Financial Narrative Overview

Title V federal funding, in conjunction with non-federal state funding and other federal funds, are obligated and expended to support Michigan’s MCH priority needs and Title V requirements. Over one-third of Title V funding supports Children with Special Health Care Needs (CSHCN) and over one-third supports the MCH work of all 45 local health departments across the state. Additional Title V funding and match funding supports other MCH priorities, such as immunizations, childhood lead poisoning prevention, oral health for children, infant safe sleep and breastfeeding initiatives, reproductive health, Fetal Alcohol Spectrum Disorders (FASD), Regional Perinatal Quality Collaboratives (RPQCs), home visiting, rural home visiting, health equity initiatives, adolescent parenting support, staff support for Michigan Model for Health™, Pregnancy Risk Assessment Monitoring System (PRAMS), and Fetal Infant Mortality Review (FIMR). State general funds are used for Michigan’s required state match. To ensure alignment with Title V requirements, Title V leadership and the MDHHS Budget liaison meet throughout the year to review Michigan’s MCH expenditures. Expenditures for FY 2021 and budget plans for FY 2023 are discussed in Sections III.D.1 and III.D.2, respectively.

Expenditures (FY 2021 Annual Report Year)

In FY 2021, Title V funds were spent on an array of MCH programs and initiatives. The following narrative corresponds with the budget forms in this application and annual report.

Form 2

Form 2, Line 1, FY 2021 Annual Report Expended of $17,942,890 represents Title V funding from the Federal Fiscal Year (FFY) 2021 grant period that was spent down in the state Fiscal Year (FY) 2021. It does not include FFY 2020 dollars expended in FY 2021 (i.e., carryover from the FFY 2020 award), nor does it include FFY 2021 dollars expended in FY 2022 (i.e., the current fiscal year in which FFY 2021 carryover is being spent down). The Annual Report Expended amount of $17,942,890 is lower than the FY 2021 budgeted amount of $19,415,900 because the original budget included carryover dollars.

Per section 503(b) of Title V legislation, states have the authority to spend down Title V funds over a two-year grant period (i.e., to use unspent funds from the first year of the grant award in the second year of the grant award). In FY 2021 Michigan’s Title V program spent down approximately $1,048,300 in carryover funds from FY 2020 (i.e., the second year of the FFY 2020 grant period) and $17,942,890 from the FFY 2021 annual report period. These Title V expenditures supported MCH and CSHCN program work in FY 2021 as described in this annual report. Approximately $974,740 of the FFY 2021 grant was not expended in FY 2021 but will be fully expended in FY 2022 (i.e., the second year of the FFY 2021 grant period). Michigan has experienced increased Title V carryover during the past two years due to the COVID-19 pandemic. Some programs that traditionally deliver in-person health services were unable to do so and/or were operating at decreased capacity as staff were reassigned to COVID-19 mitigation activities.

Michigan’s Title V state match as reflected on Form 2, line 3, “State MCH Funds” in Annual Report Expended exceeds federal match and Maintenance of Effort requirements. Approximately 82.7% of Michigan’s state match is comprised of state general funds for CSHCS medical care and treatment. The remaining 17.3% includes state general funds that support family planning local agreements; family, maternal and children’s health; pregnancy prevention services; prenatal care and outreach; non-emergency medical transportation for CSHCN; CSHCN administration; and bequests for care and services for CSHCN. Fluctuations in State MCH Funds expended can occur each year based on significant one-time costs for CSHCS medical care and treatment. Form 2, line 5, “Other Funds” in the Annual Report Expended represents the Children with Special Needs Fund. CSHCS only spends the earnings of the fund, which in FY 2021 was $574,036. Program Income (Form 2, line 6) includes newborn screening follow-up.

As illustrated in Form 2, line 9, “Other Federal Funds,” Michigan’s MCH work was supported by a variety of other federal funds in FY 2021 including: Women, Infants and Children (WIC); State Systems Development Initiative (SSDI); Title XIX (Medicaid); Immunization; Lead Poisoning Prevention; Abstinence Education Grant Program; Personal Responsibility Education Program (PREP); Home Visiting; Early Hearing Detection; Awareness and Access to Care for Children and Youth with Epilepsy; Universal Newborn Hearing Screening; Pregnancy Risk Assessment; and Title X (Family Planning).

