Medicaid Emergency Psychiatric Services Demonstration Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10487 Medicaid Emergency Psychiatric Services Demonstration Evaluation - states	Form and Instruction	New	Available
Form CMS-10487 Medicaid Emergency Psychiatric Services Demonstration Evaluation - IMDs	Form and Instruction	New	Repair queued
Form CMS-10487 Medicaid Emergency Psychiatric Services Demonstration Evaluation - Facilities	Form and Instruction	New	Available
Parts_A-B.pdf	Supporting Statement B	Uploaded 2013-12-23	Available
Attachment_K.pdf	Supplementary Document	Uploaded 2013-12-18	Available
Attachment_I.pdf	Supplementary Document	Uploaded 2013-12-23	Available
Attachment_H.pdf	Supplementary Document	Uploaded 2013-12-23	Available
Attachment_G.pdf	Supplementary Document	Uploaded 2013-12-23	Available
Attachment_F.pdf	Supplementary Document	Uploaded 2013-12-23	Available
Crosswalks_508-cert_111813.pdf	Supplementary Document	Uploaded 2013-12-18	Available
CMS-10487 Supporting Statement A_rev_clean_022414.docx	Supporting Statement A	Uploaded 2014-02-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209880	Medicaid Emergency Psychiatric Services Demonstration Evaluation - states	Form and Instruction	New
209879	Medicaid Emergency Psychiatric Services Demonstration Evaluation - IMDs	Form and Instruction	New
209878	Medicaid Emergency Psychiatric Services Demonstration Evaluation - Facilities	Form and Instruction	New

ICR Details

OMB Control No: 0938-1225	ICR Reference No: 201312-0938-018
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 21182
Title: Medicaid Emergency Psychiatric Services Demonstration Evaluation
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/18/2014
	Date Received in OIRA: 12/23/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2017	36 Months From Approved
Responses	2,754	0	0
Time Burden (Hours)	2,613	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Inpatient care provided to adults in institutions for mental disease (IMDs) are excluded from federal Medicaid matching funds. The Affordable Care Act (ACA) authorized the Medicaid Emergency Psychiatric Demonstration (MEPD) to provide Medicaid payment for inpatient services provided by private IMDs to adults with emergency psychiatric conditions. Twelve states and 27 IMDs are participating in the MEPD. The ACA mandates an evaluation of the MEPD that includes assessment of (A) access to inpatient mental health services under the Medicaid program; average lengths of inpatients stays; and emergency room (ER) visits; (B) discharge planning by participating IMDs; (C) the impact of the MEPD on the costs of the full range of mental health services (including inpatient, emergency, and ambulatory care); and (D) the percentage of consumers with Medicaid coverage who are admitted to IMDs as a result of the MEPD as compared to those admitted to the IMDs through other means. The evaluation must include a recommendation regarding whether the MEPD should be continued after December 31, 2013, and expanded on a national basis. The evaluation involves a mixed-methods approach. Quantitative data from administrative records provided by participating states, IMDs, and referring ERs will address ACA areas A, C, and D. Qualitative data will assess discharge planning processes and, to ensure compliance with demonstration requirements, processes used to determine the existence of an emergency psychiatric condition, need for inpatient admission, and stabilization. Qualitative data will be collected through document reviews, telephone interviews with state project directors and beneficiaries, and site visits that include medical record reviews and interviews with staff of participating IMDs and associated general hospitals and ERs.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 45205	07/26/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 73546	12/06/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Medicaid Emergency Psychiatric Services Demonstration Evaluation - Facilities	CMS-10487, CMS-10487, CMS-10487	Key Informant Interview Protocols ,   Sampling Procedures for Medical Record Review ,   Medical Record Review Tools
Medicaid Emergency Psychiatric Services Demonstration Evaluation - IMDs	CMS-10487, CMS-10487, CMS-10487, CMS-10487	Key Informant Interview Protocols ,   Sampling Procedures for Medical Record Review ,   Medical Record Review Tools ,   Beneficiary Interview Protocol, Consent Form; and Recruiment Script
Medicaid Emergency Psychiatric Services Demonstration Evaluation - states	CMS-10487	Key Informant Interview Protocols

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,754	0	0	2,754	0	0
Annual Time Burden (Hours)	2,613	0	0	2,613	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Based on changes made as a result of the pilot test, the burden estimate has increased since the 60-day Federal Register notice was published, by a total of 567 hours, from a total of 2,046 hours to 2,613 hours.The largest increase is due to the pilot test's demonstration of the need for facility staff to assist the evaluation contractor in finding information in the medical records. To reflect this need, we have added 2.5 hours of staff time to assist with the medical record reviews at each of the 81 facilities that we visit in each of the two rounds of site visits, for a total increase in burden of 405 hours. A further increase in burden is due to the pilot test's demonstration of the need to obtain additional informed consents for beneficiary interviews from IMD staff. We originally asked for only 10 consents in hopes of interviewing 5 beneficiaries from each IMD. Difficulties in reaching many of the beneficiaries in the pilot test, however, revealed the need to obtain additional consents in order to complete five interviews.

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Annual Cost to Federal Government: $1,367,114

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/23/2013

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