Form CMS-10382 CMS-10382-APPENDIX-1-Guidelines

APPENDIX 1
MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION
APPLICATION PROPOSAL GUIDELINES

INTRODUCTION
Section 2707 of the Affordable Care Act authorizes a 3-year Medicaid Emergency Psychiatric
Demonstration project that permits non-government psychiatric hospitals to receive Medicaid
payment for providing Emergency Medical Treatment and Active Labor Act (EMTALA)-related
emergency services to Medicaid recipients aged 21 to 64 who have expressed suicidal or
homicidal thoughts or gestures and are determined to be dangerous to themselves or others.
Section 2707 requires that a State seeking to participate in the Demonstration project under this
section shall submit an application, at such time and in such format as the required, that includes
such information, provisions, and assurances necessary to assess the State’s ability to conduct the
Demonstration as compared with other State applicants. States participating in the
Demonstration will be selected on a competitive basis based on the responsiveness of their
applications. However, the statute also requires that, in selecting State applications for the
Demonstration, CMS shall seek to achieve an appropriate national balance in the geographic
distribution of the Demonstration.
Applicants for this Demonstration are limited to Medicaid Agencies in the States and Territories
of the United States.
Application Instructions for Potential Sites
The instructions below are intended to provide prospective Demonstration participants with a
template for submitting required information to CMS.
Application proposals should not exceed 30 pages (proposal plus appendices) on 8.5” X 11”
letter-sized paper with 1-inch margins (top, bottom, and sides), single spaced, single sided,
written in English with black ink, no smaller than12-point font. Please submit one unbound copy
suitable for photocopying and 3 bound copies.
Page limits listed for each section represent the maximum number of pages recommended for
that section. An additional three pages are allowed for appendices if needed.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 40
hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

COVER LETTER
The applicant should provide a cover letter which includes the following information (not
included in page limit):
State and name of State Medicaid Agency
Contact person name and title
Contact person telephone and fax number
Contact person e-mail address
A narrative describing the State’s interest and reasons for applying for and participating in the
Demonstration.
An acknowledgement of support for participation in the Demonstration from the State Medicaid
Director.
EXECUTIVE SUMMARY (2 pages)
Please provide a summary of your proposal that includes highlights from each section. The
summary should begin with an overview of your understanding of section 2707, the Medicaid
Emergency Psychiatric Demonstration and a brief statement of the reasons why your State
wishes to participate in the Demonstration, including the issues and problems you believe will be
addressed by participation in the Demonstration.
The summary should provide a brief statement of the goals the State seeks to achieve by
participating in the Demonstration.
1.0

INTRODUCTION

1.1

Rationale for Participation (1 page)

Explain your State's reasons for wanting to participate in the Demonstration site and what the
various entities in and outside State government (e.g., Medicaid administration, departments of
health, mental health and substance abuse, and department of public health, general and
psychiatric hospitals, mental health providers, law enforcement, etc.) may seek to achieve by the
State’s participation in the Demonstration. Discuss the goals the State seeks to achieve in
participating in the Demonstration and how it will determine whether these goals are met.
Discuss the positive changes expected from the Demonstration as well as the difficulties and the
potential negative consequences of the Demonstration. Finally, explain how the selection of
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 40
hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

your State would be a benefit to CMS in the implementation and evaluation of this
Demonstration.
2.0

BACKGROUND (4 pages)

2.1

Mental Health Issues and Service Delivery in the State

Please provide a brief history of the problems faced in your State with regard to the recognition
of treatment needs for those with mental illness and the development of policies to provide for
their treatment. In particular, discuss the changes over time in the availability, access and cost of
treatment for mental diseases in reference to, for example, the development of institutions for
mental diseases, the deinstitutionalization movement and community care model, the Medicaid
institution for mental diseases (IMDs) exclusion, the problem of patient boarding, and how
policies for mental health care may have affected the availability and cost of health care in
general. Please provide current estimates of the incidence and prevalence of mental diseases in
the State among children and adults, including an estimate of those who were found to exhibit
suicidal or homicidal gestures and were considered a danger to self and others. Include, if
possible, an estimate and description of the population likely to be affected by this
Demonstration, i.e., Medicaid eligible persons aged 21 to 64. The discussion should close with
an overview of the current problems faced by the State in providing and/or facilitating the
recognition, diagnosis and treatment of mental diseases among its population and issues
surrounding psychiatric boarding.
2.2

Psychiatric Care and Facilities

Please describe the government and non-government psychiatric facilities available in your State
that provide emergency services, assessment and treatment of mental diseases. How many are
dedicated to inpatient treatment and what are the characteristics, specialties and capacity of these
institutions?
Please describe the most likely scenario for how most patients affected by this Demonstration,
i.e., those presenting suicidal or homicidal gestures and are determined a danger to self or others,
are likely to enter the health care system for emergency care and progress through assessment,
referral, admission, treatment and discharge. Also, please describe the process the State will use
to ensure that the patients are stabilized.
2.3

Demonstration Population
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 40
hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Please describe the geographic catchment area in your State likely to be primarily served by this
Demonstration including estimates of the number of Medicaid-eligible persons expected to
receive fee-for-service treatment under Medicaid as a result of the Demonstration.
3.0

DEMONSTRATION PROPOSAL (20 pages)

Please describe the State plan for the organization, implementation, management and monitoring
of the Demonstration using the following sections as a guide to the organization of your
description.
3.1

Staff Designation and Roles

Please provide the names and contact information of the principle staff that will be responsible to
implement and manage this Demonstration in your State and briefly describe the roles of each of
the principle staff member tasked to implement and manage the Demonstration.
3.2

Administration and Management

Describe the plan for the day-to-day administration and oversight of the Demonstration,
including processes, communications and agreements with institutions directly and indirectly
involved in the Demonstration.
3.3

Facilities Selected for the Demonstration

Please provide a listing of the non-government psychiatric institutions in your State that will be
selected to participate in the Demonstration along with their location, contact information,
attributes and psychiatric specialty focus, and a brief description of their characteristics including
bed size and a recent yearly census of emergency, inpatient, and outpatient admissions served.
Briefly discuss why these facilities were selected and how their selection will be advantageous to
testing the potential of this Demonstration.
Please describe the likely referral sources for emergency and inpatient care under this
Demonstration (e.g., general hospital emergency departments, clinics, physicians, police, and
social services) and any agreements or understandings that may be established between source
entities, referral facilities and the State Medicaid Agency for the purpose of facilitating the
implementation and management of this Demonstration.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 40
hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

3.4

Medicaid Payment System and Accounting

Describe your Medicaid payment system in terms of what modifications will be made to
accommodate payment under the Demonstration. What arrangements will be made with the
institutions participating in the Demonstration? What processes will be put in place to identify
the admission/discharge or entry and exit points for payment under the Demonstration and to
facilitate billing and payment for Demonstration patients? What mechanisms will be put in place
to track payment amounts and how payments are provided for services during the patient
episode, inside and outside the Demonstration parameters, for each patient treated under the
Demonstration?
3.5

Patient Administration and Stabilization Review

The statute (i.e., section 2707 of the Affordable Care Act) requires that in applying to participate
in this Demonstration, the State shall specify “… a mechanism for how it will ensure that
institutions participating in the Demonstration will determine whether or not such individuals
have been stabilized” where stabilization is defined as “… the emergency medical condition no
longer exists with respect to the individual and the individual is no longer dangerous to self or
others.” The statute requires that this mechanism shall commence before the third day of the
inpatient stay. The statute continues in stating that, “…States participating in the Demonstration
project may manage the provision of services for the stabilization of medical emergency
conditions through utilization review, authorization, or management practices, or the application
of medical necessity and appropriateness criteria applicable to behavioral health.”
Please describe the mechanisms the State will put into place to monitor the patient flow
beginning with the determination that a patient is eligible for the Demonstration, enters care
under the Demonstration, continues care, when stabilization is achieved and when the patient is
discharged from inpatient care and/or is no longer considered a Demonstration patient. In
particular, please provide a particular focus on that part of these mechanisms that will satisfy the
requirements of the statute.
3.6

Understanding of Demonstration Waiver Authority

The statute provides for the waiver of Title XIX of the Social Security Act with respect to the
Medicaid IMD exclusion to allow the conduct of the Demonstration. Specifically, a waiver is
granted, “… relating to limitations on payments for care or services for individuals under 65
years of age who are patients in an institution for mental diseases…” for purposes of carrying out
this Demonstration.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 40
hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Please discuss your understanding of Medicaid IMD exclusion and its waiver with regard to the
provision of Medicaid services in your State under the Demonstration. Discuss whether there are
any specific State laws and regulations, if any, that bear on the successful conduct of this
Demonstration and what measures the State will need to make to enable its implementation.
3.7

CMS-State Payment Process

After Federal administrative costs for implementation, monitoring and evaluation, funding for
Medicaid services under the Demonstration will likely be limited to approximately $66,500,000
in Federal matching funds across all States participating in the Demonstration. The statute
specifies that funding provided under the Demonstration shall be allocated to States participating
in the Demonstration based on criteria to be determined by factors including the State application
and availability of funds. It is desirable to allocate funding in such a manner as to allow each
State selected to conduct the Demonstration for the full 3-year period taking into account the
number of people likely to receive services under the Demonstration. These allocations will be
based initially on State patient census estimates provided at the beginning of the Demonstration.
These allocation amounts can be adjusted over time based on the actual number of people
provided services within each State as the Demonstration proceeds, again with the intent to allow
each State to participate fully.
Under the Demonstration, in accordance with the statute, CMS will pay each State the Federal
portion of that State’s current Medicaid matching payment for services included under the
Demonstration.
States will be required to submit to CMS payment information to include the patient name,
Medicaid identification number, dates of service, location of service and payment amount. Other
patient specific information may be required if needed to substantiate the invoice.
Please describe the financial accounting and transfer process by which the State will submit
payment information to CMS and receive the Federal portion of Medicaid expenditures. In
doing so, please provide your State’s current Medicaid matching payment rate for medical
assistance services such as those included in the Demonstration and describe the processes for
annual updates and any special rate adjustments that may occur.
Describe how this process will be used or amended to account for, declare and receive federal
matching funds from CMS under this Demonstration.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 40
hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

3.8

Demonstration Monitoring and Evaluation

The CMS is required to collect information to monitor the progress of the Demonstration at each
participating institution, which may include all of the following: the number of patients admitted
and treated under the Demonstration, Medicaid/Medicare/SSI eligibility status, demographic
information, geographic residence information, transfer, admission and readmission information,
length of stay and community discharge information, and information about how eligibility for
the Demonstration was determined, how and when stabilization was achieved, and how
discharge planning and hospital discharge was accomplished.
The CMS is required to conduct an independent evaluation to determine the impact of the
Demonstration on the functioning of the health and mental health service system within the
participating States and individuals enrolled in the Medicaid program. The evaluation is to
include: (1) An assessment of the Demonstration in relation to access to inpatient mental health
services under the Medicaid program including average lengths of inpatient stays and emergency
room visits; (2) An assessment of discharge planning by participating hospitals; (3) An
assessment of the impact of the Demonstration project on the costs of the full range of mental
health services (including inpatient, emergency and ambulatory care); and (4) An analysis of the
percentage of consumers with Medicaid coverage who are admitted to inpatient facilities as a
result of the Demonstration project as compared to those admitted to these same facilities
through other means.
A key part of the competitive selection process will focus on the State’s capability, as described
in its application proposal, to report data accurately and expeditiously to CMS, Medicaid, or
other data system items, that may be necessary to use to fulfill the mandated evaluation topical
areas on discharge planning, system-wide changes in service use and cost patterns, access to
care, individual health outcomes and information to enable comparisons with similar individuals
not eligible for Demonstration participation.
The statute specifies that, as a condition of receiving payment under the Demonstration, a State
shall collect and report information, as determined necessary by the Secretary, for the purposes
of Federal oversight and the evaluation of the Demonstration. As the Demonstration
implementation process proceeds, the State will be asked to work with CMS and its support
contractor to develop a process that provides for the regular reporting of information to satisfy
the requirements for monitoring and evaluating patient flows, quality of care, adverse events,
treatment outcomes and payments made under the Demonstration. Specific data requirements
related to the evaluation effort will be determined during implementation of the Demonstration
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 40
hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

taking into account the feasibility and cost to the States in collecting and submitting this
information to the CMS evaluation team.
Please describe the State’s administrative plan and proposed process to collect, process and
report patient, treatment and payment information to CMS to comply with the monitoring and
evaluation requirements of the Demonstration.
REVIEW AND SELECTION PROCESS
Section 2707 requires that a State seeking to participate in the Demonstration project under this
section shall submit an application, at such time and in such format as the required, that includes
such information, provisions, and assurances necessary to assess the State’s ability to conduct the
Demonstration as compared with other State applicants. States participating in the
Demonstration will be selected on a competitive basis based on the responsiveness of their
applications. The statute also requires that, in selecting State applications for the Demonstration,
CMS shall seek to achieve an appropriate national balance in the geographic distribution of the
Demonstration.
An application review panel will be convened to review all applications and make
recommendations for award to the CMS Administrator. The application review panel will be
composed primarily of CMS staff from across its components with expertise in the various
clinical and administrative issues involved in the implementation of the Demonstration.
Applications will be scored by each panel member according to the responsiveness of each
section of the application to the content requirements stated in the application instructions as
indications of the understanding and abilities of the State in assisting CMS in implementing and
managing the Demonstration in accordance with of section 2707 of the Affordable Care Act.
Panel members will be instructed to provide scores for each section of the application proposal
up to the following scoring limits.
Executive Summary (2 pages)
1.0

INTRODUCTION (1 page)

5 points

1.1

Rationale for Participation (1 Page)

2.0

BACKGROUND (4 pages)

15 points
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 40
hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2.1

History of Mental Health Issues and Service Delivery in the State

2.2

Psychiatric Care and Facilities

2.3

Demonstration Population

3.0

DEMONSTRATION PROPOSAL (20 pages)
DEMONSTRATION ADMINISTRATION

3.1

Staff Designation and Roles

3.2

Administration and Management

3.3

Facilities Selected for the Demonstration
DEMONSTRATION OPERATIONS

3.4

Medicaid Payment System and Accounting

3.5

Patient Administration and Stabilization Review

3.6

Understanding of Demonstration Waiver Authority

3.7

CMS-State Payment Process

3.8.

Demonstration Monitoring and Evaluation

Total

35 points

45 points

100 points maximum

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 40
hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.