The Finance Office and the Office of Federal Affairs of the PR Department of Health maintain budget documentation for Title V funding and expenditures consistent with Section 505(a)(1).

The PRDOH manages the MCH Block Grant Funds through two Divisions each specialized in each MCH Component with a structure developed for this purpose. PRDOH assigned the administration and management of the Block Grants Funds through the Maternal, Child and Adolescent Health Division (MCAHD) and the Children with Special Medical Needs Division (CSMND). The MCAH Division is responsible of the Component A funds earmarked for the provision of services to pregnant women, mothers and infants; and Component B funds earmarked for the provision preventive services for children. The CSMND is responsible for the provision of services for the CSHCN. Each Division works in collaboration for the services and initiatives in common but maintains a separated administration of the funds as allocated by the 30-30-10 requirement. Detailed narratives from each Division’s expenditures are included below.

Expenditures of the State Maintenance of Efforts funds during the budget period of this report were computed from the local funds used for services against Catastrophic – Remediable Diseases (Program that provide funds to cover for special medical treatments provided in specialized institutions locally and in the states which were not covered by health insurances or other sources) in the pediatric population (0-21 y/o) during FY 20-21 ($6,852,482.32); and woman (22-49 y/o) during FY 20-21 ($2,708,333.48). Other local funds were directed to support Infant and Toddlers with Disabilities (0-3 y/o) during FY 20-21 ($750,000.00); Regional Pediatric Centers FY 20-21 ($395,880); and Autism FY 20-21 ($750,000). A total of $11,456,695.80 from local funds are considered as the MOE (see Supporting Documents). The PR MOE assigned surpasses the requirement of FY1989 ($10,226,318).

Maternal Child and Adolescent Health (MCAH) Division

The MCAH Program provides services to the population based in a coordinated care structure. At first level our Regional teams identify the 3-target population in the outreach and referred them according to their particular needs and ages to the different areas of services provided by the MCAH Program, other governmental agencies or community-based organizations. This structure has been helping us to provide an integrated service, educating the community, raising awareness and facilitating the access of services to improve the health and social wellbeing. Our coordinated structure improves the delivery of services and increase quality; enable the access of services, reduces costs and helps to ensure the carry out of the essential public health services.

Under the coordinated structure a health/community professional provides various services to different MCAH populations groups as established by the reporting domains. Funds were budgeted accordingly to the federal requirements and considering the behavior of the expenditures from previous years. At the end of each Budget Year, we are able to identify the professional and population served within the different groups of the MCAH population, allowing us to determine the expenditures by type of individuals served and pyramid level. The expenditures are allocated based on the population served and the category of services provided with constant monitoring to verify the compliance with the 30-30-10 requirement.

The reported FY21 expended columns in Forms 3a and 3b reflect the expenditures registered according to each pyramid level and the 30-30-10 requirements. The MCAHD expended 70% of the allotted funds for Component A&B during FY21, a total of $6,676,694.43 which represents a 42% of the total MCH Block Grant. There were no differences in Form 2 between budget and expenditures columns for the FY21 of more than the 10%. Note for minor difference were included in Form 2.

All the positions for the HVN’s were covered during this FY with Transitory positions and a Human Consultant firm was contracted to maintain and fill any vacancies. A 48% of the FY21 allocated funds for the Components A&B were invested at the main level of the Title V pyramid, Public Health Services and Systems.

The MCAH will continue with the implementation of the strategic plan developed to improve and reinforce the infrastructure to carry out the provision of the essential public health services. With this plan we expect to maintain the investment in the workforce, continue with the outreach of the MCAH services and working plan, and fully expended funds in the future.

As reported in Forms 3a and 3b the detailed expenditures of the MCAH Division for FY21 are as follows:

The expenditures for Individual served for the Components A&B are as follows:

A total of $2,448,827 was dedicated to the Component A population for woman and infants less than 1 yr. The amount of $3,933,870 was invested in the Component B for children 1 to 21 years.

