Survey of Evidence-Based Practices for Mental Health and Substance Use Disorders in State Medicaid Plans: Coverage Structures, Access and Challenges
Supporting Statement
A.1. Circumstances of Information Collection
The U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration, Center for Mental Health Services (SAMSHA/CMHS) is requesting approval for a Survey of Evidence-Based Practices for Mental Health and Substance Use Disorders in State Medicaid Plans: Coverage Structures, Access and Challenges. This is a one-time data collection on current and planned State Medicaid activities and policies related to eight mental health/substance abuse evidence-based practices. The data collection is part of a project to increase attention to Medicaid mental health and substance abuse service issues among State Medicaid and Mental Health/Substance Abuse Directors, as well as to improve the effectiveness of State Medicaid mental health and substance abuse services. SAMHSA/CMHS will implement a survey to directors of State Medicaid programs. This program is authorized under Section 501(d)(4) of the Public Health Service Act or 42USC(5)(4).
SAMHSA/CMHS will disseminate a comprehensive survey instrument for state Medicaid directors that will provide information on state Medicaid coverage and implementation of mental health and substance abuse evidence-based practices (EBPs) from a number of valuable vantage points. The survey is voluntary, and will provide data on which states are currently covering EBPs within their Medicaid programs and which EBPs they are covering, state mechanisms for advancing EBPs in their Medicaid mental health and substance abuse programs, how states fund EBPs using Medicaid, how/whether states use SAMHSA toolkits and other materials to ensure fidelity to the practices, and access issues. The Survey of Evidence-Based Practices for Mental Health and Substance Use Disorders in State Medicaid Plans: Coverage Structures, Access and Challenges includes questions on the overall management and delivery of mental health and substance abuse services within Medicaid and on the implementation of eight specific EBPs within the state Medicaid program.
A.2. Purpose and Use of Information
Consistent with its mission, SAMHSA/CMHS is seeking the information to help develop and disseminate materials that will promote the adoption and reimbursement of evidence-based practices in the prevention, treatment, rehabilitation and/or support of persons who are Medicaid recipients and have mental health and/or substance use conditions. The survey will serve as the cornerstone of data gathering on selected evidence-based practices and will provide additional detail on opportunities for further discussions on State experiences concerning providers or service-specific Medicaid mental health and substance abuse practices.
SAMHSA/CMHS is heavily invested in learning more about the use of EBPs for mental health and substance use disorders in order to promote their continued use. The survey will enable SAMHSA/CMHS to know more about what states are already doing to adopt these EBPs. In addition, the individual respondents will benefit from participating in the survey because SAMHSA/CMHS plans to use the information collected from the survey to develop numerous products for dissemination to State Medicaid and Mental Health/Substance Abuse Directors. These products will be designed for the purpose of helping Medicaid directors adopt, deliver, and refine existing policies about mental health and substance abuse EBPs.
The following are examples of questions that will help to inform SAMHSA/CMHS of the funding mechanisms used to support each evidence-based practice:
Does Medicaid facilitate blending/braiding of Medicaid funding with other resources in order to support MedMAP services?
Is there a specific billing code and/or modifier that distinguishes MedMAP from other medication management units of service?
The following are examples of questions that will assist SAMHSA/CMHS in assessing the access to each evidence-based practice:
Does Medicaid offer providers any incentives to deliver MedMAP services?
Is your state engaged in any activities to promote MedMAP and/or improve access?
SAMHSA/CMHS will use the information collected to analyze a number of key questions, including:
How widespread is the coverage of mental health/substance abuse EBPs in state Medicaid programs?
How are states incorporating mental health/substance abuse EBPs into their state Medicaid plans?
How do states best support mental health/substance abuse EBPs in a managed care environment?
How do state Medicaid programs pay for mental health/substance abuse EBPs?
More detailed information about data analysis is included in section A.16.
A.3. Use of Information Technology
This activity will rely on data gathered from a self-administered survey of State Medicaid Directors. Surveys will be administered electronically via email to alleviate administrative burden on individual respondents. Responses will be collected in an electronic version of the instrument and emailed back to the contractor responsible for data collection.
