CMS-10398 #62 Quarterly Progress Report (QPR) Template

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

62 - Sec1003QtrlyReportForm20200221-4.xlsx

GenIC #62 (New): Data Collection for Section 1003 of the SUPPORT Act

OMB: 0938-1148

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Overview

Quarterly Report Instructions
Tables I-1-5.
Tables II-1-3.
Table III.
Table IV.
Table V.
Lookup Tables 1-4.

Sheet 1: Quarterly Report Instructions
OMB 0938-1148
Quarterly Report for Substance Use-Disorder Prevention that Promotes
Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act:
Section 1003 Demonstration Project to Increase Substance Use Provider Capacity
State:
[Enter State Name]
Name of Project Director:
[Enter Project Director]
Name of party submitting report if not Project Director:
[Enter Submittor]
Date:
[Enter Date]
SECTION I: Milestones
In the past three months, have you started or completed activities related to the following?:
1) Activities that support assessment of the mental health and substance use disorder (SUD) treatment needs of the state to determine the extent to which providers are needed to address the SUD treatment and recovery needs of Medicaid beneficiaries; please enter in Table I-1 (see Table I-1-5 Tab).
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If yes, please describe in Table I-1.
2) Activities that support the development of state infrastructure (i.e., recruiting providers, providing training or technical assistance); please enter in Table I-2 (see Table I-1-5 Tab).
[Pull Down to Select]
If yes, please describe in Table I-2
3) Activities to improve reimbursement, training, and education to expand Medicaid provider capacity to deliver SUD treatment and recovery services; please enter in Table I-3 (see Table I-1-5 Tab).
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If yes, please describe in Table I-3.
4) Activities to develop projections regarding the extent to which the state would increase the number and capacity of Medicaid providers offering SUD treatment or recovery services, as well as the willingness of Medicaid providers to offer SUD treatment or recovery; please enter in Table I-4 (see Table I-1-5 Tab).
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If yes, please describe in Table I-4.
5) Activities related to the analysis comparing the state’s SUD prevalence with the national average, as measured by per capita opioid drug overdoses and the prevalence of substance use and opioid-related diagnoses among Medicaid enrollees; please enter in Table I-5 (see Table I-1-5 Tab).
[Pull Down to Select]
If yes, please describe in Table I-5.
SECTION II: Enrollee Data
Please indicate whether your state intends to target the subpopulations below per your application. Select "Yes" for all applicable subpopulations in Table II-1 (see Table II-1-3. Tab).
Metric: Medicaid Beneficiaries With Newly Initiated SUD Treatment/Diagnosis: number of beneficiaries with an SUD diagnosis and an SUD-related service during the measurement period but not in the three months before the measurement period in Table II-2 (see Table II-1-3. Tab).
Metric: Medicaid Beneficiaries With SUD Diagnosis (Quarterly): number of beneficiaries with an SUD diagnosis and an SUD-related service during the measurement period in Table II-3 (see Table II-1-3. Tab).
SECTION III: Section III: Substance Use Disorder Treatment or Recovery Services Data
SUD Services by Category: Please include number of beneficiaries in the measurement period receiving any SUD treatment service during the measurement period in Table III (see Table III. Tab).
Are there any known reporting issues for data provided in Section III? If yes, please describe below.
[Please enter text]
SECTION IV: Barrier Data
Please describe any efforts in the past quarter to address barriers to providers treating Medicaid beneficiaries with SUD (e.g., provider unwillingness to serve Medicaid beneficiaries, lack of providers’ recognition of opioid use disorder in their enrollee populations, and provider understanding of medication-assisted treatment) in Table IV (see Table IV. Tab).
Please describe any activities funded through the grant in the past quarter to address reimbursement or financial incentives to encourage providers to treat patients with or at risk for SUD.
[Please enter text]
SECTION V: Additional Information
Please describe any resource changes in the past quarter (new staff, loss of key staff, new contracts for information technology [IT] infrastructure, relevant partnerships, other) in Table V (see Table V. Tab).
If there is anything else that the Centers for Medicare & Medicaid Services should be aware of related to this grant, then please describe below.
[Please enter text]
PRA Disclosure Statement: Planning grant states participating in the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act: Section 1003 Demonstration Project to Increase Substance Use Provider Capacity Demonstration Project do not currently submit specific Substance Use Disorder information necessary for the statutorily required reports (Section 1903(6)(B) of the Social Security Act) that CMS must submit to Congress. In order to meet the Congressionally mandated reporting requirements, CMS must collect this information, via a standardized template. Planning grant states are required to report this information as a condition of grant funding. The process for collecting information and completing the Quarterly Progress Report (QPR) template is intended to minimize the paperwork burden by or for the Federal Government, and to strengthen the partnership between the Federal Government and the Grantees. Grantees are provided with the QPR template in Excel format, and associated instructions. The completed QPR Excel spreadsheets will be submitted to the Federal Government by the Grantees via an online web-based document sharing repository, thereby streamlining data collection and minimizing paperwork burden.