MCH priorities across the Title V population health domains were supported by federal and state dollars in FY 2021. For example, in the Title V child health domain, a state priority is to “expand access to developmental, behavioral, and mental health services through routine screening, strong referral networks, well-informed providers, and integrated service delivery systems.” A Title V state action plan that links to this priority is childhood lead poisoning prevention. Other federal awards helped to support this Title V priority such as the CDC Childhood Lead Poisoning Prevention Program (CLPPP). In the perinatal/infant health domain, a state priority is to “create and enhance support systems that empower families, protect and strengthen family relationships, promote care for self and children, and connect families to their communities.” Federal grants such as the CDC Early Hearing Detection and Intervention (EHDI) State Program; HRSA Maternal, Infant and Early Childhood Home Visiting Program (MIECHV); and HRSA Universal Newborn Hearing, Screening and Intervention help support this priority and related work.

30/30/10 Requirement

Michigan tracks expenditures to comply with the Title V 30/30/10 legislative requirements. That is, a minimum of 30% of total funding must be expended for CSHCN; a minimum of 30% of total funding must be expended for preventive and primary care for children ages 1-21; and a maximum of 10% of total funding can be expended for Title V administration. In FY 2021, expenditures were tracked by CSHCN; preventive and primary care for children ages 1-21; pregnant women, mothers, and infants; and others. Expenditures track the required amount, variance, percent of total and percent required to assure legislative compliance. In FY 2021, 32.0% of Title V FFY 2021 expenditures were for preventive and primary care for children; 38.9% of expenditures were for services for CSHCN; and 3.0% of expenditures were for Title V administrative costs. The remaining 26.1% of expenditures were for pregnant women, mothers, infants, and others (including men and non-pregnant women). Funding across the Title V populations supported work related to Local Maternal and Child Health (LMCH), medical care and treatment for CSHCN, reproductive health, oral health, safe sleep, Fetal Alcohol Spectrum Disorders (FASD), childhood lead poisoning prevention, immunizations, Regional Perinatal Quality Collaboratives (RPQCs), and surveillance mechanisms such as PRAMS, maternal mortality surveillance, and Fetal Infant Mortality Review (FIMR).

To assure the 30/30/10 requirement is documented and to record expenditures by the types of individuals served, the Local MCH (LMCH) program has specific budget project titles in the Electronic Grants Administration & Management System (EGrAMS) and in the LMCH Year End Report. The LMCH Year End Report has a table to capture the types of individuals served and another table that mirrors the federal reporting of the MCH Types of Services. The FY 2021 budget project titles in EGrAMS included the following two categories:

• MCH – Children
• MCH – All Other

Expenditures for CSHCN also have specific project titles in EGrAMS to record and document expenditures for medical care, treatment, case management services, outreach, and advocacy.

For the 30% children requirement, Michigan tracks related expenditures at the state and local level including immunizations for children and adolescents, oral health services for school-age children, family planning and reproductive health for adolescents and young adults, teen pregnancy prevention and parenting support, childhood lead poisoning prevention and case management, special projects such as services for children with FASD, and other LMCH activities. Michigan has also implemented a mid-year check-in to assure expenditures are on track for the 30% children requirement.

In Form 2, Annual Report Expended, the following line items had a variance of 10% or more of the original budgeted amount, for the following reasons:

• Line 1.A, Preventive and Primary Care for Children, FY21 annual report expended does not include carryover dollars whereas the original budget included carryover estimates.

• Line 1.C, Title V Administrative Costs, were lower than expected due to a vacant position.
• Line 3, State MCH Funds, were lower than expected due to realized Medical Care and Treatment expenses being lower than anticipated.
• Line 5, Other Funds, were lower than expected due to the Children with Special Needs Fund earnings being lower than anticipated.
• Line 6, Program Income, was lower than budgeted due to Newborn Screening earnings being less than appropriated.

Local MCH

Title V funding is allocated to each of the 45 local health departments (LHDs) in Michigan through the LMCH program. Each LHD receives a fixed amount of funds, with allocations ranging from $15,490 to $1,709,654. LMCH funds are available to support one or more of the Title V national and state performance measures plus locally identified needs. Each LHD completes a work plan for each selected national, state and/or local performance measure. Activities and expenditures within the work plan are categorized by population characteristic. Expenditures are also reported on by the MCH Pyramid of Services.

