HLTH 5033 Module 2 Grant-Restricted Program Budget Example

Three Funding Sources, One Home Visiting Program: A Program Budget With Justifications That Respects Grant Restrictions

Student Name

American College of Education

HLTH5033: Financial Management in Public Health

Module 2 Assignment

Instructor Name

October 12, 2026

The Program

The composite county health department analyzed in the previous module runs a program in which nurses visit low-income women expecting their first child at home, from pregnancy until the child turns two. Nurses visit families at home to support prenatal health, parenting, child development and the mother's own goals for school and work. The program is modeled on a design with strong long-term evidence: in a randomized trial followed for 15 years, women visited by nurses during pregnancy and infancy were identified as perpetrators of child abuse and neglect in 0.29 verified reports compared with 0.54 in the comparison group, and low-income unmarried mothers had fewer subsequent births, less time receiving welfare and fewer arrests (Olds et al., 1997).

This paper presents the program's budget for fiscal 2027, July through June, with a justification for each line and an explanation of how costs are assigned to its three funding sources: a state maternal and child health subgrant, Medicaid billing for targeted case management, and the county levy.

Personnel

Personnel is the program's largest cost because the service is the nurse. The budget funds six registered nurses at an average salary of $78,000, or $468,000; a nurse supervisor at $92,000; two community health workers at $44,000 each, or $88,000; and a half-time data clerk at $20,000. Salaries total $668,000. Fringe benefits at the county's rate of 34%, covering retirement, health insurance and payroll taxes, add $227,120, for personnel costs of $895,120.

The staffing reflects the program model. Each nurse carries about 25 families, so six nurses serve about 150 families at a time. The supervisor provides the weekly reflective supervision the model requires and covers caseloads during vacancies. Community health workers, added three years ago, help families enroll in benefits, find housing and keep appointments, which frees nurses to focus on health and parenting.

Operating Costs

Mileage is budgeted at 60,000 miles, about 7,500 for each nurse and community health worker, at the county's reimbursement rate of $0.70 a mile, or $42,000, based on last year's actual travel. Program supplies, including infant scales, educational materials and developmental screening kits, are $18,000. Training and model certification for new staff are $14,000. The home visiting data system license is $9,600, and phones and tablets for field staff are $7,200. Interpreter services, needed for about a fifth of families, are $12,000. Operating costs total $102,800, and total direct costs are $997,920.

Indirect costs, the program's share of the department's finance, human resources, facilities and information technology, are budgeted at 15% of direct costs, or $149,688, consistent with the de minimis rate available under the federal guidance for financial assistance to recipients without a negotiated rate (Guidance for Federal Financial Assistance, 2024). Total program cost is $1,147,608, or about $7,650 per family per year.

Assigning Costs to Funding Sources

Each funding source brings its own rules, and the budget must show which costs each will pay. The state subgrant of $600,000 is restricted to allowable costs of the home visiting program and includes indirect costs at 15%, so it supports $521,739 in direct costs and $78,261 in indirect costs. Its direct portion is assigned to four nurse positions with their fringe, half of the supervisor's salary and fringe, those nurses' mileage and part of the supplies and interpreter lines. Medicaid targeted case management billing is projected at $246,500, based on about 2,900 billable visits to Medicaid-enrolled families at the state's rate of $85 per visit. The county levy covers the remaining $301,108.

Three rules shape the allocation. Costs charged to the grant must be reasonable, allocable to the program and treated consistently with the department's other activities, the core tests of allowability in the federal cost principles. Staff whose time is split between the grant and other funding must document their effort, so the supervisor and data clerk will record time by funding source each pay period. And the state's subgrant agreement prohibits supplanting: the county may not reduce its own contribution because the grant exists. A budget that adds up is not enough; each dollar has to be able to show which rule allowed it to be spent where it was.

Risks in the Budget

Two assumptions carry most of the risk. The Medicaid revenue depends on families remaining enrolled in Medicaid and on nurses documenting visits correctly; a 15% shortfall would cost about $37,000. The budget therefore assumes a billing review each quarter and sets aside a small contingency within the levy portion. The state grant depends on state appropriations, which have been flat for three years while costs rose; if the grant were cut by 10%, the program would need either $60,000 more from the levy or a reduction of about one nurse and 25 families. The budget narrative will present both scenarios to the board now rather than when a cut arrives.

Cash Flow and Reimbursement Timing

A balanced annual budget can still run out of cash in the middle of the year, and this program's funding makes that likely without planning. The state subgrant reimburses expenses quarterly, usually about 45 days after each quarter ends, so the department spends grant money for up to four and a half months before it is repaid. Medicaid claims for targeted case management are paid about 30 to 60 days after submission, and claims denied for documentation errors take longer. The county levy, by contrast, arrives on the county's tax calendar, mostly in two installments. The budget therefore includes a monthly cash projection. It shows the program's cumulative gap peaking at about $210,000 in the second quarter, before the first grant reimbursement and the first large Medicaid remittance arrive. The county's pooled cash can cover the gap, but the finance office needs to know in advance. To reduce it, program staff will submit grant reimbursement requests monthly where the state allows and will review Medicaid claims before submission to cut denials. The cash projection will be updated each month alongside the budget-to-actual report.

Justification Summary

The budget is built from the program's model outward: families served determine nurse positions, nurse positions determine mileage and supplies, and total direct costs determine indirect costs. Each funding source pays only for costs it allows, with documentation that would satisfy an auditor. The cost per family, about $7,650 a year, is best judged against the program's long-term effects on child maltreatment, subsequent births and economic self-sufficiency documented in the original trial, rather than against the cost of a single clinic visit. A projection of outcomes for families enrolled nationally through 2013 estimated that the model would prevent, among other results, about 42,000 incidents of child maltreatment and 10,000 preterm births by 2031 (Miller, 2015). The department should present the budget to the board with that comparison, and with the two risk scenarios, so that approval reflects both the value and the vulnerability of the program's funding.

References

Guidance for Federal Financial Assistance, 89 Fed. Reg. 30046 (2024).

Miller, T. R. (2015). Projected outcomes of Nurse-Family Partnership home visitation during 1996-2013, USA. Prevention Science, 16(6), 765-777. https://doi.org/10.1007/s11121-015-0572-9

Olds, D. L., Eckenrode, J., Henderson, C. R., Jr., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L. M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. JAMA, 278(8), 637-643. https://doi.org/10.1001/jama.1997.03550080047038