Title V MCH Compliance & Legislative Requirements

The Title V Compliance Framework

Title V compliance is governed by a layered framework of requirements. At the top are the statutory requirements written directly into Title V of the Social Security Act (42 U.S.C. 701-710). Below those sit the Uniform Administrative Requirements in 2 CFR 200 that apply to all federal grants. And beneath those are MCHB-specific guidance documents, Information Memoranda, and grant terms and conditions.

Unlike program-specific compliance frameworks such as the CSBG Organizational Standards or UDS reporting for HRSA Section 330 grantees, Title V compliance is largely defined by the statute itself. The legislative requirements are straightforward in concept but demanding in execution, particularly the Maintenance of Effort and set-aside rules that require careful financial tracking.

Set-Aside Requirements: The 30/30/10 Rule

Title V legislation mandates three specific set-asides that constrain how states allocate their federal Title V funds. These set-asides are among the most closely monitored compliance requirements in the program:

30% for Children and Adolescents

At least 30% of the federal Title V allocation must be spent on preventive and primary care services for children and adolescents. This set-aside ensures that Title V maintains a strong focus on the child health population even when maternal health or CSHCN issues dominate the political or public attention landscape. The 30% is calculated against the total federal allocation received by the state, not against total expenditures including state match.

Allowable expenditures under this set-aside include well-child visits, immunization programs, developmental screening, adolescent well-visits, injury prevention, nutrition programs, school health services, and other preventive and primary care activities targeting children ages 1 through 21.

30% for Children with Special Health Care Needs

At least 30% of the federal Title V allocation must be spent on services for children with special health care needs (CSHCN). This is one of the most significant CSHCN funding streams in the country and reflects the historical role of Title V in building systems of care for children with complex conditions.

Allowable expenditures under this set-aside include care coordination, specialty referral networks, family support services, transition planning for youth aging out of pediatric systems, medical home development, early intervention linkages, and systems-building activities that improve access to services for CSHCN. States must be able to identify and document which expenditures count toward this set-aside through their financial systems.

No More Than 10% for Administration

No more than 10% of the federal Title V allocation may be used for administrative costs. This cap is more restrictive than many other federal programs and requires careful cost allocation. Administrative costs typically include general management, accounting, legal services, human resources functions, and other overhead activities not directly related to program implementation.

The key distinction is between administration and program management. Activities like data collection, performance measure monitoring, quality improvement, training, and technical assistance are generally classified as program costs, not administrative costs, as long as they are directly related to Title V program implementation. States should establish clear cost allocation policies that distinguish administrative from programmatic activities and document the basis for the allocation.

Maintenance of Effort (MOE)

The Maintenance of Effort requirement is one of Title V's most important and most misunderstood compliance obligations. MOE requires that each state maintain its own spending on maternal and child health at least at the level it spent in FY1989 — the baseline year established by the 1989 amendments to Title V. This is a separate requirement from the match and serves a different purpose: while the match ensures that states contribute to the Title V partnership, MOE prevents states from using federal Title V funds to replace (supplant) existing state MCH investments.

How MOE Is Calculated

Each state's MOE amount is fixed at its FY1989 level of state spending on maternal and child health. This amount was established decades ago and does not adjust for inflation. The state must demonstrate in its TVIS submission that it continues to spend at least this amount from state funds on MCH activities.

The practical implication is that MOE is rarely a binding constraint in dollar terms — most states spend far more on MCH today than they did in 1989, even without adjusting for inflation. However, MOE compliance can become an issue during periods of state budget cuts. If a state reduces its MCH appropriation below the FY1989 baseline, it is in violation of MOE regardless of its current spending level relative to the federal allocation.

MOE Documentation Requirements

States must report their MOE compliance annually through TVIS. The documentation typically includes:

• FY1989 baseline amount: The established state MCH spending level from the baseline year, documented in the state's historical TVIS records
• Current state MCH expenditures: Detailed accounting of state funds spent on maternal and child health activities in the reporting year, demonstrating that the total meets or exceeds the baseline
• Source identification: Clear identification of funding sources counted toward MOE, ensuring only state and local (non-federal) funds are included

The Match Requirement: $3 State for Every $4 Federal

In addition to MOE, Title V requires a state match of $3 in state or local funds for every $4 in federal funds received. This 3:4 ratio (equivalent to a 75% match rate) is calculated against the state's total federal allocation. If a state receives $10 million in federal Title V funds, it must provide at least $7.5 million in state/local matching funds.

The match must come from non-federal sources. Allowable match sources include state general fund appropriations, state special fund appropriations (such as dedicated MCH revenue), local government contributions, and certain in-kind resources that meet the documentation requirements of 2 CFR 200. Federal funds from other programs cannot be used as Title V match.

For detailed guidance on match calculations and budgeting, see the Budget & Financial Management section.