Table 1 summarizes spending by 45 LHDs in FY 2021 by the MCH Pyramid of Services (i.e., direct, enabling, and public health services and systems).

Table 1. LMCH Spending by MCH Pyramid of Services

For FY 2021, each LHD was encouraged to select one to two national or state performance measures and/or locally identified measures. Out of 45 LHDs, 43 LHDs chose at least one national performance measure or state performance measure (with the remaining two LHDs selecting only local performance measures).

In total, six LHDs chose one performance measure; 20 chose two performance measures; 8 chose three performance measures, 3 chose four performance measures; 7 chose five performance measures; and 1 chose six performance measures. Table 2 summarizes the number of LHDs expending funds in each performance measure, the amount expended, and the number of clients served.

Table 2. LMCH Spending by Performance Measure

Form 5

Form 5 reflects the number and percent of the MCH population served by the Title V program in Michigan, as defined by both Title V funding and Title V state match. As reflected in Form 5a, the estimated total count of individuals served via direct and enabling services (i.e., the top two levels of the MCH Pyramid of Services) was 534,264. This count includes individuals who received a service funded by Title V federal dollars or non-federal state match dollars as reported on Form 2, line 8. For FY 2021 reporting, data on individuals served were collected from Local MCH, Nurse-Family Partnership (NFP), Rural Home Visiting, 3rd grade sealants program, childhood lead support and education, safe sleep program, Family Planning, FASD, immunizations, Michigan Adolescent Pregnancy and Parenting Program (MI-APPP), PREP Michigan Organization on Adolescent Sexual Health, breastfeeding support, FIMR family interviews, Parent Leadership in State Government, and CSHCS medical care and treatment. Form 5b provides an estimate on the total percentage of populations who received a Title V supported service in each of the MCH population groups across all three levels of the MCH Pyramid of Services (i.e., direct, enabling, and public health services and systems). This estimate includes all individuals and populations served by the total federal and state match as reported in Form 2, line 8. As reported on Form 5b, the Title V program served 100% of pregnant women, 100% of infants, 72% of children, 72% of CSHCN and 5% of others which includes males and non-pregnant women of childbearing age. For more details, see Form 5 field notes.

Michigan continuously explores ways to expand the reach of Title V. For example, Regional Perinatal Quality Collaboratives (RPQCs) began work in one region of the state in 2015. Currently, nine RPQCs represent all ten Prosperity Regions in Michigan. In FY 2021, eight RPQCs received financial support from Title V and/or state match funds. The RPQCs supported MCH activities and served as regional leaders for implementation of the Mother Infant Health and Equity Improvement Plan.

Payer of Last Resort

Michigan supports Title V regulations to use Title V funds as the payer of last resort. The comprehensive contract for each local health department includes contractual language which emphasizes this payment structure for programs that provide direct or enabling services to individuals such as LMCH, lead poisoning prevention, immunizations, oral health, and CSHCS programs. The remaining Title V funds are used for systems-level work in infrastructure or related to the ten essential services, which are non-claims related reimbursement.

Budget (FY 2023 Application Year)

Together with state general funds and other federal funds, the Title V MCH block grant is used to address the state’s MCH priority needs, improve performance related to the targeted MCH outcomes, and expand systems of care for the MCH and CSHCN populations. The Title V state action plan narrative includes information on how Title V funding is utilized within each population domain. Michigan’s Title V Leadership Team—which includes the Title V MCH director, Title V CSHCN director, and key Title V administrative staff—meets on a regular basis to discuss all aspects of Title V, including the budget and how federal and non-federal funds are used to address the state’s MCH needs.

Form 2, Line 1, Federal Allocation, FY 2023 Application Budgeted amount of $18,917,600 is based on the estimated Federal Fiscal Year (FFY) 2023 award amount. Michigan will also spend approximately $1,000,000 in carryover funds from the FFY 2022 award. As indicated in Section 503(b) of the Title V legislation, “Any amount payable to a State under this title from allotments for a fiscal year which remains unobligated at the end of such year shall remain available to such State for obligation during the next fiscal year.” That is, the Title V budget period is 24 months and therefore states can spend any unobligated funds from the first year of the grant period as “carryover” in the second year. The FFY 2022 Title V dollars that will be spent down in FY 2023 will primarily support MCH Special Projects.