Any existing information on the relevant mental health/substance abuse EBPs used by state Medicaid programs will be pre-populated into the individual survey instruments prior to being administered to respondents, so no duplication of effort will occur. The information being collected through this survey cannot be obtained through any existing information technology. It is not routinely recorded in any electronic information medium that could be adapted to obtain the data required to address the research objectives.
A.4. Efforts to Identify Duplication
Efforts to avoid duplication include a review of data maintained by SAMHSA’s contractor on state Medicaid programs’ use of mental health and substance abuse EBPs. Some states post useful information sources, such as their mental health provider handbooks, on their state program websites. SAMHSA’s contractor will scan these websites and also conduct a review of data from previously conducted surveys for existing information on state Medicaid programs’ use of mental health and substance abuse EBPs. Any existing information on relevant EBPs being administered across state Medicaid programs will be incorporated into the individual survey instruments prior to being sent to respondents so no duplication of effort will occur. Existing data can and will be used whenever possible. The respondents will then be asked to confirm, update, or correct any existing information in the survey and to fill in missing information where possible. The survey is necessary because there is no source of current, correct, and complete information on the use of mental health and substance abuse EBPs among all of the state programs.
A.5. Involvement of Small Entities
No small businesses are involved as respondents in the proposed data collection effort. Respondents are all individuals who are directors of State Medicaid programs.
A.6. Consequences If Information Collected Less Frequently
This one-time data collection is necessary to describe EBPs taking place across state Medicaid programs. The information provided through the survey will be vital to increasing awareness and understanding of Medicaid mental health/substance abuse EBP activities. Without these data, SAMHSA/CMHS will not be able to identify what practices are already being implemented across state programs in order to then develop products for increasing their use.
A.7. Consistency with the Guidelines in 5 CFR 1320.5(d)(2)
There are no special circumstances required for the collection of information in this data collection.
A.8. Consultation Outside the Agency
In accordance with the paperwork Reduction Act of 1995, SAMHSA published a 60-day notice in the Federal Register announcing the agency’s proposed data collection activity. This notice was published on January 31, 2011 (Vol. 76, Page 5391). There were no public comments submitted to SAMHSA in response to the Federal Register notice.
SAMHSA, in collaboration with the Centers for Medicare and Medicaid Services (CMS), reviewed the survey developed by the contractor (Abt Associates) and its partners – the National Academy for State Health Policy (NASHP) and the National Association of State Medicaid Directors (NASMD). In the initial design phase of the project and the development of the instrument, face-to-face and telecommunication meetings took place from November 2008 to March 2009, between the contractor and its partners. Individuals from CMS that provided initial feedback on the survey included: Theresa Pratt, Acting Director, Disabled and Elderly Health Programs Group, CMSO; Peggy Clark, CMSO; and Suzanne Bosstick, CMSO.
At the end of the initial survey development phase, a panel of individuals who constitute the Medicaid and Mental Health Technical Advisory Group (TAG) reviewed a draft of the survey. The TAG is comprised of a cross-section of mental health and Medicaid experts from around the country. In particular, comments were solicited on the survey content, structure, and wording. All recommendations for changes from the group were then incorporated into the survey instrument. The current members of the TAG are listed in Exhibit 1.
Following a subsequent round of revisions in September 2010, the instrument was again reviewed by SAMHSA and CMS staff. The instrument was finalized in November 2010.
Exhibit 1 Technical Advisory Group (Expert Panel) Members |
Kevin Martone, Assistant Commissioner, Division of Mental Health Services, New Jersey Department of Human Services, 50 East State Street, Trenton, NJ 08625, Phone: (609) 292-3717 |
Doug Porter, Assistant Secretary, Washington Health and Recovery Services Administration, P.O. Box 45502, Olympia, WA 98504-5502, Phone: (360) 725-1867, Fax: (360) 586-9551 |
William Hogan, Commissioner, Alaska Department of Health and Social Services, Alaska Office Building, Room 427, P.O. Box 110601, Juneau, Alaska 99811-0601, Phone: (907) 465-3030 |
Stephen W. Mayberg, Director, California Department of Mental Health, 1600 9th Street, Room 151, Sacramento, CA 9 5814, Phone: (916) 654-2309 , Fax: (916) 654-3198 |
John Easterday, Administrator, Wisconsin Division of Mental Health and Substance Abuse Services, 1 W. Wilson St., Room 850, P.O. Box 7851, Madison, WI 53707, Phone: (608) 267-9391, Fax: (608) 266-2579 |
Vivianne M. Chaumont, Director, Division of Medicaid & Long-Term Care, Nebraska Department of Health and Human Services, 301 Centennial Mall South, Lincoln, Nebraska 68509, Phone: (402) 471-2135, Fax: (402) 471-9449 |
Tara Larson, Chief Clinical Operating Officer, North Carolina Division of Medical Assistance, 2501 Mail Service Center, Raleigh, NC 27699, Phone: (919) 855-4265 |
Virginia Trotter Betts, Commissioner, Tennessee Department of Mental Health & Developmental Disabilities, Cordell Hull Building, 3rd Floor, 425 Fifth Avenue, North, Nashville, TN 37243-0675, Phone: (615) 532-6500, Fax: (615) 532-6514 |
Linda Kelly, Office of Health Insurance Programs, New York Department of Health, One Commerce Plaza, Albany, NY 12210, Phone: (518) 473-8919 |
No payments or gifts are planned to respondents for completing the survey.
A.10. Assurance of Confidentiality
This is a survey of state directors of Medicaid programs who are also public officials. As such, their identities are already in the public realm. Although SAMHSA/CMHS will ask permission before printing the contact information of the directors, SAMHSA’s contractor will likely associate particular EBPs with specific state programs in the final report. Therefore, the identities of the directors of the programs will be easily recognized. However, the survey consists of objective questions on state policies and practices and the information from respondents is part of their regular business knowledge. There are no questions of a personal nature, including personal choices or behaviors.
A.11. Questions of a Sensitive Nature
There are no questions of a sensitive nature in the survey.
A.12. Estimates of Annualized Hour Burden
The total burden for the individual is estimated at 60 minutes. Time estimates are based on experience with similar instruments in other studies of comparable organizations. In addition, the survey was pretested by a diverse group of three existing State Medicaid Directors. Exhibit 2 presents estimates of the reporting burden for survey respondents based on the results of the pre-testing.
A.12.1. Number of Respondents, Frequency of Response, and Annual Hour Burden
The survey will have 51 respondents and will take on average 60 minutes (1 hour) to complete. The survey will be administered one time. This estimated burden is based on a pretest of the instrument with three current Medicaid State Directors.
A.12.2. Hour Burden Estimates by Each Form and Aggregate Hour Burdens
There is a single version of the survey. The aggregate hour burden is 1 hour (60 minutes). This estimated burden is based on a pretest of the baseline instrument with Medicaid State Directors.
A.12.3. Estimates of Annualized Cost to Respondents for the Hour Burdens
Exhibit 2 offers an estimate of reporting burden for a sample of 51 respondents to a 60-minute survey (Appendix A). Based on past surveys and recent job postings of directors, NASMD estimates a Medicaid State Director’s average hourly wage at $62.50. Other than their time to complete the survey, there are no direct monetary costs to respondents.
Exhibit 2 Estimate of Reporting Burden |
|||||
Data Collection Sources |
Number of Respondents |
Minutes per Respondent |
Response Burden in Hours |
Cost/ |
Cost to Respondents |
Medicaid State Directors |
51 |
60 |
51 |
$62.50 |
$3,187.50 |
A.13. Estimates of Annualized Cost Burden to Respondents
There is no capital/startup or operation and maintenance cost involved in collecting the information.
A.14. Estimates of Annualized Cost to the Government
The total estimated cost to the Federal Government for the Survey of Evidence-Based Practices for Mental Health and Substance Use Disorders in State Medicaid Plans: Coverage Structures, Access and Challenges data collection activity is $112,995. This includes the cost of the survey development, implementation and analysis ($107,995) plus 5% of a GS-13 SAMHSA employee’s (project officer’s) time at $100,000 annual salary ($5,000).
This is a new data collection.
A.16. Time Schedule, Publication and Analysis Plans
SAMHSA/CMHS will use the survey data to analyze the following key issues:
How widespread is the coverage of mental health and substance abuse EBPs in state Medicaid programs? What services have achieved broad acceptance, what services are lagging in adoption and why?
How do state Medicaid programs seek input and recommendations on evidence-based practices? How do these input structures support EBP implementation? For early adopters and leading states, what are the lessons learned?
How are states incorporating EBPs into their state Medicaid plans? What are the relative benefits in each of the identified options?
How do states best support EBPs in a managed care environment? Is model contract language emerging? What are the challenges in the fee-for-service delivery systems?
How do state Medicaid programs pay for EBPs? What challenges do states report in pooling resources with other funding streams? What are successful blending/braiding models that can be disseminated to better support these practices through Medicaid? What are states primary concerns/barriers about funding these services?
In states that cover EBPs in their Medicaid program, are these services accessible? How is eligibility/medical necessity determined? How are they managed?
How do states provide sufficient coverage of implementation and operations to assure fidelity to the program standards that tie to effectiveness?
How do states track quality and fidelity measures? Is there model licensing, contract, regulatory language that supports fidelity to the models?
The data will also inform the development of EBP Implementation Reports that describe the selected practices and provide information and guidance on the adoption and reimbursement of these practices in State Medicaid programs. SAMHSA/CMHS anticipates the following products will be developed as a result of survey data analysis:
Survey Significant Findings and Themes: This brief will provide an overview of survey findings around several themes. SAMHSA/CMHS anticipates that major items of interest will include a discussion of state evidence-based practice advisory and stakeholder structures, and an analysis of state reimbursement strategies to support EBPs.
Internal Report: Using survey data, the contractor will generate an internal report that will guide project technical assistance efforts. Analysis of survey data will allow project partners to better understand the implementation challenges faced by states, and to target information and materials more effectively to those needs.
Web site tools and resources: The survey data, significant findings analysis and internal brief will inform the development of a series of tools and resources that will be available to states via the project webpage. These tools may include best policy practices to support EBPs, model licensing, contract and/or regulatory language, and billing FAQs.
A.17. Display of Expiration Date
The expiration date will be displayed.
A.18. Exceptions to Certification Statement
This submission describing data collection requests no exceptions to the Certificate for Paperwork Reduction Act (5 cfr 1320.9).
B. Collections of Information Employing Statistical Methods
B.1. Respondent Universe and Sampling Methods
The universe of 51 directors of state Medicaid programs located in every U.S. state and the District of Columbia will be surveyed for this data collection. No additional sampling will be used to select potential respondents.
B.2. Information Collection Procedures
The names of state Medicaid directors will be obtained from SAMHSA’s contractor, who maintains and continuously update lists of the directors of all state agencies and their contact information.
A self-administered survey will be distributed to Medicaid Directors in the 50 states and the District of Columbia. In order to be the least burdensome to sites, the surveys will be distributed and collected via email. Whenever possible, an electronic version of the survey will be available to respondents. Upon completion of the survey, respondents will be asked to return completed surveys to SAMHSA’s contractor via email or facsimile within four weeks.
B.2.1. Statistical Methodology for Stratification and Sample Selection
This project requires no sampling procedures because SAMHSA/CMHS will survey State Medicaid Directors from all U.S. states and the District of Columbia, which composes a universe of 51 state directors.
No weights will be calculated for analyzing and reporting the survey results. The final products, including an internal report for SAMHSA/CMHS and a brief for public distribution, will contain the descriptive results of the survey data. Both products will provide survey findings using simple frequencies and other descriptive statistics for particular EBPs. SAMHSA/CMHS anticipates that major items of interest will include a discussion of state evidence-based practice advisory and stakeholder structures and an analysis of state reimbursement strategies to support EBPs.
B.2.3. Degree of Accuracy Needed for the Purpose Described in the Justification
Because SAMHSA/CMHS is surveying a universe of respondents, the main concern will be maximizing the survey response rate in order to be able to assume accuracy of results. SAMHSA/CMHS anticipates achieving an 80 percent response rate to minimize non-response bias.
B.2.4. Unusual Problems Requiring Specialized Sampling Procedures
There are no unusual problems requiring specialized sampling procedures.
B.2.5. Use of Periodic (Less Frequent Than Annual) Data Collection Cycles
The survey is a one-time data collection necessary to increase SAMHSA’s awareness and understanding of Medicaid mental health/substance abuse evidence-based practice activities.
B.3. Methods to Maximize Response Rates
All State Medicaid Directors will be expected to complete the questionnaire in order to develop a complete understanding of the use of EBPs. Because SAMHSA/CMHS is delivering the survey directly to state directors using updated contact information from the contractor’s database, SAMHSA/CMHS expects fewer non-responses due to an inability to locate sample members. The instrument was developed with consideration to length and reading level so it is appropriate for directors to complete. In addition, the instrument was pretested with a diverse group of three current state Medicaid directors to ensure usability.
In addition, two weeks after the surveys have been distributed, SAMHSA contractors will follow-up with non-respondents by telephone to remind them to complete the survey and to answer any questions. An intensive effort will be made to obtain responses from all respondents. In addition, callers will remind state Medicaid directors of the potential usefulness of the final products resulting from the survey, since many of them use similar reports produced from other types of efforts that collect and disseminate best practices. Explaining the value of the products that will result from the data collection should encourage respondents to complete and submit the survey.
The expected response rate for completion of the survey is a minimum of 80 percent.
The survey instrument has been drafted and has undergone two reviews: (1) a review by the project’s Medicaid and Mental Health Technical Advisory Group (listed in section A.8.); and (2) a pretest with three current state Medicaid directors.
An annotated version of the survey with embedded comments and questions was provided to the TAG members, along with discussion questions about the instrument for review. TAG members provided the project team with constructive feedback that was used to adapt the instrument and survey method and to potentially provide better response rates and outcomes.
In order to accurately determine the burden placed on respondents as well as further test the clarity of the survey questions, a pretest was conducted in which a total of three State Medicaid Directors from diverse programs responded to the survey to assess the reliability of the instrument. Three states were selected to serve as pilot sites from the contractor’s database of state agency directors, which reflected a diversity of Medicaid/mental health experience. Specifically, SAMHSA’s contractor purposely selected three types of states to participate in the pretesting:
One state had a close working relationship with their state mental health authority;
A second state had a more remote relationship with their state mental health authority; and
A third state had significant managed care penetration in its Medicaid program.
Revisions were made to the instrument in response to comments received from all of these reviews. Modifications to the length, content, and structure of the survey have been made based on the results of the survey pretest interviews. Respondents provided generally positive feedback indicating that they could readily answer the questions and that the time to complete the survey was not onerous (about 60 minutes).
The information for this project is being collected by Abt Associates Inc., a research and consulting firm, on behalf of SAMHSA/CMHS. With oversight from SAMHSA/CMHS staff, Abt Associates Inc. is responsible for the study design, instrument development, data collection, analysis, and report preparation.
The instrument for this project and the plans for analyses were developed by Abt Associates Inc. and its partner the National Academy for State Health Policy (NASHP), with input from the National Association of State Medicaid Directors (NASMD). The current team includes:
Shelagh Smith, MPH, CHES (Task Order Officer)
Sr. Public Health Advisor, Center for Mental Health Services
Substance Abuse & Mental Health Services Administration
One Choke Cherry Rd. 2-1111
Rockville, MD 20857
240-276-1966 (phone)
Gail K. Robinson, PhD (Project Director)
Vice President, Abt Associates Inc.
4550 Montgomery Ave., Suite 800 North
Bethesda, MD 20814
301-634-1787 (phone)
Caryn Nagler
Associate, Abt Associates Inc.
4550 Montgomery Ave., Suite 800 North
Bethesda, MD 20814
301-634-1762 (phone)
Diane Justice
Senior Program Director, National Academy for State Health Policy
1233 20th St NW, Suite 303
Washington, DC 20036
202-903-2798 (phone)
Kitty Purington
Policy Specialist, National Academy for State Health Policy
10 Free Street, 2nd Floor
Portland, Maine 04101
207-874-6524 (phone)
Attachment 1: Survey Instrument
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Abt Single-Sided Body Template |
| Author | Administrator |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |