Generic Supporting Statement
Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions
(CMS-10398, OMB 0938-1148)
Generic Information Collection # 59 (New)
Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations
Implementation Plan and Monitoring Reports Documents, Templates and Assessment Report
Center for Medicaid and CHIP Services (CMCS)
Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS) works in partnership with States to implement the Medicaid and the Children’s Health Insurance Program (CHIP). Together these programs provide health coverage to millions of Americans. Medicaid and CHIP are based in Federal statute, associated regulations and policy guidance, and the approved State plan documents that serve as a contract between CMS and States about how Medicaid and CHIP will be operated in that State. CMS works collaboratively with States in the ongoing management of programs and policies, and CMS continues to develop implementing guidance and templates for States to use to elect new options available because of the Affordable Care Act or to comply with new statutory provisions. CMS also continues to work with States through other methods to further the goals of health reform, including program waivers and demonstrations, and other technical assistance initiatives.
Under section 1115(a) of the Social Security Act, the Secretary of Health and Human Services (“Secretary”) may authorize a state to conduct experimental, pilot, or demonstration projects that, in the judgment of the Secretary, promote the objectives of title XIX of the Act. The Secretary (1) may, under section 1115(a)(1), waive provisions in section 1902 of the Act; and/or (2) may, under section 1115(a)(2)(A), authorize federal matching funds for state expenditures that would not otherwise be matchable (i.e., expenditure authority) under section 1903 of the Act. Section 1902 of the Act lists what elements the Medicaid state plan must include, such as provisions relating to eligibility, beneficiary protections, benefits and services and cost sharing. Section 1903, “Payments to States,” describes expenditures that may be “matched” with federal title XIX dollars, allowable sources of non-federal share, and managed care requirements.
On November 13, 2018, CMS released a letter #18-011 to all State Medicaid Directors announcing opportunities to design innovative service delivery systems for providing community-based services, for adults with a serious mental illness (SMI) or children with a serious emotional disturbance (SED) who are receiving medical assistance, as mandated by section 12003 of the 21st Century Cures Act (Cures Act). Section 12003 of the Cures Act also mandated that this State Medicaid Director (SMD) letter include opportunities for demonstration projects under section 1115(a) of the Social Security Act (the Act) to improve care for adults with SMI and/or children with SED.
Section 1115 demonstration monitoring and evaluation Special Terms and Conditions (STC), and the letter #18-011, make clear that CMS remains committed to ensuring state accountability for the health and well-being of Medicaid enrollees and that monitoring and evaluation are important for understanding the outcomes and impacts of approaches to Medicaid SMI demonstrations. For this purpose, CMS is undertaking efforts to help states monitor the elements of these demonstrations, while giving them the flexibility to adapt to changing conditions in their states. States with approved SMI demonstrations are required to develop implementation and monitoring plans, including monitoring metrics, monitoring protocol, regular monitoring reports describing their implementation progress and availability assessments.
In addition, the special terms and conditions (STC) for these 1115 demonstrations address that states are required to submit in their regular monitoring reports, information on milestones and performance measures that they elected to represent key indicators of progress toward meeting the goals for the demonstrations.
Furthermore, to improve the quality and efficiency of the reporting requirements for SMI/SED demonstrations, CMS in conjunction with state advisory groups developed a set of standardized monitoring tools for states to use for their regular reporting, including:
The Medicaid Section 1115 SMI Demonstration Implementation Plan (this is one-time submission);
The Medicaid Section 1115 SMI Demonstration monitoring protocol (this is one-time submission);
The Medicaid Section 1115 SMI Demonstration monitoring report template;
The Medicaid Section 1115 SMI Demonstration metrics workbook/planned metrics; and
The Medicaid Section 1115 SMI Current Availability Assessment.
As specified in official 1115 policy communications to states, such as the SMD letter #18-011 and the section 1115 SMI/SED demonstration states’STCs: In accordance with 42 CFR 431.428 states must submit all post-approval deliverables as stipulated by CMS and within the timeframes outlined within the STCs for the specific Medicaid 1115 State Demonstration.
The STCs require states that are testing approaches to SMI/SED demonstrations to submit to CMS for approval a draft implementation plan, and a monitoring protocol with quantitative metrics developed collaboratively between CMS and the state. States with SMI/SED section 1115 demonstrations are required per the STCs to report performance on the metrics in quarterly and annual monitoring reports.
For 1115 SMI/SED demonstrations states will include in their section 1115(a) demonstration reports, information detailing milestones and performance measures representing key indicators of progress toward meeting the goals for this initiative. Participating states will report on a common set of measures and the states and CMS will agree to additional measures and measure concepts specific to a particular state’s demonstration parameters.
The letter #18-011 states that for these 1115 demonstrations, CMS will provide guidance to participating states on development of monitoring protocols that will identify expectations for quarterly and annual monitoring reports, including agreed upon performance measures, measure concepts, and qualitative narrative summaries.
Similar guidance and templates for other types of section 1115 demonstrations have been approved under other generic packages, such as the SUD Gen IC (specifically, CMS-10398 #53), which includes:
The Medicaid Section 1115 SUD Demonstration Implementation Plan (this is one-time submission);
The Medicaid Section 1115 SUD Demonstration monitoring protocol (this is one-time submission);
The Medicaid Section 1115 SUD Demonstration monitoring report template; and
The Medicaid Section 1115 SUD Demonstration metrics workbook/planned metrics.
However, while the SMI/SED templates are similar in structure to the templates approved under other generic packages, there is no duplication of data collection or reporting requirements. This January 2020 package is for the following templates and metrics specific to the section 1115 SMI/SED demonstration opportunity:
The Medicaid Section 1115 SMI Demonstration Implementation Plan (this is one-time submission);
The Medicaid Section 1115 SMI Demonstration monitoring protocol template (this is one-time submission);
The Medicaid Section 1115 SMI Demonstration monitoring report template;
The Medicaid Section 1115 SMI Demonstration monitoring workbook/planned metrics; and
The Medicaid Section 1115 SMI Current Availability Assessment.
The templates, metrics and current availability assessment are also consistent with the requirements of the STCs to which approved states have agreed. In addition, CMS convened a State Advisory Group on May 16, 2019, to review and provide comments on these templates, their content and the metrics. CMS made adjustments in consideration of those comments, including:
Re-categorized four metrics from “required” to “recommended” in the Medicaid Section 1115 SMI Demonstration metrics monitoring workbook/planned metrics based on feedback that data required to report on these metrics may be difficult for states to collect
Provided a cut-off date to determine if beneficiaries falls under the SMI or SED category in the Medicaid Section 1115 SMI Current Availability Assessment.
Clarified that Medicaid beneficiaries who are eligible to receive a service—rather than those who receive a service—should be included in calculations/counts for the Medicaid Section 1115 SMI Current Availability Assessment
Other feedback from the State Advisory Group that did not result in adjustments included:
State Advisory Group members requested CMS provide guidance on defining beneficiaries with SMI and SED. States will identify the populations covered by the demonstration, and individually establish data definitions for beneficiaries with SMI and SED.
State Advisory Group members suggested CMS remove data elements from the Medicaid Section 1115 SMI Current Availability Assessment. States that are unable to provide data for certain elements may use the “Notes” columns in each section of the template to explain any missing or incomplete data the state is unable to report.
CMS believes that the templates, metrics, and current availability assessment are noncontroversial, as they are consistent with the requirements of the STCs to which approved states have agreed and are similar to the templates currently used by states for other section 1115 demonstrations. CMS does not anticipate any adverse reaction from interested parties.
Respondents (State Medicaid Agencies) will manually populate the necessary data fields in the templates and submit to the CMS project officer and monitoring lead electronically via the Performance Metrics Database & Analytics (PMDA). By incorporating these Medicaid Section 1115 SMI/SED demonstration-monitoring documents into the Medicaid 1115 PMDA workflow, submissions are parsed and validated, notifying the state of any upfront potential problems with their submissions, reducing downstream communication, and subsequent needs for clarification or modifications to the templates and metrics.
