Expenditures

At the time of the July 2023 submission, obligations of the 2022 grant are not fully liquidated. Expenditures and unliquidated obligations for performance ending September 30, 2023, are reported in the financial forms and narrative. Obligations will be paid in the 90-day liquidation period and reported in the Final Federal Report (FFR) due January 30, 2023. 

The narrative is organized to emphasize performance generally about financial resources of the 2022 grant, state expenditures in the FFY 2022 period, and local match associated with subawards of the 2022 grant. Expenditures, including the level of detail needed to demonstrate compliance with 30-30 statutory requirements and the 10% administrative cap are reported in the annual report.

Notes on Expenditures

1) Each annual federal allotment has a two-year period of availability, permitting two grants to overlap by 12 months. For example, at the time of the July 2023 report submission, the 2022 and 2023 grant funds are available for obligation and expenditure. The 2024 funds in this Application will be initially available in the 2nd year of the 2023 grant period. Nebraska regularly exercises the two-year spending authority given to states to obligate the annual allotment of Title V Maternal Child Health Block Grant in the succeeding fiscal year of the allotment. 

2) Title V statutory expenditure requirements are based on the allotment, not the expenditures in a 12-month fiscal year period. The overlap does provide greater flexibility than some grants, yet also requires careful grants management to ensure full compliance with statutes and regulations.

3) Non-federal match for this report is predominately state funds expended in the FFY 2022 period, i.e., October 1, 2021, through September 30, 2022. Subrecipient Tribal MCH programs and community-based projects contribute third-party and non-federal cash expenditures aligned with a subaward period (April 1 through March 31) and not aligned with the FFY or state fiscal year (SFY) July 1 through June 30.

Circumstances challenge alignment of requirements

Two disclaimers are intended to explain any misalignments between financial, program, and performance measures in this annual report. 

1) Title V needs to fit the two-year spending authority of the federal block grant in an annual reporting framework. In a 12-month fiscal year period there are two open grants, i.e., the succeeding year of 2022 funding availability overlaps with the initial year of the 2023 allotment. Overlapping grants could each arguably be credited to the performance demonstrated in the State Action Plan narrative, and the program forms. While all expenditures are clearly attributable to a specific grant allotment, outcomes during the same period are not so clearly aligned to specific funding. 

2) Nebraska’s state fiscal year (SFY) is July 1 through June 30. State appropriations and spending authority do not align with the FFY. For purposes of this report, state expenditures are reported based on payments in the FFY period October 1 through September 30. Adjusting for fiscal period helps explain any variance between the budget and expense greater than 10% in financial forms. Despite these challenges, NDHHS has sound financial and administrative controls in place, and supporting documentation is maintained to demonstrate fiscal compliance.

Programs & special projects

With the 2022 federal allotment, NDHHS supported a wide variety of maternal and child health (MCH) activities in 11 state-level public health programs through an internal allocation, all administered within NDHHS. Individual program budgets are often in conjunction with state support and/or other federal awards. A number of subaward agreements with community-based organizations and the four federally recognized Tribal governments headquartered in Nebraska further extend a statewide impact.

1. An Aerial View:  Federal–State Partnership and Other Federal Funds (Form 2)

Title V includes the block grant (BG) and state funds (SF), the focus of this narrative. A variety of contracts (procurement of goods and services) are sourced with the federal block grant and state funds are overseen by NDHHS program managers. 

The multi-faceted programs of the Maternal & Child Health (MCH) team ($383,002 BG) comprise much of the content of the State Action Plan, which is described elsewhere in this report. MCH program staff are an integral part of the Title V State Action Plan group and led a variety of initiatives and coordinated state-level activities with other programs/units to address many of Nebraska MCH priorities and activities across population domains.

The Office of MCH Epidemiology ($123,923 BG; Title V funds also provided additional support ($99,393 BG) beyond the CDC award to the Pregnancy Risk Assessment Monitoring System (PRAMS).) successfully recruited a CDC MCH Epidemiology Assignee in September 2020. The Child and Maternal Death Review team (CMDRT) continued to implement the reorganized Maternal Mortality Review Committee under the CMDRT by training a MCH Epidemiology Coordinator. The first MMRC report (deaths that covered years 2014 – 2018) was completed and available on the DHHS website. Other activities of the Office included continuing with the second investment into National Survey of Children’s Health oversample, supporting the N-MIECHV data and performance management system, and continuing analysis and production of an internal report on the Medicaid-Birth linkage. 

