Form CMS-10398 #59 CMS-10398 #59 Implementation Plan Template

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]

Section 1115 SMI/SED Demonstration Implementation Plan
July 23, 2019
Overview: The implementation plan documents the state’s approach to implementing SMI/SED
demonstrations. It also helps establish what information the state will report in its quarterly and
annual monitoring reports. The implementation plan does not usurp or replace standard CMS
approval processes, such as advance planning documents, verification plans, or state plan
amendments.
This template only covers SMI/SED demonstrations. The template has three sections. Section 1
is the uniform title page. Section 2 contains implementation questions that states should answer.
The questions are organized around six SMI/SED reporting topics:
1. Milestone 1: Ensuring Quality of Care in Psychiatric Hospitals and Residential Settings
2. Milestone 2: Improving Care Coordination and Transitioning to Community-Based Care
3. Milestone 3: Increasing Access to Continuum of Care, Including Crisis Stabilization
Services
4. Milestone 4: Earlier Identification and Engagement in Treatment, Including Through
Increased Integration
5. Financing Plan
6. Health IT Plan
State may submit additional supporting documents in Section 3.
Implementation Plan Instructions: This implementation plan should contain information
detailing state strategies for meeting the specific expectations for each of the milestones included
in the State Medicaid Director Letter (SMDL) on “Opportunities to Design Innovative Service
Delivery Systems for Adults with [SMI] or Children with [SED]” over the course of the
demonstration. Specifically, this implementation plan should:
1. Include summaries of how the state already meets any expectation/specific activities
related to each milestone and any actions needed to be completed by the state to meet all
of the expectations for each milestone, including the persons or entities responsible for
completing these actions; and
2. Describe the timelines and activities the state will undertake to achieve the milestones.
The tables below are intended to help states organize the information needed to demonstrate they
are addressing the milestones described in the SMDL. States are encouraged to consider the
evidence-based models of care and best practice activities described in the first part of the SMDL
in developing their demonstrations.
The state may not claim FFP for services provided to Medicaid beneficiaries residing in IMDs,
including residential treatment facilities, until CMS has approved a state’s implementation plan.
1

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]

Memorandum of Understanding: The state Medicaid agency should enter into a Memorandum
of Understanding (MOU) or another formal agreement with its State Mental Health Authority, if
one does not already exist, to delineate how these agencies will work with together to design,
deliver, and monitor services for beneficiaries with SMI or SED. This MOU should be included
as an attachment to this Implementation Plan.
State Point of Contact: Please provide the contact information for the state’s point of contact
for the implementation plan.
Name and Title:
Telephone Number:
Email Address:

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Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
1. Title page for the state’s SMI/SED demonstration or SMI/SED components of the broader
demonstration
The state should complete this transmittal title page as a cover page when submitting its implementation
plan.
State

Enter state name.

Demonstration name

Enter full demonstration name as listed in the
demonstration approval letter.

Approval date

Enter approval date of the demonstration as
listed in the demonstration approval letter.

Approval period
Implementation date

Enter the entire approval period for the
demonstration, including a start date and an end
date.
Enter implementation date(s) for the
demonstration.

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Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
2. Required implementation information, by SMI/SED milestone
Answer the following questions about implementation of the state’s SMI/SED demonstration. States should respond to each prompt listed in the tables. Note any
actions that involve coordination or input from other organizations (government or non-government entities). Place “NA” in the summary cell if a prompt does
not pertain to the state’s demonstration. Answers are meant to provide details beyond the information provided in the state’s special terms and conditions.
Answers should be concise, but provide enough information to fully answer the question.
This template only includes SMI/SED policies.
Prompts
Summary
SMI/SED. Topic_1. Milestone 1: Ensuring Quality of Care in Psychiatric Hospitals and Residential Settings
To ensure that beneficiaries receive high quality care in hospitals and residential settings, it is important to establish and maintain appropriate standards
for these treatment settings through licensure and accreditation, monitoring and oversight processes, and program integrity requirements and processes.
Individuals with SMI often have co-morbid physical health conditions and substance use disorders (SUDs) and should be screened and receive treatment
for commonly co-occurring conditions particularly while residing in a treatment setting. Commonly co-occurring conditions can be very serious, including
hypertension, diabetes, and substance use disorders, and can also interfere with effective treatment for their mental health condition. They should also be
screened for suicidal risk.
To meet this milestone, state Medicaid programs should take the following actions to ensure good quality of care in psychiatric hospitals and residential
treatment settings.
Ensuring Quality of Care in Psychiatric Hospitals and Residential Treatment Settings
1.a Assurance that participating
Current Status: Provide information on current state policies and requirements for ensuring quality of care in
hospitals and residential settings psychiatric hospitals and residential settings.
are licensed or otherwise
authorized by the state primarily
to provide mental health
treatment; and that residential
treatment facilities are accredited
by a nationally recognized
accreditation entity prior to
Future Status: Describe planned activities to address milestone not already met and any other plans for enhanced
participating in Medicaid
quality assurance policies for inpatient and residential treatment settings.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