The PMDA application, which issued for submission, will historically retain all monitoring data and related documents, reducing the number of duplicate records required and the need for respondents to retain records.
The characteristics of the monitoring and evaluation requirements for each Medicaid section 1115 demonstration project are determined as part of CMS and state negotiations that culminate the demonstration’s STCs. These STCs include a section describing the monitoring, evaluation requirements and corrective actions. Together, these STCs describe the process by which states should submit these required reports.
Per each demonstration’s STCs, states are required to submit to CMS quarterly monitoring reports within 60-days of the end of each quarter, as well as an annual report within 90-days of a demonstration year’s completion.
Currently, there are inconsistencies in the manner in which states submit their required monitoring reports, in significant part due to minimal standardization of the collection instrument. This causes time- consuming reviews and does not support efficient or robust monitoring and assessment across the section 1115 demonstration portfolio.
To support more efficient, timely and accurate review of states’ Medicaid Section 1115 SMI/SED demonstrations monitoring reports submissions, CMS has standardized the reporting methodology and together with automation of the reporting submission will support:
Insight into an approved State’s approach to implementation of the SMI/SED included in the Letter #18-011, which crosswalks to SMI/SED requirements in the monitoring metrics and reports, providing a clear basis for assessing the state’s implementation of such requirements.
Consistency of monitoring and evaluation of requirements and other policy approaches that complement SMI/SED requirements.
Streamlined communication and shorter timeframes for state development and CMS approval of implementation and monitoring plans for SMI/SED demonstrations,
Accuracy in state reporting and reduction in timeframes for state reporting and CMS review of monitoring metrics and reports.
More robust evaluation in so much as it is informed by a clear implementation plan and monitoring data.
Improvements in needed mid-course corrections and the identification and diffusion of best practices under SMI/SED demonstrations.
To achieve these goals, CMS has developed for the Medicaid section 1115 SMI/SED demonstrations standardized implementation plan, current availability assessment, and monitoring reporting template and performance metrics, as follows:
Medicaid Section 1115 SMI/SED Implementation Plan
The state will submit the Medicaid Section 1115 SMI/SED demonstration Implementation Plan to provide information about implementation of the state’s demonstration requirements and to respond to each prompt listed in the tables.
The information in the implementation plan flows down from the state’s SMI Special Terms and Conditions (STC). It creates an implementation framework that crosswalks to the all requirement segments of the Medicaid section 1115 SMI/SED demonstration Monitoring Protocol Template.
Medicaid Section 1115 SMI/SED Monitoring Protocol Template
The state will use the Medicaid section 1115 SMI/SED demonstration Monitoring Protocol Template to develop its Monitoring Protocol that specifies the details of the state’s monitoring plans for the demonstration. It is comprised of two components – qualitative and quantitative (metrics) reporting plans. The metrics component of the Monitoring Protocol is described below under Monitoring Metrics Template.
The Medicaid Section 1115 SMI/SED demonstration Monitoring Protocol helps the state specify the methods of data collection and timeframes for reporting on the state’s progress on required measures and milestones. In addition, the Medicaid section 1115 SMI/SED demonstration Monitoring Protocol helps states identify the demonstration baseline and performance targets to be achieved by the end of the demonstration.
Medicaid Section 1115 SMI/SED Demonstration Monitoring Report Template
The Monitoring Report Template mirrors the Monitoring Protocol, and like the Protocol, it is comprised of qualitative and quantitative (metrics) performance information that the state reports to CMS on a quarterly and annual basis. Performance values on the metrics in the approved Monitoring Protocol are reported in the Monitoring Metrics Template described below.
Medicaid Section 1115 SMI/SED Demonstration Monitoring Workbook
The Monitoring Metrics Workbook is one of the two components of both the Monitoring Protocol and the Monitoring Report Templates described above. It is an Excel file which contains a set of metrics for the SMI/SED demonstrations.
For the Monitoring Protocol, the state will review the metrics listed in the ‘Protocol’ tab of the Medicaid section 1115 SMI/SED demonstration Metrics Workbook and the accompanying metrics technical specifications, and use the template to identify the metrics it plans to report, including any additional state-identified metrics. The state also identifies annual goals and targets, as well as any deviations from CMS technical specifications. The state’s performance on the CMS approved metrics is reported on a quarterly and annual basis under the subsequent ‘Report’ tabs.
Medicaid Section 1115 SMI/SED Current Availability Assessment
The purpose of the Medicaid section 1115 SMI/SED demonstration Current Availability Assessment template is intended to help states meet the requirements outlined in the SMDL #18-011 to provide annual assessments of the availability of mental health services throughout the state. In addition, the purpose of the assessment of the availability of mental health services is to help CMS understand and gather data on the state’s SMI/SED population and the services available to them. The assessment will allow CMS and the state to monitor how the state’s available mental health services evolve over the duration of the demonstration.
The availability assessment is completed with the implementation plan and is updated every year and submitted to CMS with the annual monitoring reports.
No deviations from the generic PRA request.
The total approved burden ceiling of the generic ICR is 154,104 hours, and CMS previously requested to use 59,141 hours, leaving our burden ceiling at 94,963 hours.
Each state submits three quarterly and one annual report per year. Annual reports require somewhat higher level of effort than quarterly reports due to additional metrics reported.
Each state’s first report will require some additional effort for programming/calculating the metrics; all subsequent reports will require a lower level of effort.
Estimates are provided by state by year, given that CMS can approve demonstrations for varying lengths of time.
All templates are completed by a health services manager and/or a computer programmer.
Wage Estimates
To derive average costs, we are using data from the U.S. Bureau of Labor Statistics’ May 2019 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes/current/oes_nat.htm). In this regard, the following table presents the mean hourly wage, the cost of fringe benefits and overhead (calculated at 100 percent of salary), and the adjusted hourly wage.
Occupation Title |
Occupation Code |
Mean Hourly Wage ($/hr) |
Fringe Benefits and Overhead ($/hr) |
Adjusted Hourly Wage ($/hr) |
Computer programmer |
15-1251 |
44.53 |
44.53 |
89.06 |
Health services manager |
11-9111 |
55.37 |
55.37 |
110.74 |
As indicated, we are adjusting our employee hourly wage estimates by a factor of 100 percent. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. Nonetheless, we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method.
Collection of Information Requirements and Associated Burden Estimates
Currently, there are 7 (seven) states with an approved Medicaid Section SMI demonstration for reporting, however, we anticipate this number to expand somewhat, so for the purpose of calculating burden we are estimating ten (10) states.
The Medicaid Section 1115 SMI/SED Implementation Plan
The Implementation Plan consists of a one-time submission for year-one of the demonstration.
The Implementation Plan would be developed by a health services manager and a computer programmer. We estimate it would take a total of 20 hours (per state) to complete one response. This would consist of 8 hours at $89.06/hr for a computer programmer to review technical specifications and 12 hours at $110.74/hr for a health services manager to: complete the metrics workbook (4 hr), the narrative portion by reviewing the monitoring report template and budget neutrality materials for attestations (4 hr), QA the monitoring protocol (4 hr). and submit the implementation plan to PMDA.
In aggregate, we estimate a burden of 200 hours (10 states x 20 hr) at a cost of $20,414 ([8 hr x $89.06/hr x 10 states] + [12 hr x $110.74/hr x 10 states]).
Monitoring protocol consists of a one-time submission for year-one of the demonstration. The protocol would be developed by a health services manager and a computer programmer:
We estimate it would take a total of 14 hours (per state) at $110.74/hr for a health services manager to: complete the implementation plan template (8 hr) and compile relevant documents (4 hr), QA the implementation plan (2 hr) and submit the implementation plan to PMDA.
In aggregate, we estimate a burden of 140 hours (10 states x 14 hr) at a cost of $15,504 (140 hr x $110.74/hr).
We aimed to streamline reporting by allowing states to check a box if it has no updates/changes to report. We assumed that for approximately 1/4 of the reports, the average state would elect not to report updates.