The Adolescent & Reproductive Health Programs ($366,324 BG) supported education and preventative health practices that improve reproductive health outcomes, such as decreasing STDs/STIs, preventing unintended pregnancies, promoting appropriate birth spacing, and encouraging a healthy lifestyle. Subawards with six community-based organizations focused on engaging adolescents through outreach and education events, to increase their utilization of reproductive health services to make informed decisions, decrease STD/STI rates among youth, and decrease unintended pregnancies.

Women’s Health Initiatives (WHI) ($99,599 BG) provided support to the Women’s Health Advisory Council. In addition, WHI either led or participated in a variety of other external and internal collaborations regarding MCH initiatives. The Birth Defects Registry ($66,387 BG) provided training to hospitals to use the state electronic birth defect reporting system, performed data quality checks to assure the birth defect data are accurate and complete, and engaged with MCH programs to provide accurate, complete, and timely information about children with birth defects. 

The Newborn Screening Program ($478,783 BG; $347,773 SF) staff conducted continuous monitoring, tracking, and follow-up activities to ensure all Nebraska newborns receive a valid screen for all required conditions. This work included tracking activities for all approximately 25,000 births and for drawn early, unsatisfactory, post-transfusion, inconclusive, and presumptive positive screening results. Beyond the CDC and HRSA awards for Early Hearing Detection and Intervention (EHDI) ($54,602 BG), additional support from Title V included a subaward to the University of Nebraska-Lincoln (UNL) for HearU Nebraska, providing hearing aids to children ages 0-18 with priority to newly identified children ages 0-3. EHDI was also able to temporarily employ a part-time UNL audiology student.

Most internal allocations are within the Division of Public Health, while one, the Medically Handicapped Children’s Program (MHCP) ($1,106,986 BG; $770,558.33 SF) is organizationally within the Division of Children & Family Services. MHCP and its partners are essential to the CYSHCN domain. MHCP field staff statewide provide ongoing family-centered case management services to program participants. During the 2022 Block Grant period MHCP continued use of Parent Resource Coordinators (PRC). The program partnered with the University of Nebraska Medical Center (UNMC)’s Munroe Meyer Institute (MMI) to conduct Specialty Clinics, neonatal intensive care follow-up through TIPS (Tracking Infant Progress Statewide) program, and the Teratogen Project, which provided accurate and timely information on exposures to potentially damaging agents during pregnancy and lactation. 

Subawards to Tribal governments and local communities ($846,132.35 BG; $330,199 local/non-federal cash & third-party/in-kind) helped ensure Public Health Services and Systems and provided enabling services (and some direct services in Tribal programs) in communities across Nebraska. The 2022 federal award provided assistance to six local health departments, two community-based organizations, and four subawards with federally recognized Tribes headquartered in Nebraska (Omaha, Ponca, Santee Sioux, and Winnebago). Local and Tribal activities are enhanced and more likely sustained by subrecipients contributing local resources to the total costs (Form 2, line 5). The additional resources are a good indicator of genuine partnerships, steadfast commitment, and appreciation for community-specific solutions to Nebraska’s MCH priorities.

Other federal funds (Form 2, Line 9) under the control of the Title V administration is defined by Nebraska as the broad oversight by the MCH Director and the CYSHCN Director. Many other program managers supervised by the MCH Director and CYSHCN Director of Title V are more directly responsible for the administration of the other federal awards. Those expenditures do not perfectly align with this report because of the varying fiscal years and report dates which do not correspond with the Title V MCH Block Grant. Not all prior awards have been fully expended because of varying periods of spending authority. 

2. MOE, Match, and 30-30-10 Compliance (Form 2)

The total state match (Form 2, line 7) is a combination of state funds ($3,147,763) plus local funds and in-kind support ($330,199). The total value of matching resources, including local match, is 90.6% ($3,477,962) or 82% state funds alone of the 2022 federal Title V expended/unliquidated obligations reported ($3,837,413). This exceeds the 3:4 match minimum, and the Maintenance of Effort ($2,626,360, Form 2, line 7A). 

Nebraska is compliant with the statutory requirement to expend at least 30% of the federal allotment for Children 1 through 21 years (Form 2, line 1A), plus at least 30% CYSHCN (Form 2, line 1B). NDHHS uses accounting codes by MCH populations to track payments by federal allotment and to identify compliance with the 30%-30% requirement. 