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Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
1.b Oversight process (including
unannounced visits) to ensure
participating hospital and
residential settings meet state’s
licensing or certification and
accreditation requirements

Summary
Current Status: Provide information on current state policies and requirements for ensuring quality of care in
psychiatric hospitals and residential settings.
Future Status: Describe planned activities to address milestone not already met and any other plans for enhanced
quality assurance policies for inpatient and residential treatment settings.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

1.c Utilization review process to
ensure beneficiaries have access
to the appropriate levels and
types of care and to provide
oversight on lengths of stay

Current Status: Provide information on current state policies and requirements for ensuring quality of care in
psychiatric hospitals and residential settings.
Future Status: Describe planned activities to address milestone not already met and any other plans for enhanced
quality assurance policies for inpatient and residential treatment settings.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

1.d Compliance with program
integrity requirements and state
compliance assurance process

Current Status: Provide information on current state policies and requirements for ensuring quality of care in
psychiatric hospitals and residential settings.
Future Status: Describe planned activities to address milestone not already met and any other plans for enhanced
quality assurance policies for inpatient and residential treatment settings.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

1.e State requirement that
psychiatric hospitals and
residential settings screen
beneficiaries for co-morbid
physical health conditions,
SUDs, and suicidal ideation, and
facilitate access to treatment for
those conditions

Current Status: Provide information on current state policies and requirements for ensuring quality of care in
psychiatric hospitals and residential settings.
Future Status: Describe planned activities to address milestone not already met and any other plans for enhanced
quality assurance policies for inpatient and residential treatment settings.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

5

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
1.f Other state
requirements/policies to ensure
good quality of care in inpatient
and residential treatment
settings.

Summary
Current Status: Provide information on current state policies and requirements for ensuring quality of care in
psychiatric hospitals and residential settings.
Future Status: Describe planned activities to address milestone not already met and any other plans for enhanced
quality assurance policies for inpatient and residential treatment settings.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

SMI/SED. Topic_2. Milestone 2: Improving Care Coordination and Transitioning to Community-Based Care
Understanding the services needed to transition to and be successful in community-based mental health care requires partnerships between hospitals,
residential providers, and community-based care providers. To meet this milestone, state Medicaid programs, must focus on improving care

coordination and transitions to community-based care by taking the following actions.

Improving Care Coordination and Transitions to Community-based Care
2.a Actions to ensure psychiatric Current Status: Provide information on the state’s current care coordination benefits/requirements including actions to
hospitals and residential settings connect beneficiaries with community-based care including pre-discharge planning, post discharge follow-up, and
carry out intensive pre-discharge information-sharing among providers.
planning, and include
Future Status: Describe planned improvements to care coordination benefits/requirements and connections to
community-based providers in
community-based care, including pre-discharge planning, post discharge follow-up, and information-sharing among
care transitions.
providers.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.
2.b Actions to ensure psychiatric
hospitals and residential settings
assess beneficiaries’ housing
situations and coordinate with
housing services providers when
needed and available.

Current Status: Provide information on the state’s current care coordination benefits/requirements including actions to
connect beneficiaries with community-based care including pre-discharge planning, post discharge follow-up, and
information-sharing among providers.
Future Status: Describe planned improvements to care coordination benefits/requirements and connections to
community-based care, including pre-discharge planning, post discharge follow-up, and information-sharing among
providers.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

6

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
2.c State requirement to ensure
psychiatric hospitals and
residential settings contact
beneficiaries and communitybased providers through most
effective means possible, e.g.,
email, text, or phone call within
72 hours post discharge

Summary
Current Status: Provide information on the state’s current care coordination benefits/requirements including actions to
connect beneficiaries with community-based care including pre-discharge planning, post discharge follow-up, and
information-sharing among providers.
Future Status: Describe planned improvements to care coordination benefits/requirements and connections to
community-based care, including pre-discharge planning, post discharge follow-up, and information-sharing among
providers.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

2.d Strategies to prevent or
decrease lengths of stay in EDs
among beneficiaries with SMI or
SED prior to admission

Current Status: Provide information on the state’s current care coordination benefits/requirements including actions to
connect beneficiaries with community-based care including pre-discharge planning, post discharge follow-up, and
information-sharing among providers.
Future Status: Describe planned improvements to care coordination benefits/requirements and connections to
community-based care, including pre-discharge planning, post discharge follow-up, and information-sharing among
providers.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

2.e Other State
requirements/policies to improve
care coordination and
connections to community-based
care

Current Status: Provide information on the state’s current care coordination benefits/requirements including actions to
connect beneficiaries with community-based care including pre-discharge planning, post discharge follow-up, and
information-sharing among providers.
Future Status: Describe planned improvements to care coordination benefits/requirements and connections to
community-based care, including pre-discharge planning, post discharge follow-up, and information-sharing among
providers.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

7

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
SMI/SED. Topic_3. Milestone 3: Increasing Access to Continuum of Care, Including Crisis Stabilization Services
Adults with SMI and children with SED need access to a continuum of care as these conditions are often episodic and the severity of symptoms can vary
over time. Increased availability of crisis stabilization programs can help to divert Medicaid beneficiaries from unnecessary visits to EDs and admissions
to inpatient facilities as well as criminal justice involvement. On-going treatment in outpatient settings can help address less acute symptoms and help
beneficiaries with SMI or SED thrive in their communities. Strategies are also needed to help connect individuals who need inpatient or residential
treatment with that level of care as soon as possible. To meet this milestone, state Medicaid programs should focus on improving access to a continuum of
care by taking the following actions.
Access to Continuum of Care Including Crisis Stabilization
3.a The state’s strategy to
Current Status: Provide information on the status of the state's assessment of mental health provider availability and
conduct annual assessments of
an overview of the current continuum of care, including crisis stabilization, the state’s ability of the state to track
the availability of mental health
availability of beds, and the use of patient assessment tools.
providers including psychiatrists, Future Status: Describe plans to expand community-based services, including references to the financing plan as
other practitioners, outpatient,
appropriate, and the state’s plans to improve annual assessments of the availability of mental health providers and the
community mental health
state’s ability to track availability of beds, and plans to encourage widespread use of patient assessment tools.
centers, intensive
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
outpatient/partial hospitalization, persons or entities responsible and timeframe for completion of each action.
residential, inpatient, crisis
stabilization services, and
FQHCs offering mental health
services across the state,
updating the initial assessment of
the availability of mental health
services submitted with the
state’s demonstration
application. The content of
annual assessments should be
reported in the state’s annual
demonstration monitoring
reports.

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Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
3.b Financing plan

Summary
Current Status: Provide information on the status of the state's assessment of mental health provider availability and
an overview of the current continuum of care, including crisis stabilization, the state’s ability of the state to track
availability of beds, and the use of patient assessment tools.
Future Status: Describe plans to expand community-based services, including references to the financing plan as
appropriate, and the state’s plans to improve annual assessments of the availability of mental health providers and the
state’s ability to track availability of beds, and plans to encourage widespread use of patient assessment tools.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

3.c Strategies to improve state
tracking of availability of
inpatient and crisis stabilization
beds

Current Status: Provide information on the status of the state's assessment of mental health provider availability and
an overview of the current continuum of care, including crisis stabilization, the state’s ability of the state to track
availability of beds, and the use of patient assessment tools.
Future Status: Describe plans to expand community-based services, including references to the financing plan as
appropriate, and the state’s plans to improve annual assessments of the availability of mental health providers and the
state’s ability to track availability of beds, and plans to encourage widespread use of patient assessment tools.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

3.d State requirement that
providers use a widely
recognized, publicly available
patient assessment tool to
determine appropriate level of
care and length of stay

Current Status: Provide information on the status of the state's assessment of mental health provider availability and
an overview of the current continuum of care, including crisis stabilization, the state’s ability of the state to track
availability of beds, and the use of patient assessment tools.
Future Status: Describe plans to expand community-based services, including references to the financing plan as
appropriate, and the state’s plans to improve annual assessments of the availability of mental health providers and the
state’s ability to track availability of beds, and plans to encourage widespread use of patient assessment tools.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

9

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
3.e Other state
requirements/policies to improve
access to a full continuum of
care including crisis stabilization

Summary
Current Status: Provide information on the status of the state's assessment of mental health provider availability and
an overview of the current continuum of care, including crisis stabilization, the state’s ability of the state to track
availability of beds, and the use of patient assessment tools.
Future Status: Describe plans to expand community-based services, including references to the financing plan as
appropriate, and the state’s plans to improve annual assessments of the availability of mental health providers and the
state’s ability to track availability of beds, and plans to encourage widespread use of patient assessment tools.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

SMI/SED. Topic_4. Milestone 4: Earlier Identification and Engagement in Treatment, Including Through Increased Integration
Critical strategies for improving care for individuals with SMI or SED include earlier identification of serious mental health conditions and focused efforts
to engage individuals with these conditions in treatment sooner. To meet this milestone, state Medicaid programs must focus on improving mental health
care by taking the following actions.
Earlier Identification and Engagement in Treatment
Current Status: Provide information on current strategies to increase earlier identification/ engagement in treatment,
4.a Strategies for identifying
integration of behavioral care in non-specialty settings, and specialized programs for young people with SED/SMI.
and engaging beneficiaries
with or at risk of SMI or SED Future Status: Describe planned strategies to increase early identification/ engagement in treatment, integration of
in treatment sooner, e.g., with behavioral health care in non-specialty settings, and availability of specialized programs for young people with
SED/SMI.
supported employment and

supported programs

Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

4.b Plan for increasing
integration of behavioral health
care in non-specialty settings to
improve early identification of
SED/SMI and linkages to
treatment

Current Status: Provide information on current strategies to increase earlier identification/ engagement in treatment,
integration of behavioral care in non-specialty settings, and specialized programs for young people with SED/SMI.
Future Status: Describe planned strategies to increase early identification/ engagement in treatment, integration of
behavioral health care in non-specialty settings, and availability of specialized programs for young people with
SED/SMI.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.
10

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
4.c Establishment of specialized
settings and services, including
crisis stabilization, for young
people experiencing SED/SMI

Summary
Current Status: Provide information on current strategies to increase earlier identification/ engagement in treatment,
integration of behavioral care in non-specialty settings, and specialized programs for young people with SED/SMI.
Future Status: Describe planned strategies to increase early identification/ engagement in treatment, integration of
behavioral health care in non-specialty settings, and availability of specialized programs for young people with
SED/SMI.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

4.d Other state strategies to
increase earlier
identification/engagement,
integration, and specialized
programs for young people

Current Status: Provide information on current strategies to increase earlier identification/ engagement in treatment,
integration of behavioral care in non-specialty settings, and specialized programs for young people with SED/SMI.
Future Status: Describe planned strategies to increase early identification/ engagement in treatment, integration of
behavioral health care in non-specialty settings, and availability of specialized programs for young people with
SED/SMI.
Summary of Actions Needed: Specify a list of actions needed to be completed to meet milestone criteria. Include
persons or entities responsible and timeframe for completion of each action.

11

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
SMI/SED.Topic_5. Financing Plan
State Medicaid programs should detail plans to support improved availability of non-hospital, non-residential mental health services including crisis
stabilization and on-going community-based care. The financing plan should describe state efforts to increase access to community-based mental health
providers for Medicaid beneficiaries throughout the state, including through changes to reimbursement and financing policies that address gaps in access
to community-based providers identified in the state’s assessment of current availability of mental health services included in the state’s application.
Current Status
F.a Increase availability of nonhospital, non-residential crisis
stabilization services, including
services made available through
Future Status
crisis call centers, mobile crisis
units, observation/assessment
centers, with a coordinated
community crisis response that
Summary of Actions Needed
involves collaboration with
trained law enforcement and
other first responders.
F.b Increase availability of onCurrent Status
going community-based services,
e.g., outpatient, community
Future Status
mental health centers, partial
hospitalization/day treatment,
assertive community treatment,
and services in integrated care
Summary of Actions Needed
settings such as the Certified
Community Behavioral Health
Clinic model.

12

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
SMI/SED. Topic_6. Health IT Plan
As outlined in State Medicaid Director Letter (SMDL) #18-011, “[s]tates seeking approval of an SMI/SED demonstration … will be expected to submit a
Health IT Plan (“HIT Plan”) that describes the state’s ability to leverage health IT, advance health information exchange(s), and ensure health IT
interoperability in support of the demonstration’s goals.” 1 The HIT Plan should also describe, among other items, the:
• Role of providers in cultivating referral networks and engaging with patients, families and caregivers as early as possible in treatment; and
• Coordination of services among treatment team members, clinical supervision, medication and medication management, psychotherapy, case
management, coordination with primary care, family/caregiver support and education, and supported employment and supported education.
Please complete all Statements of Assurance below—and the sections of the Health IT Planning Template that are relevant to your state’s demonstration
proposal.
Statements of Assurance
Statement 1: Please provide an
Enter text here
assurance that the state has a
sufficient health IT
infrastructure/ecosystem at every
appropriate level (i.e. state,
delivery system, health
plan/MCO and individual
provider) to achieve the goals of
the demonstration. If this is not
yet the case, please describe how
this will be achieved and over
what time period

See SMDL #18-011, “Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness or Children with a Serious
Emotional Disturbance.” Available at https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf.

1

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Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Statement 2: Please confirm that
your state’s SUD Health IT Plan
is aligned with the state’s
broader State Medicaid Health
IT Plan and, if applicable, the
state’s Behavioral Health IT
Plan. If this is not yet the case,
please describe how this will be
achieved and over what time
period.

Summary
Enter text here

Statement 3: Please confirm that
the state intends to assess the
applicability of standards
referenced in the Interoperability
Standards Advisory (ISA) 2 and
45 CFR 170 Subpart B and,
based on that assessment, intends
to include them as appropriate in
subsequent iterations of the
state’s Medicaid Managed Care
contracts. The ISA outlines
relevant standards including but
not limited to the following
areas: referrals, care plans,
consent, privacy and security,
data transport and encryption,
notification, analytics and
identity management.

Enter text here

2

Available at https://www.healthit.gov/isa/.

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Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
To assist states in their health IT efforts, CMS released SMDL #16-003 which outlines enhanced federal funding opportunities available to states “for state
expenditures on activities to promote health information exchange (HIE) and encourage the adoption of certified Electronic Health Record (EHR)
technology by certain Medicaid providers.” For more on the availability of this “HITECH funding,” please contact your CMS Regional Operations Group
contact. 3
Enhanced administrative match may also be available under MITA 3.0 to help states establish crisis call centers to connect beneficiaries with mental
health treatment and to develop technologies to link mobile crisis units to beneficiaries coping with serious mental health conditions. States may also
coordinate access to outreach, referral, and assessment services—for behavioral health care--through an established “No Wrong Door System.” 4
Closed Loop Referrals and e-Referrals (Section 1)
1.1 Closed loop referrals and eCurrent State: # and/or % of Behavioral Health Providers who have adopted “Certified” EHRs (CEHRT-Certified
referrals from physician/mental
EHR Technologies) and utilize it for e-referrals and or closed loop referrals.
health provider to
1) # and/or % of Behavioral Health Providers who utilize “Direct” secure messaging for e-referrals and or
physician/mental health provider
closed loop referrals
2) # and/or % of Primary Care Providers who have adopted “Certified” EHRs (CEHRT-Certified EHR
Technologies) that are utilizing it for e-referrals and or closed loop referrals with mental health providers
3) # or % of Primary Care Providers who utilize “Direct” secure messaging for e-referrals and or closed loop
referrals with Mental Health Providers
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

See SMDL #16-003, “Availability of HITECH Administrative Matching Funds to Help Professionals and Hospitals Eligible for Medicaid EHR Incentive
Payments Connect to Other Medicaid Providers.” Available at https://www.medicaid.gov/federal-policy-guidance/downloads/smd16003.pdf.
4
Guidance for Administrative Claiming through the “No Wrong Door System” is available at https://www.medicaid.gov/medicaid/finance/admin-claiming/nowrong-door/index.html.
3

15

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
1.2 Closed loop referrals and ereferrals from
institution/hospital/clinic to
physician/mental health provider

Summary
Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

1.3 Closed loop referrals and ereferrals from physician/mental
health provider to community
based supports

Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

Electronic Care Plans and Medical Records (Section 2)
2.1 The state and its providers
Current State: Describe the current state of the health IT functionalities outlined below:
can create and use an electronic
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
care plan
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

16

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
2.2 E-plans of care are
interoperable and accessible by
all relevant members of the care
team, including mental health
providers

Summary
Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

2.3 Medical records transition
from youth-oriented systems of
care to the adult behavioral
health system through electronic
communications

Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

2.4 Electronic care plans
transition from youth-oriented
systems of care to the adult
behavioral health system through
electronic communications

Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

17

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
2.5 Transitions of care and other
community supports are accessed
and supported through electronic
communications

Summary
Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

Consent - E-Consent (42 CFR Part 2/HIPAA) (Section 3)
3.1 Individual consent is
Current State: Describe the current state of the health IT functionalities outlined below:
electronically captured and
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
accessible to patients and all
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
members of the care team, as
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
applicable, to ensure seamless
partner entities who help beneficiaries enter hours into the state’s online portal.
sharing of sensitive health care
Future State: Describe the future state of the health IT functionalities outlined below:
information to all relevant parties Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
consistent with applicable law
to make progress in moving from the current to future state:
and regulations (e.g., HIPAA, 42
CFR part 2 and state laws)
Interoperability in Assessment Data (Section 4)
4.1 Intake, assessment and
Current State: Describe the current state of the health IT functionalities outlined below:
screening tools are part of a
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
structured data capture process
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
so that this information is
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
interoperable with the rest of the partner entities who help beneficiaries enter hours into the state’s online portal.
HIT ecosystem
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

18

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
Electronic Office Visits – Telehealth (Section 5)
5.1 Telehealth technologies
Current State: Describe the current state of the health IT functionalities outlined below:
support collaborative care by
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
facilitating broader availability
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
of integrated mental health care
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
and primary care
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:
Alerting/Analytics (Section 6)
6.1 The state can identify
patients that are at risk for
discontinuing engagement in
their treatment, or have stopped
engagement in their treatment,
and can notify their care teams in
order to ensure treatment
continues or resumes (Note:
research shows that 50% of
patients stop engaging after 6
months of treatment 5)

Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

Interdepartmental Serious Mental Illness Coordinating Committee. (2017). The Way Forward: Federal Action for a System That Works for All People Living
With SMI and SED and Their Families and Caregivers. Retrieved from
https://www.samhsa.gov/sites/default/files/programs_campaigns/ismicc_2017_report_to_congress.pdf
5

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Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
6.2 Health IT is being used to
advance the care coordination
workflow for patients
experiencing their first episode
of psychosis

Identity Management (Section 7)
7.1 As appropriate and needed,
the care team has the ability to
tag or link a child’s electronic
medical records with their
respective parent/caretaker
medical records

7.2 Electronic medical records
capture all episodes of care, and
are linked to the correct patient

Summary
Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:
Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:
Current State: Describe the current state of the health IT functionalities outlined below:
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting hours
due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or training CE
partner entities who help beneficiaries enter hours into the state’s online portal.
Future State: Describe the future state of the health IT functionalities outlined below:
Summary of Actions Needed: Specify a list of action items, milestones and responsible individuals/departments needed
to make progress in moving from the current to future state:

20

Medicaid Section 1115 SMI/SED Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Section 3: Relevant documents
Please provide any additional documentation or information that the state deems relevant to successful
execution of the implementation plan. This information is not meant as a substitute for the information
provided in response to the prompts outlined in Section 2. Instead, material submitted as attachments
should support those responses.

PRA Disclosure Statement This information is being collected to assist the Centers for Medicare &
Medicaid Services in program monitoring of Medicaid Section 1115 Severe Mental Illness and Severe
Emotional Disturbance Demonstrations. This mandatory information collection (42 CFR § 431.428) will be
used to support more efficient, timely and accurate review of states’ monitoring report submissions of
Medicaid Section 1115 Severe Mental Illness and Severe Emotional Disturbance Demonstrations, and also
support consistency in monitoring and evaluation, increase in reporting accuracy, and reduction in
timeframes required for monitoring and evaluation. Under the Privacy Act of 1974 any personally
identifying information obtained will be kept private to the extent of the law.
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 #59). The time required to complete this information
collection is estimated to average 29 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.

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