The MCAH Division under the established working plan does not provide Direct Services.   Services as preventive, primary or specialty care visits, to pregnant women and children, dental care, birth control methods, pharmacy and laboratories services among others are provided by the GHP.

An investment of $3,340,247 for enabling services which includes all services provided under the Home Visiting Program and services provided by the Perinatal Nurses. Under this category are included the salaries and benefits of the health care professional who provided these services. Services under this category are not included in the State Plan submitted to CMS neither provided through any other source.

The amount of $3,933,870 was dedicated to the main level of Public Health Services and Systems. This includes activities and infrastructure to carry out the essential public health services under MCAH Division like the evaluation and monitoring section, needs assessments, Prenatal and Adolescent Health Campaigns. Also, salaries and benefits of personnel like the Consultants and Physicians who helps with the policy and standards development, program guidelines and planning are reported under this category. This level includes the professionals like the CHW's, Health Educators and Social Workers who facilitate the dissemination and the implementation of the Program initiatives in the community. Also, production and development the materials to complement all the MCAH Initiatives are considered under this category. The investment in the administration of funds and the Program Management is considered as infrastructure as well as the development of the workforce capacity. This level as previously stated is the main level under the MCAH Program.

Other Federal Funds expenditures under MCAH are reported in Form 2.

Children with Special Medical Needs (CSMN) Division

A. Expended

Federal Allocation: $6,342,722.00

The total expenditure of Title V funds for FY 2021 was $6,342,722.00. The amount breaks down as follows:

1) Direct Services: $520,777.11.  The amount breaks down as follows:

a) Pharmacy: $135,568.43. Payment of special formulas for children and youth with inborn errors of metabolism ages 6-21 years.

b) Physicians/Charges: $360,211.50. Payment of specialty clinical providers such as plastic surgery, orthodontia and orthopedic surgery, for services provided through a formal process similar to paying a medical billing claim.

c) Durable Medical Equipment: $24,997.18. Payment of earphones not reimbursed by public or private payers. 

2) Enabling services: $4,946,910.60 Salary and operational support to Regional Pediatric Centers to enable CSHCN access health care, case management, care coordination and referrals. 

3) Public Health Services and Systems: $875,034.29. Needs assessment, program planning, implementation and evaluation, and policy development activities.

Other funds:  $759,132.77

The total expenditure of other funds for FY 2021 was $759,132.77.  The amount breaks down as follows:

1) Enabling services: $759,132.77.  The amount breaks down as follows:

   a) $152,000.00 for the operational support of the newborn screening laboratory; and

b) $607,132.77 for the operational support of the Regional Pediatric Centers.

Program Income: $74,874.29

The total expenditure of Program Income funds for FY 2021 was $74,874.29 for operational support to Regional Pediatric Centers to enable CSHCN access health care, case management, care coordination and referrals (enabling services).

Other Federal Funds: $5,305,535.40

The total expenditure of other federal funds for FY 2021 was $5,305,535.40. The amount breaks down as follows:

1) $191,642.01, EHDI, for activities directed to reduce the lost to follow up and documentation of infants after the newborn hearing screening; and

2) $120,061.17, BDSPS, for population-based birth defects surveillance and prevention activities.

3) $144,374.70 PR EHDI, to complete and implement a sustainable, Early Hearing Detection and Intervention Information System (EHDI-IS) capable of accurately identifying, matching, collecting, and reporting data on all occurrent births that is unduplicated and individually identifiable through the three components of the EHDI process (screening, diagnosis, and early intervention).

4) $1,095,217.16, Zika MCH Services Program, for activities directed to ensure that community-based, comprehensive high-quality health and social services are available to infants and children affected by ZIKV and their families

5) $3,754,240.36, Zika CMS Health Services Program, to support a system of care that assures that community-based, comprehensive high quality health and social services are available to infants and children affected by ZIKV and their families.

Program allocations have taken into account the 30-30-10 requirements established by Title V. The FY 22 budget distribution for components reflects: 60% to the Components A&B and 40% to CSHCN including the no more than 10% for administration of funds. Efforts are made to match funds according to the identified needs through the three groups of individuals that comprise the Maternal and Child Health Services Block population.

Puerto Rico assures that the MCH funds are used for the purposes outlined in Title V, Section 505 of the Social Security Act. Traditionally for components A&B, a fair method has been used to allocate Title V funds among individuals and geographic areas having unmet needs. The fair allocation of funds is guided by an Integrated Index of Maternal and Infant Health Status (IIMIHS) developed by the MCAH Division to assess the health needs of the target population by municipality. One of the benefits of using this Index is that the information necessary to evaluate each of its variables is available on an ongoing basis through analysis of birth and death files.

PRDOH assigned the administration and management of the Block Grants Funds in two Divisions: Maternal, Child and Adolescent Health (MCAH) Division and the Children with Special Medical Needs (CSMN) Division. The MCAH Division is responsible of the Component A funds earmarked for the provision of services to pregnant women, mothers and infants; and Component B funds earmarked for the provision preventive services for children. The CSMN Division is responsible for the provision of services for the CSHCN.

Compliance with the 30-30-10 requirements;

Allocations of funds by MCH Population Groups are as follows:

Amount requested $15,906,262(as assigned for BY 2021-22)

A) $3,976,565 (25%): for the provision of services to pregnant women, mothers and infants.

B) $4,771,879 (30%): for the provision of preventive services for children.

C) $5,567,192 (35%): for the provision of services to CSHCN.

D) $1,590,626 (10%): From this amount, 5% is for grant administration of                               

Components A and B; and 5% for administration of the CSHCN program.

Budget allocation:

The MCAH Division allocates the funds up to 55% of the total Block Grant considering the behavior of the expenditures of previous years as explained in the Expenditures Section for both components. The CSMN Division allocates a 35% of the total of the Block Grant for CSHCN services.

Administration:

Up to 10% of the federal allocation is earmarked for the administration of the Grant.

For both Divisions up to a 10% of the total grant is assigned for the administration of for each individual budget: 5% MCAH Division and 5% CSMN Division. The total of 10% assigned will be invested to support salaries, benefits, office supplies and equipment of staff in charge of the administration and fiscal management of each allocation, newspaper advertisements for the public review of the annual Progress Report, information systems, mailing, AMCHP annual membership and others.

Maintenance of Effort: Puerto Rico follows the maintenance of effort requirements as described in Section 505(a)(4). For Budget Period 21 the local funds appropriations used for the services against catastrophic remediable diseases provided locally and in the States to children’s (0 -21 y/o) and WRA (22- 49 y/o), Autism Program and Regional Pediatric Centers are presented as the MOE. The local funds ($11,456,695) used to provide special medical services to the MCH population surpasses the requirements for the Puerto Rico FY’s1989 Maintenance of Effort ($10,226,318).

Local funds assigned to the Office for Services against Catastrophic Remediable Diseases covered services provided to 45 children (1-21y/o) ($6,852,483) during FY 2021. Also covered services for 22 females (22–49 y/o) during FYs 2021 ($2,708,333). See supporting documents for details. Services to CSHCN were also provided in the Pediatric Centers, the Autism Centers and the Early Intervention Program with local funds ($1,895,880).

For this Budget we need to keep in mind that in 2016 the US Congress enacted the PR Oversight, Management and Economic Stability Act (PROMESA), installing the Financial Management and Oversight Board (FMOB) with decision-making power on all fiscal matters. That means that the Local Government Budget is the one approved by the FMOB, and during previous years it has changed in different occasions. The local funds allocated for the Program for Services against Catastrophic Remediable Diseases and other local funds allocated for services to the MCA population may be presented for the MOE.  

Several earmarked state funds allocated for special services and programs were also identified. These include $296,168 for the operational support of the CSHCN Regional Pediatric Centers and $750,000 for the Autism Program. The CSHCN Program Income estimated for FY2023 is $255,000.

As described, the efforts of the Commonwealth of Puerto Rico surpass the matching requirements of Puerto Rico FY’s1989 Maintenance of Effort ($10,226,318). The table below summarize funds provided by the State for programs providing services to the MCA population.

Programs Addressing Different MCH Needs Supported with State Funds

                                        2022-2023

       1. Estimated proportion for primary preventive services according to FMOB.

        2. Funds used for CSHCN population.

In addition to MCH dollars and the State funds listed above, there are other federal sources of funds that contribute to the achievement of the MCH outcomes. These other federal funds are included in Form 2. Additional detailed budget information of each Component is included below.

Additional detailed earmarking by pyramid level and other federal funds:

FY23 budget for Components A&B is $9,543,757, a 60% of the total MCH Block Grant budget. An estimated 55% (8,748,444) was assigned for services provision in both components and 5% ($795,313) for administration of the funds.

Budget for Individual served for the Components A&B in FY23 are as follows:

A total of $ 3,976,566 (25%) assigned for the Component A: woman and infants less than 1 yr. The amount of $4,771,879 (30%) directed to the Component B for children 1 to 21 years.

Under Components A & B no Direct Services are provided. For FY22 the amount of $4,771,879 was assigned to provide the enabling services and $4,771,878 for level of Public Health Services and Systems. Other earmarked FY20 federal funds were reported in Form 2.

Children with Special Health Care Needs (CSHCN)

Federal Allocation: $6,362,504.00 (40.0% of the total federal allocation)

Of the Title V Federal Allocation for FY 2023, the amount earmarked for CSHCN is $5,567,191.00 (35.0%).  In addition, an allocation of $795,313.00 (5%) is earmarked for CSHCN Title V administrative costs (fiscal and administrative support for management of the CSHCN Title V allocation).

The $5,567,191.00 breaks down as follows:

1. $457,101.17 are earmarked for direct services for CSHCN including payment of specialty clinical providers such as neurosurgery, plastic surgery, orthodontia and orthopedic surgery, and earphones not reimbursed by public or private payers.
2. $4,342,046.86 are earmarked for enabling services (salary and operational support to the Regional Pediatric Centers and Autism Centers to enable CSHCN access health care, case management, care coordination and referrals). operational support to the Birth Defects Surveillance and Prevention System activities including those related to CSHCN domain state priority: Reduce the prevalence at birth of neural tube defects;  for operational support to the Hereditary Diseases Detection, Diagnosis and Treatment Program activities, and to support  the newborn screening for CCHD; and
3. $768,042.96 are earmarked for new public health services and systems activities including improving the efficiency and effectiveness of the billing and collection processes for services provided; workforce development; policy development and quality assurance and improvement activities related to the following CSHCN domain selected priorities:  a) Increase the number of CSHCN who receive regular ongoing comprehensive health care within a medical home; b) Increase the number of CSHCN aged 12 to 17 years who receive adequate support and services for their transition to adult health care; and c) Decrease the age when children at risk for Autism Spectrum Disorders (ASD) receive their first diagnostic evaluation.  

Other funds: $296,168.36

The amount of nonfederal state funds budgeted for FY 2023 to support services for CSHCN is $296,168.36 for the operational support of the Regional Pediatric Centers (salaries).

 Program Income: $255,000.00

The estimated amount of program income funds for FY2023 is $255,000.00.  The amount breaks down as follows: a) $ 229,500.00 (90%) for operational and administrative support to the RPCs and the Autism Centers and b) $25,500.00 (10%) for administrative costs.

Other Federal Funds: $395,000.00

The amount of other federal state funds budgeted for FY 2023 is $395,000.00. The amount breaks down as follows:

1. $235,000.00, EHDI, for activities directed to reduce the lost to follow up and documentation of infants after the newborn hearing screening.
2. $160,000.00, PR EHDI, to complete and implement a sustainable, Early Hearing Detection and Intervention Information System (EHDI-IS) capable of accurately identifying, matching, collecting, and reporting data on all occurrent births that is unduplicated and individually identifiable through the three components of the EHDI process (screening, diagnosis, and early intervention).

CSHCN Budget Grand Total:  $7,308,672.36