Administrative costs (Form 2, 1C.) are $85,890 (2.2%), far below the 10% statutory cap.  These costs are primarily attributable to the salary, benefits, and indirect costs of the Federal Aid Administrator III position, allocable to performing grants management of the 2022 Title V Block Grant. Additional costs attributable to administrative costs include the annual membership dues to the Association of Maternal Child Health Programs (AMCHP), travel, training, and other direct costs to administer the 2022 federal allotment.

3. Expense by Types of Individuals and Health Coverage (Form 3a) aligned to #s of individuals (Form 5a) who received Direct and Enabling services

The 2022 allotment of Title V federal funds to Nebraska is $3,912,446. At the time of the July 2023 report submission, the total expenditures/remaining obligations across the five types of individuals served (Form 3a, IA) is $3,751,523, 97.8% of the projected final expense. A total 88,466 persons received an individually delivered Direct or Enabling Service at a cost of $4,411,037 ($2,043,190 BG; $2,367,847 SF).

4. Expense by Types of Services (Form 3b) to the #s receiving individually delivered services (Form 5a) and the total percentage of the population served by Title V Federal-State Partnership (Form 5b)

Nebraska expenditures of the Federal-State Partnership were 63.1% ($4,411,037) for Direct and Enabling Services (Form 3b) for individually delivered services to 88,466 persons (Form 5a). Expenditures for Public Health Services and Systems (Form 3b) comprise the other 36.9% ($2,574,139), reaching an average 81% of the MCH population (Form 5b).

The broad-based category budget (Forms 2, 3a, and 3b) is presented on a presumed 2024 allotment (grant) like the level of recent awards. A precise 2024 budget will be finalized and approved within NDHHS during the first year of spending authority.

Notes on the budget

These three overarching points are intended to give foundation to the remainder of the narrative. 

1) Each annual allotment has a two-year period of availability that permits two grants to overlap by 12 months. For example, at the time of the July 2023 submission of the 2024 application, the 2022 and 2023 grant funds are available for obligation and performance. The 2023 funds will be available in the 2nd year of the 2023 grant period. 

2) The statutory “30-30-10” requirements are based on the allotment, not the expenditures in a 12-month fiscal year period. The overlap does provide greater flexibility than some grants, yet also requires careful grants management to ensure full compliance with statutes and regulations. Meeting statutory requirements by allotment is carefully balanced with the timing and amount of the next allotment. 

3) The State of Nebraska operates in a state fiscal year (SFY) period different than the federal fiscal year (FFY). In more recent Title V applications, NDHHS determined it better to budget state MCH funds based on historical expenditures year-to-year in the FFY period, and not on the state appropriation. For the Title V application, the state MCH match budget is an estimate of the payments anticipated will be transacted in the FFY period. This minimizes a variance budget-to-expenditure for Title V purposes, though with less exactness than the internal budget process based on the state appropriations.

The value of two-year authority

Because Nebraska exercises the two-year spending authority, there is a sufficient level of 2023 federal block grant unobligated at the time of the July 2023 submission requesting 2024 funds. Nebraska Title V can continue operations well into the FFY 2024 period that begins October 1, 2023. The two-year authority is a safety net to ensure continuing operations, chiefly payroll which is the largest percentage of the budget. Seamless, ongoing activities performed by the Title V workforce and subsequent outcomes transcend fiscal year periods and is one significant benefit of states’ ability to obligate the block grant funds in the year following the award.

Management strategies ensure compliance

A carefully developed budget precedes expense, and compliance requirements are based on expenditure. Two open block grants in a 12-month period presents grant management complexities. In recent years, several process improvements led by the Federal Aid Administrator III (responsible for the block grant administration) have gradually improved accuracy to administratively manage the separate grants. Two primary strategies, initiated separately and implemented with continuous quality improvements over three grant cycles, are described below.

1) The first strategy began the shift to a minimum three-to-six-month offset into the FFY period to obligate subawards and contracts. That same time offset includes a delay to begin incurring state-level workforce costs, the major cost driver. The offset permits receipt of one or two Notices of Award authorizing sufficient funds to obligate and incur major costs. It also allows sufficient time for performance and reporting to coincide with the July submission of the report. For example, a dozen 2022 subawards that ended March 31, 2023, are mostly liquidated; actual expense and counts are included in the July 2023 submission. While the April through March period is the ideal, it has not been feasible for all agreements to fit within that period. 

2) A second strategy began with the 2018 block grant to pilot a process to identify within separate internal program budgets any authorized, unobligated funds available for obligation in the succeeding year. The pilot created an opportunity for continuous quality improvement to “build a better budget” process. Spreadsheet tools developed for internal allocations identify if the authorized funds are on track to be expended as budgeted. Linked cells share information across multiple worksheets within the individual allocation workbooks. Earlier versions of the worksheets included Step 1 (by population) and Step 2 (line items). Those worksheets were enhanced and co-located in a workbook to improve links and functionality. Step 2 (line-item budget) links to Step 3 (monitoring) worksheet used to routinely reconcile expense to the general ledger, calculating unliquidated obligations and any authorized, unobligated funds. The three-step process is a logical progression to track budget-to-expense and stay on track to meet statutory expenditure requirements on two populations (30-30 earmarks). 

Step 1 budget by population

The worksheet seeks high-level information from individual NDHSS program managers, briefly describing planned expense – who, what, when, and projected expense by percentage of each population. If personnel costs are included, program manager provides staff name, position, FTE for individual staff (detailed calculations are done in Step 2). Additionally, Step 1 helps identify a preliminary budget of the subsequent award, dependent on variables if the performance and planned expense aligns with 2023 funds and/or 2024 funds. Program managers each submit a Step 1 to the block grant administrator. Later, with budget approval, program managers can refer to the program’s Step 1 worksheet to assist with coding payment requests by MCH population. Subsidiary accounting codes delineate actual expense by MCH population. 

Step 2 line-item budget

From Step 1, the grant administrator uses the information to create Step 2 for separate allocation workbooks, adding detailed calculations for individual personnel. Using Excel formulas, personnel line items calculate the FTE allocable to the grant for wage and benefits for each staff, multiplied by a projected number of total pay periods, the same number for all staff in all programs. Payroll conversion from one grant to the next is completed for all staff performing work of the grant. The block grant administrator schedules a one-on-one with each program manager to review the Step 2 worksheet, editing as needed. With mutual agreement between the block grant administrator and each NDHHS program manager, the grant administrator aggregates Step 1 worksheets. Links connect results from certain cells into the new “roll-up” workbook the grant administrator uses to identify if total projected expense is at least 30% for each of the two “earmarked” populations (the 30-30 statutory expenditure requirements). Though subawards use a different budget-to-expense workbook, total subaward obligations by populations also link to the aggregated “roll-up” workbook. The block grant administrator presents the refined grant budget to Title V co-directors, i.e., the MCH Director and the CSHCN Director, with the final outcome to approve the 2023 budget towards the end of the initial year of spending authority, which timing coincides with the 4th Quarter Notice of Award that informs of the total, final 2023 allotment. That same process will take place for a precise 2024 budget that will be finalized and approved within NDHHS during the first year of spending authority.

Step 3 monitoring

The grant administrator performs budget-to-expense reconciliation periodically using the Step 3 “monitoring” worksheet, noting any unexpected variance from budget. Step 3 provides a foundation for a periodic check-in with the individual program managers to stay current and connected regarding obligations and expense, allowing for course corrections that may be needed for the grant. The “roll-up” workbook updates from separate allocation workbooks’ monitoring worksheets to aid the grant administrator’s role to oversee the separate block grants overlap within a 12-month period, each with compliance requirements.

A query of accounting transactions by business units (aligned to internal programs and subawards) and subsidiary codes assists block grant administrator with routine compliance checks for two open, separate block grants. If monitoring detects that the projected date for payroll conversion needs to change, budgets are easily updated by the value for the number of pay periods. 

Non-competitive MCH Tribal Setaside

NDHHS prioritizes its longstanding commitment to the MCH Tribal setaside, a non-competitive process established in 2003 in recognition of Tribal sovereignty and respect for our special government-to-government relationship with the four federally recognized Tribal governments headquartered in Nebraska. The 2024 Tribal setaside is expected to be at a similar funding level ($200,000) as with recent years. The current Tribal subawards of 2023 block grant are for the period April 1, 2022, through March 31, 2023.  

