Why Title V Mistakes Are Costly
Title V compliance errors can trigger consequences ranging from MCHB corrective action requests and conditions on future awards to reduced allocations and increased federal oversight. Unlike competitive grants where a compliance failure might affect a single project period, Title V compliance issues can affect a state's entire MCH infrastructure — because Title V is the backbone funding for maternal and child health in every state.
The good news is that most Title V compliance failures are preventable. They stem from inadequate systems, poor planning, or misunderstanding of requirements — not from intentional non-compliance. This guide identifies the most common mistakes and provides specific strategies for avoiding each one.
Mistake 1: Failing to Meet Maintenance of Effort
MOE failures are among the most serious Title V compliance issues because they suggest that the state is using federal Title V funds to replace existing state investments — the exact scenario MOE was designed to prevent.
How It Happens
MOE failures typically occur during periods of state budget cuts. A governor or legislature reduces the state health department's MCH appropriation, and the state Title V director is left with state spending below the FY1989 baseline. The challenge is that the FY1989 baseline is often embedded deep in institutional memory, and new MCH directors may not even know their state's MOE amount until a problem arises.
How to Prevent It
- Know your MOE number: The FY1989 baseline should be documented in your Title V files and understood by the MCH director, fiscal officer, and anyone involved in budget advocacy. If the number has been lost over time, work with MCHB to reconstruct it.
- Monitor state budget proposals early: Engage in the state budget process and flag potential MOE issues before appropriations are finalized. It is far easier to prevent a cut than to restore funding after the budget is enacted.
- Document broadly: Identify all state and local MCH expenditures that can legitimately count toward MOE. Some states narrowly define their MOE base and miss expenditures in other state agencies that serve MCH populations.
- Build MOE awareness into leadership transitions: When MCH directors or fiscal officers change, MOE documentation and institutional knowledge should be part of the transition briefing.
Mistake 2: Set-Aside Violations
Failing to meet the 30/30/10 set-aside requirements is a common finding, particularly the 30% CSHCN set-aside. The children/adolescent set-aside is usually easier to meet because most states have substantial programming in this area. The CSHCN set-aside, however, requires that states intentionally invest in this population, and states without robust CSHCN programs sometimes fall short.
Common Patterns
- CSHCN under-spending: States allocate less than 30% to CSHCN because CSHCN programs are less visible or less politically prominent than maternal health or child immunization programs
- Poor cost categorization: The state spends adequately on CSHCN activities but fails to properly categorize those expenditures in TVIS, making it appear that the set-aside is not met
- Administrative cost creep: Over time, indirect cost charges, administrative positions, and overhead allocations push administrative costs above the 10% cap
How to Prevent It
- Build set-aside compliance into the budget development process from the start — do not check set-asides as an afterthought
- Ensure your fiscal team understands which expenditures count toward each set-aside category and reviews categorizations quarterly
- Track indirect cost charges against the 10% administrative cap throughout the year, not just at year-end. For guidance on indirect cost management, see the Budget & Financial Management section.
Mistake 3: Weak Alignment Between Needs Assessment and State Action Plan
One of the most common narrative weaknesses in TVIS submissions is a disconnect between the needs assessment findings and the state action plan. MCHB reviewers expect a clear, traceable logic chain: the needs assessment identifies priority issues, those priorities drive NPM selection, and the state action plan describes evidence-based strategies to address those priorities. When the action plan includes activities that do not connect to identified needs — or when the needs assessment identifies critical issues that the action plan ignores — the application is weakened.
How to Prevent It
- Create a crosswalk: Build an explicit crosswalk document that maps each needs assessment finding to specific NPMs, strategies, and ESMs. Use this crosswalk as a reference when drafting TVIS narratives.
- Address gaps honestly: If the needs assessment identifies a priority that the state cannot address due to resource constraints, say so in the application narrative. MCHB values transparency over the appearance of comprehensiveness.
- Involve program staff in the needs assessment: When program managers participate in the needs assessment process, they develop ownership of the findings and are more likely to design programs that align with identified needs.
Mistake 4: Poor ESM Selection
Evidence-based Strategy Measures are the most operationally meaningful tier of the Title V performance framework, but they are also the most frequently problematic. States make several common errors in ESM design:
- ESMs that are not measurable: Defining an ESM that the state cannot actually calculate because the data collection system does not exist or has not been implemented
- ESMs that are too broad: Creating an ESM that measures general program activity rather than a specific evidence-based strategy. "Number of MCH programs" is not an ESM — "Number of birthing hospitals implementing the Ten Steps to Successful Breastfeeding" is.
- ESMs with weak evidence linkage: Selecting a strategy with limited evidence connecting it to the target NPM, making the logic chain unconvincing
- Too few ESMs: Relying on a single ESM per NPM when the state's strategy portfolio for that NPM is more complex and could benefit from multiple tracking measures
How to Prevent It
Before finalizing an ESM, apply a four-part test: (1) Can we actually collect the data to calculate this measure? (2) Does this measure track a specific, nameable strategy? (3) Is there published evidence linking this strategy to the target NPM? (4) Can the state directly influence this measure through Title V-funded activities? If the answer to any question is no, redesign the ESM. The MCH Evidence Center provides curated evidence reviews for each NPM that can help states identify appropriate strategies and design measurable ESMs.
Mistake 5: Incomplete TVIS Narratives
The TVIS narratives are where states tell the story of their Title V program — what they do, why they do it, and what results they are achieving. Weak narratives are generic, lack specificity, and fail to connect activities to outcomes. MCHB reviewers read 59 state submissions; vague language blurs together and fails to demonstrate meaningful program activity.
