CMS-10398 $59 Monitoring Report Template

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]
Medicaid Section 1115 Serious Mental Illness/Serious
Emotional Disturbance (SMI/SED) Demonstration
Monitoring Report Template
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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Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]
1. Title Page for the State’s SMI/SED Demonstration or SMI/SED Components of Broader
Demonstration
The state should complete this Title Page at the beginning of a demonstration and submit as the title page
for all SMI/SED Monitoring Reports. The content of this table should stay consistent over time.
State

Enter state name.

Demonstration name

Enter full demonstration name as listed in the demonstration
approval.

Approval date for
demonstration

Enter approval date of the demonstration as listed in the
demonstration approval letter (MM/DD/YYYY).

Approval period for
SMI/SED
Approval date for SMI/SED,
if different from above
Implementation date of
SMI/SED, if different from
above
SMI/SED (or if broader
demonstration, then
SMI/SED -related)
demonstration goals and
objectives

Enter the entire approval period for the demonstration. This should
include a start date and an end date (MM/DD/YYYY – MM/DD/YYY).
Enter approval date for the SMI/SED demonstration as listed in the
demonstration approval letter if different from above (MM/DD/YYYY).
Enter SMI/SED demonstration implementation date (MM/DD/YYYY).
The state should consider its SMI/SED implementation date to be the
date the state began claiming federal financial participation for
services provided to individuals in IMDs.
Enter summary of the SMI/SED (or if broader demonstration, then
SMI/SED-related) demonstration goals and objectives as summarized
in the STCs and/or demonstration fact sheet.

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Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]
2. Executive Summary
The executive summary should be reported in the fillable box below. It is intended for summary-level
information only. The recommended word count is 500 or less.
Enter the executive summary text here

.

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Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]
3. Narrative Information on Implementation, by Milestone and Reporting Topic

Prompt

State response

1.2 Ensuring Quality of Care in Psychiatric Hospitals and Residential Settings (Milestone 1)
1.2.1 Metric Trends
EXAMPLE: The number of beneficiaries with SMI/SED who were
☐ The state reports the following metric trends,
treated for mental health in an IMD decreased by 5% due to an increase
including all changes (+ or -) greater than 2 percent
in crisis stabilization services in the state.
related to Milestone 1.

Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Insert the first
measurement period in
which the current
trend (+ or – two
percent) was reported.
EXAMPLE:
01/01/2018–03/31/2018

☐ The state has no metrics trends to report for this reporting topic.

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Related metric
(if any)

Insert the metric related
to the trend reported.
EXAMPLE:#20:
Beneficiaries with
SMI/SED treated in an
IMD for mental health

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

1.2.2 Implementation Update
Compared to the demonstration design and operational
For implementation updates, insert annual or quarterly report in which
details, the state expects to make the following changes
the updated was first reported.
to:
☐ i) The licensure or accreditation processes for
participating hospitals and residential settings
☒ ii) The oversight process (including unannounced
visits) to ensure participating hospital and residential EXAMPLE: ii) The state increased the frequency of unannounced visits
from twice a year to three times a year in January 2019.
settings meet state’s licensing or certification and
accreditation requirements
☐ iii) The utilization review process to ensure
beneficiaries have access to the appropriate levels and
types of care and to provide oversight on lengths of
stay
☐ iv) The program integrity requirements and
compliance assurance process
☐ v) The state requirement that psychiatric hospitals
and residential settings screen beneficiaries for comorbid physical health conditions, SUDs, and suicidal
ideation, and facilitate access to treatment for those
conditions
☐ vi) Other state requirements/policies to ensure good
quality of care in inpatient and residential treatment
settings
☐ The state has no implementation update to report for this reporting topic.
☐ The state expects to make the following program
changes that may affect metrics related to Milestone 1.
☐ The state has no implementation update to report for this reporting topic.
2.2 Improving Care Coordination and Transitions to Community-Based Care (Milestone 2)
2.2.1 Metric Trends
☐ The state reports the following metric trends,
including all changes (+ or -) greater than 2 percent
related to Milestone 2.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Insert the
measurement period in
which the update was
first reported.

Insert the metric related
to the reported update
(if any) or write “N/A”.

EXAMPLE:
ii) 01/01/2019–
03/31/2019

EXAMPLE:
ii) N/A

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

☐ The state has no metrics trends to report for this reporting topic.
2.2.2 Implementation Update
Compared to the demonstration design and operational
details, the state expects to make the following changes
to:
☐ i) Actions to ensure that psychiatric hospitals and
residential treatment settings carry out intensive predischarge planning, and include community-based
providers in care transitions
☐ ii) Actions to ensure psychiatric hospitals and
residential settings assess beneficiaries’ housing
situations and coordinate with housing services
providers
☐ iii) State requirement to ensure psychiatric
hospitals and residential settings contact beneficiaries
and community-based providers within 72 hours post
discharge
☐ iv) Strategies to prevent or decrease the lengths of
stay in EDs among beneficiaries with SMI or SED
(e.g., through the use of peers and psychiatric
consultants in EDs to help with discharge and referral
to treatment providers)
☐ v) Other State requirements/policies to improve
care coordination and connections to communitybased care
☐ The state has no implementation update to report for this reporting topic.
☐ The state expects to make the following program
changes that may affect metrics related to Milestone 2.
☐ The state has no implementation update to report for this reporting topic.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

3.2 Access to Continuum of Care, Including Crisis Stabilization (Milestone 3)
3.2.1 Metric Trends
☐ The state reports the following metric trends,
including all changes (+ or -) greater than 2 percent
related to Milestone 3.
☐ The state has no metrics trends to report for this reporting topic.
3.2.2 Implementation Update
Compared to the demonstration design and operational
details, the state expects to make the following changes
to:
☐ i) State requirement that providers use an
evidenced-based, publicly available patient
assessment tool to determine appropriate level of
care and length of stay
☐ ii) Other state requirements/policies to improve
access to a full continuum of care including crisis
stabilization
☐ The state has no implementation update to report for this reporting topic.
☐ The state expects to make the following program
changes that may affect metrics related to Milestone 3.
☐ The state has no implementation update to report for this reporting topic.
4.2 Earlier Identification and Engagement in Treatment, Including Through Increased Integration (Milestone 4)
4.2.1 Metric Trends
☐ The state reports the following metric trends,
including all changes (+ or -) greater than 2 percent
related to Milestone 4.
☐ The state has no metrics trends to report for this reporting topic.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

4.2.2 Implementation Update
Compared to the demonstration design and operational
details, the state expects to make the following changes
to:
☐ i) Strategies for identifying and engaging
beneficiaries in treatment sooner (e.g., with
supported education and employment)
☐ ii) Plan for increasing integration of behavioral
health care in non-specialty settings to improve early
identification of SED/SMI and linkages to treatment
☐ iii) Establishment of specialized settings and
services, including crisis stabilization services,
focused on the needs of young people experiencing
SMI or SED
☐ iv) Other state strategies to increase earlier
identification/engagement, integration, and
specialized programs for young people
☐ The state has no implementation update to report for this reporting topic.
☐ The state expects to make the following program
changes that may affect metrics related to Milestone 4.
☐ The state has no implementation update to report for this reporting topic.
5.2 SMI/SED Health Information Technology (Health IT)
5.2.1 Metric Trends
☐ The state reports the following metric trends,
including all changes (+ or -) greater than 2 percent
related to its health IT metrics.
☐ The state has no metrics trends to report for this reporting topic.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

5.2.2 Implementation Update
Compared to the demonstration design and operational
details, the state expects to make the following changes
to:
☐ i) The three statements of assurance made in the
state’s health IT plan
☐ ii) Closed loop referrals and e-referrals from
physician/mental health provider to physician/mental
health provider and/or physician/mental health
provider to community based supports
☐ iii) Electronic care plans and medical records
☐ iv) Individual consent being electronically
captured and made accessible to patients and all
members of the care team
☐ v) Intake, assessment and screening tools being
part of a structured data capture process so that this
information is interoperable with the rest of the
health IT ecosystem
☐ vi) Telehealth technologies supporting
collaborative care by facilitating broader availability
of integrated mental health care and primary care
☐ vii) Alerting/analytics
☐ viii) Identity management
☐ The state has no implementation update to report for this reporting topic.
☐ The state expects to make the following program
changes that may affect metrics related to health IT.
☐ The state has no implementation update to report for this reporting topic.
6.2 Other SMI/SED-Related Metrics
6.2.1 Metric Trends
☐ The state reports the following metric trends,
including all changes (+ or -) greater than two 2 percent
related to other SMI/SED-related metrics.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

☐ The state has no implementation update to report for this reporting topic.
6.2.2 Implementation Update
☐ The state expects to make the following program
changes that may affect other SMI/SED-related metrics.
☐ The state has no implementation update to report for this reporting topic.
7.1 Annual Assessment of the Availability of Mental Health Providers
7.1.1 Description Of Changes To Baseline Conditions And Practices
☐ Describe and explain any changes in the mental
health service needs (for example, prevalence and
distribution of SMI/SED) of Medicaid beneficiaries with
SMI/SED compared to those described in the Initial
Assessment of Availability of Mental Health Services.
Recommended word count is 500 words or less.
☐ This is not an annual report, therefore the state has no update to report for this reporting topic.
☐ Describe and explain any changes to the organization
of the state’s Medicaid behavioral health service
delivery system compared to those described in the
Initial Assessment of Availability of Mental Health
Services. Recommended word count is 500 words or
less.
☐ This is not an annual report, therefore the state has no update to report for this reporting topic.
☐ Describe and explain any changes in the availability
of mental health services for Medicaid beneficiaries
with SMI/SED in the state compared to those described
in the Initial Assessment of Availability of Mental
Health Services. At minimum, explain any changes
across the state in the availability of the following
services: inpatient mental health services; outpatient and
community-based services; crisis behavioral health
services; and care coordination and care transition
planning. Recommended word count is 500 words or
less.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

☐ This is not an annual report, therefore the state has no update to report for this reporting topic.
☐ Describe and explain any changes in gaps the state
identified in the availability of mental health services or
service capacity while completing the Availability
Assessment compared to those described in the Initial
Assessment of Availability of Mental Health Services.
Recommended word count is 500 words or less.
☐ This is not an annual report, therefore the state has no update to report for this reporting topic.
7.1.2 Implementation Update
Compared to the demonstration design and operational
details, the state expects to make the following changes
to:
☐ i) The state’s strategy to conduct annual
assessments of the availability of mental health
providers across the state and updates on steps taken
to increase availability
☐ ii) Strategies to improve state tracking of
availability of inpatient and crisis stabilization beds
☐ The state has no implementation update to report for this reporting topic.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

8.1 SMI/SED Financing Plan
8.1.1 Implementation Update
Compared to the demonstration design and operational
details, the state expects to make the following changes
to:
☐ i) Increase availability of non-hospital, nonresidential crisis stabilization services, including
services made available through crisis call centers,
mobile crisis units, and observation/assessment
centers, with a coordinated community crisis
response that involves law enforcement and other
first responders
☐ ii) Increase availability of on-going communitybased services, e.g., outpatient, community mental
health centers, partial hospitalization/day treatment,
assertive community treatment, and services in
integrated care settings such as the Certified
Community Behavioral Health Clinic model
☐ The state has no implementation update to report for this reporting topic.
9.2 Budget Neutrality
9.2.1 Current Status and Analysis
☐ If the SMI/SED component is part of a broader
demonstration, the state should provide an analysis of
the SMI/SED-related budget neutrality and an analysis
of budget neutrality as a whole. Describe the current
status of budget neutrality and an analysis of the budget
neutrality to date.
9.2.2 Implementation Update
☐ The state expects to make the following program
changes that may affect budget neutrality.
☐ The state has no implementation update to report for this reporting topic.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

10.1 SMI/SED-Related Demonstration Operations and Policy
10.1.1 Considerations
☐ States should highlight significant SMI/SED (or if
broader demonstration, then SMI/SED-related)
demonstration operations or policy considerations that
could positively or negatively impact beneficiary
enrollment, access to services, timely provision of
services, budget neutrality, or any other provision that
has potential for beneficiary impacts. Also note any
activity that may accelerate or create delays or
impediments in achieving the SMI/SED demonstration’s
approved goals or objectives, if not already reported
elsewhere in this document. See report template
instructions for more detail.
☐ The state has no related considerations to report for this topic.
10.1.2 Implementation Update
☐ The state experienced challenges in partnering with
entities contracted to help implement the demonstration
(e.g., health plans, credentialing vendors, private sector
providers) and/or noted any performance issues with
contracted entities.
☐ The state has no implementation update to report for this reporting topic.
☐ The state is working on other initiatives related to
SMI/SED.
☐ The state has no implementation update to report for this reporting topic.
☐The initiatives described above are related to the
SMI/SED demonstration as described (States should
note similarities and differences from the SMI/SED
demonstration).
☐ The state has no implementation update to report for this reporting topic.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