Competitive Request for Applications (RFA) 

NDHHS periodically conducts a competitive subaward process, releasing a Request for Applications (RFA) to offer a significant level of financial support for community projects. Like the prior 2019 RFA, a 2021 RFA offered 2021 grant funds initial, and subsequent awards with 2023 funds, and anticipates another RFA for the 2024 grant. The RFA seeks stakeholder-engaged projects in unique community-based activities to respond to one or more of four state-level, child-focused priorities identified in the 2020 Title V Needs Assessment. The Evaluation Committee members independently review and score Concept Papers based on the “fit” to the RFA. Successful applicants consult with DHHS to develop work plans based on Concept Paper approval.

A separate RFA process was simultaneously conducted by the NDHHS Reproductive Health program with the exclusive focus on Sexually Transmitted Disease Among Youth, another priority resulting from the 2020 Needs Assessment. Successful applicants in the two RFA processes submitted work plans for October 1, 2021, through March 31, 2022. The initial period of performance was shorter than a 12-month period to better align with the 2021 grant. The 2022 subawards began April 1, 2022, and continued through March 31, 2023.  A subsequent renewal (2023 subawards) for the April 1, 2023, through March 31, 2024, period has been executed for each agreement.

Federal–State Partnership and Other Federal Funds (Form 2)

The phrase ‘Federal-State partnership’ (Form 2, line 8) may be intended as finances alone, though the partnership truly includes all types of resources, e.g., research, expertise and sharing experiences across states through our common federal partner. The Federal-State partnership is an example of building an alliance to tackle state priorities unique to Nebraska, yet often shared with or like those experienced by other states in the nation.

Nebraskans have a proud heritage lending a helping hand to neighbors in tough times. Like physically lending a hand, the same spirit is shown by Nebraska statutes and state funds that protect and support MCH and CYSHCN. The state side of the Federal-State partnership is a significant part of the requested budget (Form 2, line 3). Without the federal support of Title V block grant, however, it would be infeasible to achieve the same level of performance across state priorities in the State Action Plan. The other federal funds (Form 2, line 9) that fall within the administrative oversight of the Title V co-directors, i.e., the MCH Director and the CSHCN Director, signify the additional surrounding supports to Nebraska families.

MOE, Match, and 30-30-10 Compliance (Forms 2 and 3a)

The total state match (Form 2, line 7) is budgeted as a combination of state funds plus local funds and in-kind support. The total value of matching resources is budgeted to meet the 3:4 match minimum, and the Maintenance of Effort (Form 2, line 7A). 

Nebraska will be compliant with the statutory requirement to expend at least 30% of the federal allotment for Children 1 through 21 years (Form 2, line 1A), plus at least 30% CSHCN (Form 2, line 1B). NDHSS uses accounting codes by MCH populations to track payments by federal allotment and to identify compliance with the 30%-30% requirement. 

Administrative costs below the 10% cap (Forms 2 and 3b)

Administrative costs (Form 2, 1C.) are budgeted at $78,929, which presumably will again be far below the 10% statutory cap depending on the 2024 final authorization. These costs will be primarily attributable to the salary, benefits and indirect costs of the Federal Aid Administrator III position, allocable to performing grants management of the 2024 Title V Block Grant. Grants management is chiefly the time associated with a variety of functions that include: financial resource management generally and specifically based on allowable costs; assistance in linking finances to the State Action Plan and ancillary state-level MCH work; ensuring transparency and accountability in collaboration with NDHHS colleagues on program budgets, allowable costs, and expense tied to performance; oversight directly or assisting others with oversight in pre- and post-award processes of subawards; technical assistance to subrecipients; monitoring subawards and ensuring other compliance requirements of the federal award are planned for and met; and planning for audit-readiness and responding to auditor requests. Additional planned expense attributable to administrative costs include the annual membership dues to the Association of Maternal Child Health Programs (AMCHP), travel, training and other direct costs to administer the 2023 allotment.

Forecasting the preliminary 2024 line-item budget

A three-step process described in preceding paragraphs was used for the 2022 grant budget development and monitoring budget-to-expense to prepare the 2022 expense report submitted in July 2023. It forecasts a similar fine-tuning process for the subsequent 2024 budget presented in this Application. When additional information is known about the federal 2024 allotment, increased accuracy and completeness will go into the internal NDHHS budget process. This is expected to begin in November or December for an approximate 12-month period within the two-year authority. The internal budget process will continue to be detailed and precise, carefully considering statutory requirements, the State Action Plan, and the overlapping 12-month period of the 2023 and 2024 federal allotments.