The MIECHV program provides voluntary, evidence-based home visiting services for at-risk eligible families with children up to kindergarten entry. HRSA allocates MIECHV program formula grant funds to states based partly on the proportion of children under age 5 living in poverty in each state, among other factors. In fiscal year 2018, states received an average of $6.9 million in MIECHV program formula grant funding, ranging from $1.2 million provided to North Dakota to $21.4 million to California (see appendix I for a list of all states and their fiscal year 2016 through 2018 funding). Generally, the state’s public health or social services department is the lead agency that receives and administers the funds. States target MIECHV program resources to at-risk communities and have the flexibility to tailor the program to serve the specific needs of their communities. States are generally required to provide home visiting services using an HHS-approved evidence-based program model. Currently, HHS has determined through its Home Visiting Evidence of Effectiveness review that 18 evidence-based home visiting models meet HHS-established criteria for evidence of effectiveness, and are therefore eligible for MIECHV funding. States may select programs to implement from the models that have been approved by HHS, or states may choose to implement a home visiting service delivery model that qualifies as a promising approach, as defined in the statute. In MIECHV-funded home visiting programs, professionals meet regularly with families and provide services tailored to the families’ specific needs, such as teaching parenting skills, promoting early learning in the home, or conducting screenings and providing referrals to address caregiver depression, substance abuse, and family violence. According to HHS, the MIECHV program builds upon decades of scientific research showing that home visits by a nurse, social worker, or early childhood educator during pregnancy and early childhood have the potential to improve the lives of children and families. From fiscal years 2013 through 2018, the number of families served and number of home visits conducted nearly doubled (see table 1). The MIECHV program is the primary federal program focusing exclusively on evidence-based home visiting, according to HHS. However, in addition to administering the MIECHV program, states may have other home visiting programs that may be supported by funds from other federal programs, such as Temporary Assistance for Needy Families and the Maternal and Child Health Services Block Grant. These home visiting programs may provide services that differ from those provided under the MIECHV program. For example, states may provide home visiting services through these programs that use program models that are different from the MIECHV program models approved by HHS. The MOE requirement in the MIECHV program’s authorizing statute provides that funds provided to an eligible entity receiving a MIECHV grant “shall supplement, and not supplant, funds from other sources for early childhood home visitation programs or initiatives.” To demonstrate their compliance with this statutory requirement, states are required by HRSA to report in their annual grant applications their MOE spending for the prior fiscal year. HRSA provides guidance to states on how to report their MOE spending in the annual NOFOs. For example, since fiscal year 2013, the MOE guidance in the NOFOs generally has directed states to only report spending that meets the following criteria: paid for with state general funds, spent in the prior fiscal year on HHS approved evidence-based programs that include home visiting as a primary service delivery strategy, implemented in response to findings from the most current statewide needs assessment, and offered on a voluntary basis to pregnant women or caregivers of children from birth to kindergarten entry. Over time, HRSA has clarified the MOE guidance provided in the NOFOs to help address questions received from states, according to HRSA officials. We previously reported that certain grant design features affect the likelihood that states will use federal funds to supplement, rather than supplant (or replace), their own spending. One such design feature requires grant recipients to contribute their own funds in order to obtain grant funds. Requiring grant recipients to contribute their own funds can take the form of a match or MOE requirement. According to our prior report, matching grants typically contain either a single rate (e.g., 50 percent) or a range of rates (e.g., 50 to 80 percent) at which the federal government will match state spending on a particular program. An MOE requirement, in contrast, requires states to maintain existing levels of state spending on a particular program as a condition of receiving federal funds. Depending on the specific program and its MOE requirement, if a state did not previously spend any state funds on covered activities, then the state could be allowed to maintain MOE spending of $0. The MOE requirement is one of many MIECHV program requirements that HRSA is responsible for monitoring. HRSA also monitors MIECHV’s programmatic and technical requirements, such as evidence-based model implementation, policies and procedures, data collection, and organizational structure and capacity. HRSA also monitors fiscal and administrative requirements, such as those related to accounts payable and cash flow, accounting systems, and cost allocations. From fiscal years 2016 through 2018, state-reported MOE spending varied from $0 to more than $25 million, according to our review of MIECHV program grant applications (see fig. 1). For example, 28 states reported MOE spending of $0 in fiscal year 2018. Most of the 23 states that reported MOE spending greater than $0 in fiscal year 2018 reported spending less than $3 million, while three states reported spending more than $9 million. See appendix II for each state’s reported MOE spending for fiscal years 2016 through 2018. State-reported MOE spending does not necessarily reflect all state spending on all home visiting services. When states report their prior year’s MOE spending on their MIECHV grant applications, they are only required to include home visiting spending if it meets the criteria specified by HRSA in the NOFO. In addition to reporting their MOE spending in grant applications, some states also noted that they spent funds on home visiting services that did not meet those criteria. In fiscal year 2017, for example, one state reported that it had spent funds on home visiting services for a non-evidence-based model (i.e., a model not approved by HHS), and the state also funded an evidence-based program with funds other than state general funds. However, the state did not include either in its reported MOE spending because that spending did not meet the criteria for MOE spending in the NOFO. An update to the MIECHV program’s MOE guidance in the NOFO for fiscal year 2018 further impacted some state reported MOE spending. The update clarified the MOE guidance, stating that states should only report MOE spending by the recipient entity administering the MIECHV grant, and not report spending by other state agencies. According to HRSA officials—because the states were now directed to exclude some previously reported home visiting spending—five states decreased their reported MOE spending to $0. In addition, three other states reported a decrease in their MOE spending ranging from about $1.2 million to about $9.3 million because of this change (see table 2). HRSA determined that states generally met the MIECHV program’s MOE requirement because there was no supplantation of federal funds, including in states that reported no MOE spending and those that reported decreased MOE spending from the prior fiscal year. States may be permitted to report $0 in MOE spending if the non-federal spending on home visiting does not meet the criteria in the MOE guidance in the NOFO. For example, if the state had not previously funded home visiting programs that met HRSA’s MOE criteria for the MIECHV program, then the state could maintain state spending of $0, according to HRSA officials. States may report MOE spending of $0 if state general funds were spent on a home visiting model that was not approved by HRSA, if the state supports an evidence-based home visiting program with funds other than state general funds, or if the state did not support a home visiting program prior to implementation of MIECHV. HRSA determined that state-reported year-to-year decreases in MOE spending did not constitute supplantation (or replacement) of state funds with federal funds, because as described more fully below, HRSA determined there were valid reasons for the decreased MOE spending, according to agency officials. Based on our analysis of grant applications, 15 states reported decreases in MOE spending from fiscal years 2016 through 2018 (see table 3). These decreases ranged from $75,000 to $71,539 in one state, and $25,207,294 to $0 in another state. According to HRSA officials, there were three different reasons why states might have reported a decrease in MOE spending compared to the prior year: 1. The state made a technical error in its MOE calculation that subsequently was corrected. For example, some states reported a decrease in MOE spending compared to the prior year because the state previously included erroneous funding sources, such as funding for a home visiting program that did not meet the MIECHV program’s MOE criteria. 2. Circumstances outside of the state agency’s control contributed to the state reporting decreased funding, such as when a state legislature authorized budget cuts that affected home visiting funding or failed to pass a budget. For example, according to HRSA officials, one state experienced state budget challenges in fiscal years 2016 and 2017, which resulted in decreased funding for some home visiting services. The officials said this funding would have been included in the state’s reported MOE spending and these budget reductions resulted in a reduction to the reported MOE spending from the prior year. 3. The clarification to the MOE guidance that HRSA made in the fiscal year 2018 NOFO limited the spending states should report, as previously discussed. HRSA uses several methods to monitor the MIECHV program and the program’s MOE requirement is addressed to some extent as part of each, according to our review of HRSA grants monitoring documentation and interviews with HRSA officials. These monitoring methods include grant application reviews, site visits, and financial assessments, among others. The monitoring methods vary in terms of the extent to which the MOE requirement is specifically examined, who conducts the monitoring, and the frequency of monitoring (see table 4). The primary mechanism for monitoring the MIECHV program’s MOE requirement is the review of grant applications, according to HRSA officials. HRSA project officers review the MOE chart in states’ grant applications for 2 fiscal years to compare state reported MOE spending— actual non-federal expenditures—and determine if states maintained their level of spending (see table 5). If there is a missing MOE chart or potentially inaccurate MOE spending information, project officers work with states to resolve the issue. While HRSA primarily relies on its review of grant applications to monitor state compliance with the MIECHV program’s MOE requirement, the agency supplements these reviews with other monitoring techniques, and some of these techniques have identified issues with state-reported MOE spending. For example, operational site visits provide HRSA an opportunity to ask detailed questions about state-reported MOE spending and obtain supporting documentation. As a result of operational site visits, HRSA identified inaccurate state-reported MOE spending in some states. We reviewed four completed site visit reports from 2017—the most recently completed reports at the time of our review—and two of these reports had findings related to inaccurate state-reported MOE spending. For example, one site visit report noted that the state incorrectly included home visiting spending that did not use an evidence-based model in its reported MOE spending. HRSA also found some deficiencies with states’ reported MOE spending through the agency’s review of state single audits. According to HRSA officials, there were five state single audits with MIECHV MOE findings from fiscal years 2014 through 2017. We found that four of these audits identified deficiencies with how states monitored and accounted for their MOE spending. For example, one audit found that the state did not have internal controls in place to ensure that state spending met the minimum MOE requirement. In three of the four single audits that identified deficiencies, the state agencies concurred with the findings and prepared corrective action plans to address the deficiencies. As of June 2019, HRSA officials said they have taken steps, or are planning steps, to modify or provide additional guidance related to how the agency monitors the MOE requirement for the MIECHV program. Specifically: HRSA officials told us that beginning with the formula grant NOFO for fiscal year 2019, HRSA added an additional column to the MOE chart for states to provide the expenditures for the 2 years prior to the current fiscal year of the application. According to HRSA officials, this will streamline HRSA’s process to compare state-reported MOE spending across 2 prior fiscal years without having to go back to the previous year’s grant application. In February 2019, HRSA published an internal grants policy bulletin that specifically addressed MOE requirements and the agency’s monitoring of those requirements for all HRSA programs. HRSA is currently working on MIECHV program standard operating procedures that are intended to clarify staff monitoring roles and responsibilities across the agency. Completion of this resource is targeted for the end of fiscal year 2019. HRSA is also planning to add the MOE table to future MIECHV program Final Reports submitted by grantees, beginning with the fiscal year 2017 Final Report, which is due to HRSA in December 2019. According to officials, this will allow for a formal resubmission of MOE spending if there have been any changes since the submission of the most recent grant application. We provided a draft of this report to HHS for review and comment. HHS provided technical comments that we have incorporated in the report as appropriate. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the appropriate congressional committees, the Secretary of the Department of Health and Human Services, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7215 or larink@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. Washington, D.C. In addition to the contact named above, Elizabeth Morrison (Assistant Director), Andrea Dawson (Analyst in Charge), David Reed, and Kelly Snow made key contributions to this report. In addition, key support was provided by Jennifer Cook, Sarah Cornetto, Thomas James, Jean McSween, Mimi Nguyen, Stacy Ouellette, Michelle Sager, Almeta Spencer, and Matthew Valenta.

Summary: The MIECHV program provides grants to states to support evidence-based home visiting services for at-risk pregnant women and parents with young children. HHS was appropriated $400 million per year for the MIECHV grant program for fiscal years 2018 through 2022. Families volunteer to participate in the MIECHV program and are provided regular home visits and support services from a nurse, social worker, or other professional. According to HHS, the program builds upon decades of scientific research showing that home visits during pregnancy and early childhood can improve the lives of children and families. States began receiving federal MIECHV program funds in fiscal year 2010, but many states provided home visiting services prior to the MIECHV program using state or other funds. To meet the program's MOE requirement, states are required to maintain home visiting spending that meets MIECHV program criteria. GAO was asked to review the MIECHV program's MOE requirement. GAO examined (1) what is known about the MOE spending reported by states that receive federal MIECHV program funds and (2) how HHS monitors states to ensure the MOE requirement is met. GAO reviewed MIECHV program notices of funding opportunity for fiscal years 2013 through 2018 and state grant applications for fiscal years 2016 through 2018, the most recent three years available. GAO also reviewed HHS grants monitoring documentation and interviewed HHS officials. From fiscal years 2016 through 2018, state reported maintenance of effort (MOE) spending varied from $0 to more than $25 million for the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, according to GAO's review of MIECHV program grant applications. The program's authorizing statute requires states to meet an MOE requirement. MOE requirements in federal programs generally require grantees to maintain a certain level of spending to ensure grantee dollars are not replaced with federal dollars. To demonstrate their compliance with the MIECHV program's MOE requirement, states report in their annual grant applications their MOE spending for the prior fiscal year. HHS determined that states generally met the MIECHV program's MOE requirement because states did not replace state funds with federal funds, including states that reported no MOE spending or decreased MOE spending. States may be permitted to report $0 in MOE spending in certain circumstances; for example, if a state's only home visiting spending was on programs that did not meet MIECHV program criteria. According to HHS officials, state-reported decreases in MOE spending were due to errors in calculations that were subsequently corrected, clarifications to HHS's MOE guidance, or because of circumstances outside of the state agency's control. HHS uses multiple methods to monitor state compliance with the MOE requirement, according to GAO's review of HHS documentation and interviews with HHS officials. The agency's monitoring strategy includes reviews of grant applications, reviews of state single audits, and operational site visits, among other techniques. According to HHS officials, grant application reviews are the primary mechanism used to monitor state compliance, through which HHS compares state-reported MOE spending in grant applications across two fiscal years to determine if states maintained their level of spending. In addition, HHS identifies and resolves issues with state-reported MOE spending through its operational site visits and the agency's review of state single audits.