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 0938-1148 (CMS-10398 # 62). The time required to complete this information collection is estimated to average 14 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS website. 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.
Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.

Sheet 2: Tables I-1-5.
Table I-1. Mental Health and Substance Use Disorder Assessment Activities



Activity Status Grant Completion Date Anticipated Completion Date Risks and Challenges
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Table I-2. State Infrastructure Development Activities



Activity Status Grant Completion Date Anticipated Completion Date Risks and Challenges
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Table I-3. Provider Reimbursement, Training, and Education Activities



Activity Status Grant Completion Date Anticipated Completion Date Risks and Challenges
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Table I-4. Provider Volume and Capacity Projection Activities



Activity Status Grant Completion Date Anticipated Completion Date Risks and Challenges
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Table I-5. State and National Analysis Comparisons



Activity Status Grant Completion Date Anticipated Completion Date Risks and Challenges
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Sheet 3: Tables II-1-3.
Table II-1. Target Populations for Analysis



Subpopulation Intention To Target


Infants with neonatal abstinence syndrome Yes


Aged 12–21 years Yes


Pregnant Yes


Postpartum Yes


Dual eligible under Medicare and Medicaid Yes


American Indian/Alaska Native Yes


Table II-2. Beneficiaries with Newly Initiated SUD Diagnosis



Population Denominator Numerator or Count Rate/Percentage Are there any known reporting issues? If yes, please describe.
All Medicaid enrollees [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Opioid use disorder subpopulation [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Infants with neonatal abstinence syndrome [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Aged 12–21 years [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Pregnant [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Postpartum [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Dual eligible under Medicare and Medicaid [Please enter text] [Please enter text] [Please enter text] [Please enter text]
American Indian/Alaska Native [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Table II-3. Beneficiaries with SUD Diagnosis - Quarterly



Population Denominator Numerator or Count Rate/Percentage Are there any known reporting issues? If yes, please describe.
All Medicaid enrollees [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Opioid use disorder subpopulation [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Infants with neonatal abstinence syndrome [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Aged 12–21 years [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Pregnant [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Postpartum [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Dual eligible under Medicare and Medicaid [Please enter text] [Please enter text] [Please enter text] [Please enter text]
American Indian/Alaska Native [Please enter text] [Please enter text] [Please enter text] [Please enter text]

Sheet 4: Table III.
Table III. Beneficiaries Receiving SUD Treatment




Service Category No. of Enrollees With SUD Receiving Care in This Category—Fee for Service No. of Enrollees With SUD Receiving Care in This Category— Managed Care No. of Enrollees Who Received Care in This Category This Quarter but Not the Previous SUD Provider Availability: No. of providers who were enrolled in Medicaid and qualified to deliver SUD services during the measurement period SUD Provider Availability-MAT: No. of providers who were enrolled in Medicaid and qualified to deliver SUD services during the measurement period and who meet the standards to provide buprenorphine or methadone as part of MAT
Physicians' services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Services provided by other licensed practitioners [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Diagnostic and rehabilitative services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Inpatient services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Outpatient hospital services (including emergency department services) [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Prescription drugs [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Targeted case management for individuals with SUD [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Targeted case management for individuals with mental disorder and SUD [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Nurse practitioner services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Nurse midwife services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Preventive services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Clinic services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Certified Community Behavioral Health Center services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Home health services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Private duty nursing services [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]
Total [Please enter text] [Please enter text] [Please enter text] [Please enter text] [Please enter text]

Sheet 5: Table IV.
Table IV. Activities to Address Barriers

Barriers Addressed by Grant Funds Type of Barrier
(e.g., provider, Medicaid-eligible beneficiary, Medicaid system)		 Activities and Results
Provider Capacity [Please enter text] [Please enter text]
Provider Willingness [Please enter text] [Please enter text]
Financial [Please enter text] [Please enter text]
Access [Please enter text] [Please enter text]
Care Provision [Please enter text] [Please enter text]
Other [Please enter text] [Please enter text]
Other [Please enter text] [Please enter text]

Sheet 6: Table V.
Table V. Resource Changes
Changes Describe (if applicable)
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Sheet 7: Lookup Tables 1-4.
Lookup Table 1. Drop Down Options
Dropdown Options
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Yes
No
Lookup Table 2. Activity Status
Activity Status
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In Progress
Completed
Lookup Table 3. Barriers
Barriers
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Provider Capacity
Provider Willingness
Financial
Access
Care Provision
Other
N/A
Lookup Table 4. Resource Changes
Changes
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New Staff
Loss of Key Staff
New Contracts for IT Infrastructure
Relevant Partnerships
Other
N/A
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