For the annual report, we estimate it would take 12 hours at $110.74/hr for a health services manager to prepare and submit the report per state per demonstration year. In aggregate, we estimate an annual report burden of 120 hours (1 report x 12 hr x 10 states) at a cost of $13,289 (120 hr x $110.74/hr). This also includes time to submit the template to PMDA.
For each quarterly report, we estimate it would take 8 hours at $110.74/hr for a health services manager to prepare and submit each report per state per demonstration year. In aggregate, we estimate a quarterly report burden of 240 hours (3 reports x 8 hr x 10 states) at a cost of $26,578 (240 hr x $110.74/hr).
Consequently, we estimate a total burden of 360 hours (120 hr + 240 hr) at a cost of $39,867 ($13,289 + $26,578).
Low LOE metrics (for 15 metrics total: 4 annual metrics, 8 quarterly metrics, and 3 health IT metrics):
24 hours for initial report per state for the 1st year of the demonstration only (assume it’s annual and includes all metrics)
8 hours for each subsequent annual report per state
4 hours for each subsequent quarterly report per state
Medium LOE metrics (6 metrics total: 4 annual metrics, 2 quarterly metrics):
48 hours for initial report per state for the 1st year of the demonstration only (assume it’s annual and includes all metrics)
4 hours
for each subsequent annual report per state
4 hours for each subsequent quarterly report
High LOE metrics (5 annual metrics):
56 hours for initial report per state 1st year of the demonstration only (assume it’s annual and includes all metrics)
4 hours for each subsequent annual report per state
4 hours for each subsequent quarterly report per state.
Demonstration Year 1
Initial Report Quarterly Reports
24 hr (low) 4 hr (low)
48 hr (medium) 4 hr (medium)
56 hr (high) 4 hr (high)
128 hr 12 hr
164 hr per state = ([128 hr x 1 initial report] + [12 hr x 3 quarterly reports]). In aggregate we estimate a burden of 1,640 hours (164 hr x 10 states) at a cost of $146,058 (1,640 hr x $89.06/hr for a computer programmer). This also includes time to submit to PMDA.
Subsequent Years
Annual Report Quarterly Reports
8 hr (low) 4 hr (low)
4 hr
(medium) 4 hr (medium)
4 hr (high) 4 hr (high)
16 hr 12 hr
52 hr per state = ([16 hr x 1 annual report] + [12 hr x 3 quarterly reports]). In aggregate we estimate a burden of 520 hours (52 hr x 10 states) at a cost of $46,311 (520 hr x $89.06/hr for a computer programmer).
The Metrics Template becomes the Metric Workbook after States enter respective data and submit it via PMDA. Therefore, we don’t expect any additional burden association with the Workbook.
This assessment is submitted once a year along with the annual reports.
Year 1
We estimate it would take 20 hours (per state) at $110.74/hr for a health services manager to complete the availability assessment and submit to PMDA. In aggregate, we estimate a burden of 200 hours (10 states x 20 hr) at a cost of $22,148 (200 hr x $110.74/hr).
Subsequent Years
We estimate it would take 8 hours per state, in view that states will know where to collect all the necessary data for the assessment. In aggregate, we estimate a burden of 80 hours (10 states x 8 hr) at a cost of $8,859 (80 hr x $110.74/hr).
PMDA and Instruction Videos
We expect states to submit via PMDA their respective Medicaid Section 1115 SMI implementation plan, monitoring protocol, quarterly and annual reports (here forward referred to as ’monitoring documents’ and the current availability assessment reports. The 4th quarter report may be included in the annual report. We expect to maintain the same number of reports.
No statistical methods are employed in information collection and in addition, the quarterly and annual reporting data fields are not duplicating any other collections.
We expect the time for each state to complete the submission of the Medicaid Section 1115 SMI monitoring documents via PMDA to be the same or similar to the time it takes today for states to submit other deliverables and each state may approximately spend 3 to 5 minutes per submission.
Each state/territory with an approved Medicaid Section 1115 SMI/SED demonstration will be required to complete and submit via PMDA the monitoring documents established by CMS, aimed to support more efficient, timely and accurate review of states’ Medicaid Section 1115 SMI/SED demonstrations monitoring document s submissions. The burden is associated with submitting the Medicaid Section 1115 SMI monitoring report protocol/templates/and metrics provided to states/territories by CMS to assist in this effort, as well as the burden related to states viewing as necessary any instructions.
As mentioned above, each demonstration is estimated to need approximately 3 to 5 minutes per submission quarterly/annually at $110.74/hr for a Health Services Manager to submit via PMDA the necessary Medicaid Section 1115 SMI implementation plan and monitoring documents. The burden is subsumed within the preceding estimates for the Medicaid Section 1115 SMI/SED Monitoring Protocol Template, the Medicaid Section 1115 SMI/SED Demonstration Monitoring Report Template, the Medicaid Section 1115 SMI/SED Monitoring Workbook/Planned Metrics, the Medicaid Section 1115 SMI/SED Current Availability Assessment along with the time (20 min) to review the “instructions” and watch the respective videos.
Summary of Collection of Information Requirements and Burden Estimates
Requirement |
No. Respondents |
Total Responses |
Time per Response (hours) |
Total Annual Time (hours) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
SMI/SED Implementation Plan |
10 |
10 |
20 |
200 |
Varies (89.06 and 110.74) |
20,414 |
SMI/SED Demonstration Monitoring Protocol |
10 |
10 |
14 |
140 |
110.74 |
15,504 |
SMI/SED Demonstration Monitoring Report Template (Annual) |
10 |
10 |
12 |
120 |
110.74 |
13,289 |
SMI/SED Demonstration Monitoring Report Template (Quarterly) |
10 |
30 |
8 |
240 |
110.74 |
26,578 |
SMI/SED Demonstration Monitoring Metrics Workbook (Year 1) |
10 |
40 |
164 (128 hr annual + 12 hr per quarter for 3 quarters) |
1,640 |
89.06 |
146,058 |
SMI/SED Demonstration Monitoring Metrics Workbook (Subsequent Years) |
52 (16 hr annual + 12 hr per quarter for 3 quarters) |
520 |
89.06 |
46,311 |
||
SMI/SED Current Availability Assessment (Annual -Year 1) |
10 |
10 |
20 |
200 |
110.74 |
22,148 |
SMI/SED Current Availability Assessment (Subsequent Years) |
8 |
80 |
110.74 |
8,859 |
||
TOTAL |
10 |
Varies |
3,140 |
Varies |
299,161 |
Information Collection Instruments and Instruction/Guidance Documents
Video: Overview of the Standardized Monitoring Report Process (8:59 minutes) (see link)
Video: Populating and Submitting Monitoring Templates (8:24 minutes) (see link)
Video: Downloading 1115 Monitoring Report Templates (2:59 minutes) (see link)
Medicaid Section 1115 SMI/SED Implementation Plan Template (smi-impl-plan-template.pdf)
Medicaid Section 1115 SMI/SED Demonstration Monitoring Report Template (1115-SMI-Monitoring-Report-Template.docx/.pdf)
Section 1115 SMI/SED Demonstrations Monitoring Metrics Technical Specifications (1115_SMI_Metrics_Tech_specs_v1.pdf)
Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol Template (1115-SMI-Monitoring-Protocol-Template.docx/.pdf)
Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol Instructions (1115-SMI-Monitoring-Protocol-Template-Instructions.docx/.pdf)
Medicaid Section 1115 SMI/SED Demonstration Monitoring Report Instructions (1115-SMI-Monitoring-Report-Template-Instructions.docx/.pdf)
Medicaid Section 1115 SMI/SED Demonstration Monitoring Workbook (1115-SMI-Monitoring-Workbook_013020.xlsm)
Medicaid Section 1115 SMI/SED Current Availability Assessment (1115-smi-current-availability-assessment_013020.xlsm)
SMI_SED_HIT Plan Instructions (SMI_SED_HIT_Plan_Instructions.pdf)
January 11, 2018 – State Medicaid Directors letter #18-011 (smd18011.pdf)
Approval is requested within 30 days, by May 21, 2020.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |