and approval of the Work Plan before implementation.
 For initiatives in progress, enter the month and year the initiative began. If the exact month
is unknown, provide an estimate.
6. Projected end date: ______________________
 Guidance: If the initiative has a projected or scheduled end date, enter that month and
year.
 If the initiative will be ongoing without a set or projected end point, select “not applicable
(N/A).” Initiatives without a projected end date will continue to be populated in the
recipient’s SAR until a projected end date is updated in the Work Plan.
II. Evaluation Plan
 Guidance: Recipients may enter one or more objectives for each initiative. Recipients
should complete questions 1–4 of the evaluation plan separately for each objective. After
questions 1–4 are completed for an objective, the form will prompt the recipient to either
add another objective or move on to the funding sources section for an initiative.
1. Objective: ______________
 Guidance: List one objective for the initiative. Objectives should be framed as SMART
goals (specific, measurable, achievable, realistic/relevant, and time-bound).
 Objectives should be indicators of improvements in the recipient’s MFP program and/or the
recipient’s ability to provide Medicaid HCBS rather than institutional long-term care
services.
 For example: “Increase number of direct care workers operating in under-resourced rural

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areas by 15 percent by 2025.”
 Recipients will have an opportunity to add additional objectives after completing questions
1–4.
2. Describe the performance measures or indicators your state or territory will use to monitor
progress toward achieving this objective, including details on the calculation of measures
(e.g., data sources and limitations), if relevant. Describe any key deliverables.
 Guidance: In the response, recipients should identify a performance measure that will
indicate progress towards the objective. In addition, the recipient should specify:
a. The data that will be used for the performance measure
b. How this data will be collected or obtained
c. How the recipient will calculate the performance measure based on the data
d. Any limitations in the data
e. If the measure is quantitative, please indicate the data label (e.g., percent, individuals)
for the information reported in question C.II.3.b, below.
 Indicate key deliverables for this objective, if relevant.
3. Provide targets for the performance measures or indicators listed above. Include
milestones and expected time frames for key deliverables.
a. Does the performance measure include quantitative targets?
 Yes
 No
b. [If yes] Complete the quarterly fields below.
 Guidance: Recipients should select yes for (a) if performance measures have quantitative
results. Quantitative targets should be populated in the quarterly fields provided in (b).
 If quantitative targets are not appropriate for the selected performance measure or
indicator, select no for (a) and provide quarterly qualitative targets in the text box.
 For all key deliverables listed in question 2, provide the projected completion date (month,
year) in the text box.
4. Provide additional detail on strategies/approaches the state or territory will use to achieve
targets and/or meet milestones (building on initiative description). Please list the
responsible state or territory agency parties and any key external partners for achieving this
objective.
 Guidance: When listing recipient agencies and key external partners, please describe their
role and whether these partnerships are established or planned.
 Recipients may reference information provided in the OP, if relevant.
III. Funding Sources
1. Funding source(s): [select all that apply]
 MFP cooperative agreement funds for qualified HCBS and demonstration services
 MFP cooperative agreement funds for supplemental services
 MFP cooperative agreement funds for administrative activities
 MFP cooperative agreement funds for capacity-building initiatives
 State or territory equivalent funds attributable to the MFP-enhanced match
 Other
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 Specify other funding source: _______________.
In the table provided, provide projected quarterly expenditures for the initiative.
 Definition: A Cooperative Agreement is an alternative assistance instrument used
whenever substantial federal involvement with the recipient during performance is
anticipated. The difference between grants and cooperative agreements is the degree of
federal programmatic involvement rather than the type of administrative requirements
imposed.
IV. Initiative Close-Out
 Guidance: When updating the Work Plan, recipients should complete this section for
initiatives with an end date during the following semi-annual reporting period.
1. Actual initiative end date: ______________
 Guidance: The projected end date is populated from C.I.8. List the actual date that the
initiative concluded.
2. For initiatives that will no longer be sustained with MFP funding and/or state or territoryequivalent funding, indicate the status below: [select one]
 Completed initiative
 Discontinued initiative
 Indicate reason for termination: ________________
 Sustaining initiative through a Medicaid authority
 Indicate alternative funding source: ________________
 Guidance: If “discontinued initiative” is selected, indicate the reason the initiative was
discontinued.
 If “sustaining initiative” is selected, indicate alternative funding source/Medicaid authority in
text box below.

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