Compared to the demonstration design and operational
details, the state expects to make the following changes
to:
☐ i) How the delivery system operates under the
demonstration (e.g. through the managed care system
or fee for service)
☐ ii) Delivery models affecting demonstration
participants (e.g. Accountable Care Organizations,
Patient Centered Medical Homes)
☐ iii) Partners involved in service delivery
☐ iv) The state Medicaid agency’s Memorandum of
Understanding (MOU) or other agreement with its
mental health services agency
☐ The state has no implementation update to report for this reporting topic.
11 SMI/SED Demonstration Evaluation Update
11.1 Narrative Information
☐ Provide updates on SMI/SED evaluation work and
timeline. The appropriate content will depend on when
this report is due to CMS and the timing for the
demonstration. See report template instructions for more
details.
☐ The state has no SMI/SED demonstration evaluation update to report.
☐ Provide status updates on deliverables related to the
demonstration evaluation and indicate whether the
expected timelines are being met and/or if there are any
real or anticipated barriers in achieving the goals and
timeframes agreed to in the STCs.
☐ The state has no SMI/SED demonstration evaluation update to report.
☐ List anticipated evaluation-related deliverables
related to this demonstration and their due dates.
☐ The state has no SMI/SED demonstration evaluation update to report.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

12.1 Other Demonstration Reporting
12.1.1 General Reporting Requirements
☐ The state reports changes in its implementation of the
demonstration that might necessitate a change to
approved STCs, implementation plan, or monitoring
protocol.
☐ The state has no updates on general requirements to report for this topic.
☐ The state anticipates the need to make future changes
to the STCs, implementation plan, or monitoring
protocol, based on expected or upcoming
implementation changes.
☐ The state has no updates on general requirements to report for this topic.
☐ The state identified real or anticipated issues
submitting timely post-approval demonstration
deliverables, including a plan for remediation.
☐ The state has no updates on general requirements to report for this topic.
Compared to the demonstration design and operational
details, the state expects to make the following changes
to:
☐ i) The schedule for completing and submitting
monitoring reports
☐ ii) The content or completeness of submitted
reports and/or future reports
☐ The state has no updates on general requirements to report for this topic.

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Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

Medicaid Section 1115 SMI/SED Demonstration Monitoring Report – Part B
[State] [Demonstration Name]
[Demonstration Year] – [Calendar Dates for Demonstration Year]
[Reporting Period] – [Calendar Dates for Reporting Period]
Submitted on [Insert Date]

Prompt

State response

Measurement period
first reported
(MM/DD/YYYYMM/DD/YYYY)

Related metric
(if any)

12.1.2 Post-Award Public Forum
☐ If applicable within the timing of the demonstration,
provide a summary of the annual post-award public
forum held pursuant to 42 CFR § 431.420(c) indicating
any resulting action items or issues. A summary of the
post-award public forum must be included here for the
period during which the forum was held and in the
annual report.
☐ No post-award public forum was held during this reporting period, and this is not an annual report, so the state has no post-award public forum update to report for this topic.
13.1 Notable State Achievements and/or Innovations
13.1 Narrative Information
☐ Provide any relevant summary of achievements
and/or innovations in demonstration enrollment,
benefits, operations, and policies pursuant to the
hypotheses of the SMI/SED (or if broader
demonstration, then SMI/SED related) demonstration or
that served to provide better care for individuals, better
health for populations, and/or reduce per capita cost.
Achievements should focus on significant impacts to
beneficiary outcomes. Whenever possible, the summary
should describe the achievement or innovation in
quantifiable terms, e.g., number of impacted
beneficiaries.
☐ The state has no notable achievements or innovations to report for this topic.
Note: Licensee and states must prominently display the following notice on any display of Measure rates:
The MPT, FUH-CH, FUH-AD, FUA-AD, FUM-AD, AAP, APM, and APC measures (metrics #13, 14, 15, 16, 17, 18, 7, 8, 9, 10, 26, 29, 31) are Healthcare Effectiveness Data and Information Set
(“HEDIS®”) measures that are owned and copyrighted by the National Committee for Quality Assurance (“NCQA”). NCQA makes no representations, warranties, or endorsement about the quality of any
organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.
The measure specification methodology used by CMS is different from NCQA’s methodology. NCQA has not validated the adjusted measure specifications but has granted CMS permission to adjust.
Calculated measure results, based on the adjusted HEDIS specifications, may be called only “Uncertified, Unaudited HEDIS rates.”
Certain non-NCQA measures in the CMS 1115 Serious Mental Illness/Serious Emotional Disturbance Demonstration contain HEDIS Value Sets (VS) developed by and included with the permission of
the NCQA. Proprietary coding is contained in the VS. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. NCQA disclaims all liability for use or
accuracy of the VS with the non-NCQA measures and any coding contained in the VS.

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