Based on the estimated federal award and the state's Executive Budget recommendation, Title V funding is projected to be used for the following MCH programs and services in FY 2023:

• Local MCH Program (Local Health Departments)
• Medical Care and Treatment for CSHCN
• Family Planning Local Agreements
• Childhood Lead Poisoning Prevention Program
• Immunization Program
• MCH Special Projects (including FASD, breastfeeding, bullying prevention, and Handle with Care)
• Oral Health Programs for Children
• Sudden Infant Death Syndrome Prevention
• Pregnancy Prevention Services
• Bequests for Care and Services for CSHCN
• Administration

The largest amounts of Title V funding go toward the Local MCH Program (~37% of funding is awarded to Local Health Departments through non-competitive contracts) and Medical Care and Treatment for CSHCN (~36% of funding). The remaining Title V funding (~27%) is used for the programs and services listed above which impact all five Title V population domains.

As previously discussed, Michigan’s 2020 Title V needs assessment identified a new set of state priority needs and performance measures. Through local health department activities and/or state level work, it is anticipated that Title V appropriations will support activities related to federally defined National Performance Measures (NPMs) in FY 2023:

• NPM 2 (Low-risk Cesarean Delivery)
• NPM 4 (Breastfeeding)
• NPM 5 (Safe Sleep)
• NPM 9 (Bullying Prevention)
• NPM 12 (Health Care Transition for CYSHCN)
• NPM 13 (Preventive Dental Visit)

The annual LMCH Plans for FY 2023 are not available at the writing of this application. In FY 2022, Local Health Departments (LHD) selected NPMs 4, 5, 12 and 13. Due to the COVID-19 pandemic, many LHDs have not had the opportunity to consider realigning work in their LMCH plan to address NPM 2 and NPM 9, which were added to Michigan’s NPMs based on the 2020 needs assessment. In FY 2021, the format of the LMCH plan and workplan changed to better align with federal Title V requirements. Sample workplans for each national and state performance measure were developed and distributed to all LHDs. Additionally, webinars on integration of NPM 2 (Cesarean delivery) and NPM 9 (Bullying) into workplans were conducted in FY 2021. This technical assistance was intended to provide ideas and examples on how LHDs might operationalize activities to address these measures in the future.

At the state and local level, Title V funds will also be used to directly support the work of Michigan’s six State Performance Measures (SPMs):

• SPM 1 (Childhood Lead Poisoning Prevention)
• SPM 2 (Immunizations—Children)
• SPM 3 (Immunizations—Adolescents)
• SPM 4 (Medical Care and Treatment for CSHCN)
• SPM 5 (Intended Pregnancy)
• SPM 6 (Developmental, Behavioral, and Mental Health)

At the state level, all SPM program areas have allocations in the FY 2023 Title V budget. Although FY 2023 LMCH plans are not yet available, it is anticipated that local health departments will also implement work across all SPMs, based on FY 2022 LMCH plans.

The programs and activities that will support work on the above NPMs and SPMs in FY 2023 are detailed in the state action plans. LHDs use an MCH Needs Assessment to inform the creation of FY 2023 LMCH plans, including a focus on the state’s identified NPMs and SPMs as well as distinct local priorities and needs. As of the writing of this application, FY 2023 LMCH plans have not been submitted.

30/30/10 Requirement

Michigan’s commitment to adhere to the 30/30/10 Title V legislative requirement was discussed in the preceding Expenditures section. For FY 2023, this commitment is again reflected in Form 2 (Lines 1A, 1B, and 1C) in the Application Budgeted. For FY 2023, 32.4% of the total Title V budget is designated for preventive and primary care for children; 36.9% is designated for Children with Special Health Care Needs; and 3.4% is designated for administrative costs. Title V leadership will hold discussions throughout the fiscal year (in coordination with the MDHHS Budget liaison) to assure that the budget and spending are on track, and to address any new or unplanned MCH needs.

Form 2

MDHHS meets and monitors the required Title V state match which is a $3 match in non-federal funds for every $4 of federal Title V funds expended. Michigan exceeds the required match in expenditures and budgeting. Michigan’s “State MCH Funds” (Form 2, line 3) of $52,970,400, which is considered the state’s applied Maintenance of Effort for Title V, is composed of state general funds for the following appropriations: medical care and treatment for CSHCN; Family Planning local agreements; prenatal care and outreach; pregnancy prevention services; CSHCS and Family, Maternal and Child Health administration; non-emergency medical transportation; and bequests for care and services. Most of this match (approximately 85.3%) is related to medical care and treatment for CSHCN and other CSHCS-related funds. Along with other federal funds, these state MCH dollars provide a critical component of Michigan’s MCH infrastructure. In Form 2, line 5, “Other Funds” reflects income from the Children with Special Needs (CSN) Fund. Michigan’s “Program Income” (Form 2, line 6) includes Newborn Screening follow-up. Other federal funds anticipated in FY 2023 are indicated in Form 2, line 9.

Form 3a and 3b

Each year, Michigan’s Title V administrative staff also completes an assessment of “Types of Individuals Served” and “Types of Services” provided by Title V funding at the state and local level, as reflected in Form 3a and 3b, respectively.

At the local level, the LMCH Plan was transformed in 2021 based on recommendations from a workgroup (consisting of LHDs and state LMCH and Title V staff) to be in closer alignment with the Title V application. To better align with Form 3a, LHDs are now required to report types of individuals served and amount expended by population classifications. Additionally, LHDs are required to report expenditures by essential services as identified in the Title V MCH Pyramid of Services (i.e., direct services, enabling services, and public health services and systems) in a “Types of Services” table in their annual plan and year-end report. The table mirrors the federal Form 3b table. Beginning in FY 2021, budget categories in EGrAMS were reduced from five projects to two projects to create clearer alignment with the Title V 30-30-10 rule. The two projects use population classifications instead of pyramid of services. The latter will be captured through the new Types of Services reporting table.

At the state level, Title V funding is budgeted across MCH population groups and is in alignment with the 30-30-10 rule. For example, Michigan’s Title V state priority to “expand access to developmental, behavioral, and mental health services through routine screening, strong referral networks, well-informed providers, and integrated service delivery systems” aligns with the Title V child health domain through SPM 1 (childhood lead poisoning prevention) through lead screening services. Title V allocations for SPM 1 support services that contribute to the 30% requirement for primary and preventative services for children 1-21. As another example, the state priority to “ensure children with special health care needs have access to continuous health coverage, all benefits they are eligible to receive, and relevant care where they live and learn” aligns with SPM 4 (medical care and treatment for CSHCN) which contributes to the 30% requirement for CSHCN.

For state level activities that align with Form 3b, Title V allocations are assessed to determine where activities fall in the MCH Pyramid of Services. The Pyramid of Services is defined in the Title V MCH Block Grant Guidance and includes three levels: direct services, enabling services, and public health services and systems. For example, Michigan’s Title V state priority to “ensure children with special health care needs have access to continuous health coverage, all benefits they are eligible to receive, and relevant care where they live and learn” aligns with the top level of the pyramid (direct services) through SPM 4 (medical care and treatment for CSCHN). The state priority to “create and enhance support systems that empower families, protect and strengthen family relationships, promote care for self and children, and connect families to their communities” aligns with the center (enabling services) of the pyramid through NPM 4 (Breastfeeding). State level activities for NPM 4 focus on breastfeeding education and support to help improve breastfeeding initiation and duration rates. State level activities for NPM 2 (Low-risk Cesarean Delivery) focus on the state priority need to “develop a proactive and responsive health care system that equitably meets the needs of all populations, eliminating barriers related to race, culture, language, sexual orientation, age, and gender identity.” Systems level work is being implemented through the Michigan Perinatal Quality Collaborative and other systems work that focuses on core public health services.

Form 5

The total Federal-State partnership funding is evaluated when completing Form 5. MCH programs that receive Title V federal and/or state match funds are asked to provide counts of individuals served. These counts of individuals in Form 5 relate to the total expenditures provided by population serviced on Form 3. Form 5 demonstrates the reach of Title V funds and state match across MCH population groups.