Common Narrative Weaknesses
- Generic descriptions: "The state will continue to promote breastfeeding" instead of describing specific strategies, target populations, implementation sites, and expected reach
- Missing data interpretation: Reporting numbers without analysis. "The infant mortality rate was 5.8 per 1,000" without trend context, comparison to national benchmarks, equity disaggregation, or connection to Title V strategies
- Boilerplate recycling: Copying prior year narratives without updating them to reflect current data, new developments, or lessons learned
- No equity lens: Failing to discuss health disparities, which populations are disproportionately affected, and how Title V strategies address those disparities
How to Prevent It
Assign specific narrative sections to program managers who are closest to the work. Provide them with a structured template that prompts for specifics: What strategy did you implement? In which communities? Reaching how many people? With what results? What did you learn? What will you change? Then have an epidemiologist review the narrative for data accuracy and a senior manager review for strategic coherence. Good TVIS narratives are team products, not solo efforts.
Mistake 6: Not Documenting Medicaid Coordination
Medicaid coordination is a statutory requirement, not a best practice suggestion. Yet many states have outdated or nonexistent interagency agreements, informal coordination that is not documented, or coordination that is limited to leadership-level conversations without operational impact.
How to Prevent It
- Review and update your Title V-Medicaid interagency agreement at least every two years, or whenever there are significant changes in either program
- Document specific coordination activities — joint meetings, shared data analyses, coordinated outreach, aligned quality improvement initiatives — not just the existence of an agreement
- Include Medicaid coordination as a standing item in your Title V leadership meetings and TVIS development process
Mistake 7: Under-Investing in Data Infrastructure
Title V's performance measurement framework demands robust data infrastructure, but many state MCH programs operate with minimal epidemiology capacity, outdated data systems, and limited analytical tools. The result is weak performance measure data, missed ESM tracking, and narratives that cannot demonstrate program impact.
How to Prevent It
- Fund MCH epidemiology positions: Title V funds can support epidemiology staff. This is one of the highest-value investments a state can make with Title V dollars.
- Establish data-sharing agreements: Formalize data access with vital records, Medicaid, WIC, immunization registries, and other agencies before you need the data for TVIS. For more on reporting infrastructure, see the Reporting & Performance Measures section.
- Build ESM data collection into program design: When launching a new strategy, simultaneously design the data collection system that will feed the ESM. Do not add measurement as an afterthought.
- Standardize sub-recipient data: If local agencies collect data for your ESMs, provide standardized templates, training, and quality checks to ensure consistency across sites.
Mistake 8: Neglecting the Adolescent Health Domain
Many state Title V programs have historically focused their strongest efforts on maternal health and infant health, with CSHCN receiving dedicated attention through the 30% set-aside. The adolescent health domain, however, is frequently under-resourced and under-programmed. This is a strategic mistake that affects both compliance and public health outcomes.
Why It Matters
- NPM coverage requirement: States must select NPMs from at least 5 of 6 domains. If you neglect adolescent health, you still need to select and report on at least one adolescent NPM — and you need a credible strategy to improve it.
- Adolescent health gaps are real: Mental health crises, substance use, obesity, inadequate well-visit rates, and transition challenges for youth with special health care needs are significant and growing problems in most states.
- Federal attention is increasing: MCHB has been placing greater emphasis on adolescent health in recent years. States that demonstrate strong adolescent health programming are better positioned during federal reviews.
How to Prevent It
Designate an adolescent health lead within the Title V program. Include adolescent health stakeholders in the needs assessment process. Invest in adolescent well-visit promotion strategies and data systems to track progress. Partner with schools, juvenile justice systems, and youth-serving organizations to extend Title V's reach into the adolescent population. The adolescent domain does not need to consume the same resources as maternal or CSHCN, but it needs genuine programmatic attention.
Mistake 9: Treating TVIS as a Compliance Exercise Instead of a Strategic Tool
Perhaps the most pervasive and consequential mistake is approaching the annual TVIS submission as a bureaucratic obligation rather than a strategic planning and accountability tool. When TVIS is treated as a compliance checkbox, the resulting document is formulaic, backward-looking, and disconnected from the state's actual MCH strategy.
The best state Title V programs use the TVIS cycle as an annual strategic review: an opportunity to examine performance data, assess whether strategies are working, identify needed adjustments, and communicate a clear vision for the coming year. This approach produces stronger TVIS submissions and — more importantly — drives better program outcomes.
How to Prevent It
- Integrate TVIS development into your regular management cycle, not as a separate reporting exercise. Use NPM and ESM data in staff meetings, leadership briefings, and program planning sessions throughout the year.
- Engage program staff in TVIS development — they should see the application/report as a reflection of their work, not as someone else's paperwork.
- Use the TVIS submission as an occasion to present performance data to MCH leadership, agency leadership, and external stakeholders. When people see that the data matters beyond the federal report, they invest more in data quality.
Compliance Self-Assessment Checklist
Use this checklist to identify potential compliance issues before they become findings:
- MOE amount is known, documented, and tracked against current state MCH spending
- 30% children/adolescent set-aside is met in both budget and actual expenditures
- 30% CSHCN set-aside is met in both budget and actual expenditures
- Administrative costs are at or below 10% of the federal allocation
- State match of $3 for every $4 federal is documented from non-federal sources
- Needs assessment findings explicitly drive NPM selection and state action plans
- Each ESM is measurable, specific, evidence-linked, and currently being tracked
- TVIS narratives include specific data, equity analysis, and strategy-outcome connections
- Medicaid interagency agreement is current and reflects actual coordination activities
- CSHCN toll-free information and referral line is operational and staffed
- Adolescent health domain has designated programming and a credible improvement strategy
- Single Audit completed and filed if $750,000+ in federal awards expended
- SAM.gov registration is active with current UEI for the state agency and all sub-recipients