Prohibited Uses of Title V Funds

Title V legislation includes specific prohibitions on the use of funds. These prohibitions are absolute and apply regardless of state law or program design:

• Abortion services: Title V funds may not be used to pay for abortions. This prohibition is written into the Title V statute and is separate from any appropriations rider. States must ensure that their Title V cost allocation systems properly exclude abortion services from Title V-funded activities.
• Cash payments to recipients: Title V funds may not be used to make direct cash payments to individuals as income maintenance. Title V is a services program, not a cash assistance program. Funds must support the delivery of health services, systems development, or infrastructure — not income transfers.
• Inpatient hospital services (except NICU): Title V funds generally may not be used to pay for inpatient hospital services, with the exception of services provided to high-risk pregnant women and high-risk infants in neonatal intensive care settings. Routine inpatient care should be covered by Medicaid, private insurance, or other payers.
• Supplanting state funds: Title V funds cannot be used to replace existing state MCH expenditures. This is enforced through the MOE requirement. If a state reduces state MCH spending while increasing Title V federal spending in the same area, it may be found to be supplanting.

Coordination Requirements

Title V legislation requires coordination with several specific programs and systems. These coordination requirements are not aspirational — they are legal obligations that states must document in their TVIS submissions.

Medicaid Coordination

The Medicaid coordination requirement is perhaps the most operationally significant. States must maintain a written interagency agreement between the Title V agency and the state Medicaid agency. This agreement must address:

• Service coordination to avoid duplication of services covered by Medicaid
• Referral and enrollment assistance for Medicaid and CHIP-eligible families
• Data sharing arrangements for population health monitoring
• Joint planning for MCH populations served by both programs

CSHCN Information and Referral

States must provide a toll-free telephone number or equivalent accessible information system for families to obtain information about CSHCN services and referrals. This is a specific legislative requirement (42 U.S.C. 705(a)(5)(E)) that is frequently checked during federal site visits. The information line must be operational, staffed or automated to provide meaningful information, and accessible to families across the state.

Other Coordination Requirements

Title V also requires coordination with:

• WIC: Coordination with the Special Supplemental Nutrition Program for Women, Infants, and Children to ensure nutritional services reach MCH populations
• IDEA Part C: Coordination with early intervention programs for infants and toddlers with developmental delays
• Community and migrant health centers: Coordination with federally qualified health centers serving MCH populations
• Healthy Start: Coordination with the HRSA Healthy Start program in communities where both programs operate

Assurance Requirements

The Title V application includes a series of statutory assurances that states must attest to. These assurances cover the full range of legislative requirements and serve as the state's formal commitment to compliance. Key assurances include:

• Needs assessment: The state has conducted or is conducting a statewide needs assessment and will use the findings to guide program priorities
• Set-asides: The state will comply with the 30/30/10 set-aside requirements
• Match and MOE: The state will provide the required match and maintain its historical MCH spending level
• Prohibited uses: The state will not use Title V funds for prohibited purposes
• Coordination: The state will coordinate with Medicaid and other required programs
• Reporting: The state will report performance measures and financial data as required

Signing these assurances is a legal commitment. States that cannot demonstrate compliance with an assurance during a federal site visit or audit may face corrective action requirements, including conditions on future awards.

Federal Site Visits

MCHB conducts periodic site visits to state Title V programs. These visits serve both oversight and technical assistance functions. A typical site visit includes:

What MCHB Reviews During Site Visits

• Financial documentation: Verification of match, MOE, set-aside compliance, and expenditure records supporting TVIS budget submissions
• Needs assessment documentation: Evidence that the comprehensive needs assessment was conducted with appropriate methodology, stakeholder engagement, and priority-setting processes
• Performance measure data systems: The data collection infrastructure supporting NOM, NPM, and ESM reporting — data sources, quality assurance processes, and analytical methods
• Program implementation: Evidence that strategies described in the state action plan are being implemented as described, at the proposed scale, and reaching the target populations
• Coordination agreements: Current written agreements with Medicaid and other required programs
• CSHCN toll-free line: Verification that the information and referral line is operational and accessible

Preparing for a Site Visit

Site visit preparation should not be a scramble. States that maintain organized compliance documentation throughout the year will find site visits far less stressful than those that assemble documentation only when notified of a visit. Best practices include:

• Maintain a standing Title V compliance file with current versions of all required documents
• Keep Medicaid and other coordination agreements current and accessible
• Document the needs assessment process with meeting agendas, stakeholder lists, data sources, and priority-setting methodology
• Maintain financial records that clearly show match, MOE, and set-aside calculations
• Prepare program staff to describe their activities, target populations, and how their work connects to NPMs and ESMs

2 CFR 200 Requirements

In addition to Title V-specific requirements, state Title V programs must comply with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards in 2 CFR 200. These requirements govern financial management, procurement, property management, cost allowability, and audit obligations for all federal grants.

Key 2 CFR 200 requirements relevant to Title V include:

• Financial management systems: Internal controls, fund accounting, cost allocation plans, and financial reporting capabilities that meet federal standards
• Procurement standards: Competitive bidding, conflict of interest policies, and documentation requirements for purchases and contracts funded by Title V
• Sub-recipient monitoring: States must monitor sub-recipients that receive Title V pass-through funds, including financial and programmatic review
• Single Audit: States and sub-recipients expending $750,000 or more in federal awards must undergo an annual Single Audit in accordance with 2 CFR 200 Subpart F

Compliance Calendar

Title V compliance is not a once-a-year exercise. Multiple deadlines and ongoing obligations require continuous attention: