CMS-10398 #59 Monitoring Protocol Template

Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
Medicaid Section 1115 Serious Mental Illness/Serious
Emotional Disturbance (SMI/SED) Demonstration
Monitoring Protocol 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 Protocol – Part B
[State] [Demonstration Name]
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 as part of its SMI/SED Monitoring Protocol. This form should be
submitted as the title page for all 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

Enter the entire approval period for the demonstration. This should
include a start date and an end date (MM/DD/YYYY – MM/DD/YYY).

Approval date for SMI/SED,
if different from above

Enter approval date for the SMI/SED demonstration as listed in the
demonstration approval letter if different from above (MM/DD/YYYY).

Implementation date of
SMI/SED, if different from
above

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.

SMI/SED (or if broader
demonstration, then
SMI/SED -related)
demonstration goals and
objectives

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 Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
2. Proposed Modifications to SMI/SED Narrative Information on Implementation, by Milestone or Reporting Topic
Summary of proposed
modification

Related
metric
(if any)

Justification for modification

1. Ensuring Quality of Care in Psychiatric Hospitals and Residential Settings (Milestone 1)
Provide a brief description of any
Summarize how the proposed modification will alter reporting relative to the SMI/SED Monitoring
changes or modifications the state
Report Template and why this modification is needed.
expects to make in its narrative
reporting, relative to the
EXAMPLE
expectations described in the
In addition to reporting on the requested information, the state plans to report on progress on X
SMI/SED Monitoring Report
implementation activity not currently listed in the report template. The state will add this activity as a
Template (Narrative Information
new row to the “Narrative Information on Implementation” table in Part A of its Monitoring Reports.
on Implementation)
EXAMPLE
Additional topic of interest
[Add rows as needed]

☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).
2. Improving Care Coordination and Transitions to Community-Based Care (Milestone 2)
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
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Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
Summary of proposed
modification

Related
metric
(if any)

Justification for modification

☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).
3. Increasing Access to Continuum of Care, Including Crisis Stabilization Services (Milestone 3)
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).
4. Earlier Identification and Engagement in Treatment, Including Through Increased Integration (Milestone 4)
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).
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Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
Summary of proposed
modification

Related
metric
(if any)

Justification for modification

5. SMI/SED Health Information Technology (Health IT)
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]

☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).
6. Other SMI/SED-related Metrics
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).

4

Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
Summary of proposed
modification

Related
metric
(if any)

Justification for modification

7. Annual Assessment of the Availability of Mental Health Providers
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will
report the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will
report the narrative information as requested (no modifications).
8. SMI/SED Financing Plan
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will
report the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will
report the narrative information as requested (no modifications).

5

Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
Summary of proposed
modification

Related
metric
(if any)

Justification for modification

9. Budget Neutrality
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]

☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).
10. SMI/SED-Related Demonstration Operations and Policy
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).

6

Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
Summary of proposed
modification

Related
metric
(if any)

Justification for modification

11. SMI/SED Demonstration Evaluation Update
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]

☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).
12. Other Demonstration Reporting
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).

7

Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
Summary of proposed
modification

Related
metric
(if any)

Justification for modification

13. Notable State Achievements and/or Innovations
Provide a brief description of any
changes or modifications the state
expects to make in its narrative
reporting, relative to the
expectations described in the
SMI/SED Monitoring Report
Template (Narrative Information
on Implementation)
[Add rows as needed]

☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information with the modifications described above.
☐ The state has reviewed the corresponding prompts for narrative information in the SMI/SED Monitoring Report Template and confirms that it will report
the narrative information as requested (no modifications).

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Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
3. Annual Assessment of the Availability of Mental Health Providers Reporting
☐ The state will use the following time period for reporting of its Annual Assessment of the Availability
of Mental Health Providers:
EXAMPLE: The state will use data as of December 1 to conduct its Annual Assessment of Availability of
Mental Health Providers.
4. Acknowledgement of Budget Neutrality Reporting
☐ The state has reviewed the Budget Neutrality workbook provided by the project officer and
understands the expectations for quarterly and annual monitoring reports. The state will provide the
requested budget neutrality information (no modifications).
5. Retrospective reporting
If a state’s monitoring protocol is approved after its first quarterly monitoring report submission date, the
state should report data to CMS retrospectively for any prior quarters of SMI/SED demonstration
implementation. States are expected to submit retrospective metrics data in the state’s second monitoring
report submission after monitoring protocol approval, or propose an alternative plan for reporting
retrospectively on its SMI/SED demonstration.
In the monitoring report submission containing retrospective metrics data, the state should also provide a
general assessment of metrics trends from the start of the state’s demonstration through the end of the
current reporting period. The state should report this information in Part B of its report submission (Table
3: Narrative Information on Implementation, by Milestone and Reporting Topic). This general assessment
is not intended to be a comprehensive description of every trend observed in metrics data (for example,
unlike other monitoring report submissions, the state is not required to describe all metrics changes (+ or)
greater than 2 percent). Rather, the assessment is an opportunity for states to provide context for its
retrospective metrics data, to support CMS’s review and interpretation. For example, consider a state that
submits data showing an increase in the utilization of telehealth services for mental health (metric #15)
over the course of the retrospective reporting period. The state may decide to highlight this trend to CMS
in Part B of its report (under Milestone 3) by briefly summarizing the trend and providing context that
during this period, the state implemented a grant to improve access to mental health treatment in rural
areas through the use of telemedicine.
☐ The state will report retrospectively for any quarters prior to monitoring protocol approval as described
above, in the state’s second monitoring report submission after approval.
☐ The state proposes an alternative plan to report retrospectively for any quarters prior to monitoring
protocol approval: Insert narrative description of proposed changes to retrospective reporting. State
should provide justification for any proposed deviation.
6. Reporting SMI Demonstration Metrics and Narrative Information
The state should review the guidance in Appendix A of the instructions document in order to attest it will
follow CMS’s guidance on reporting metrics and narrative information, or propose any deviations. The
state should complete Table A below to reflect its proposed reporting schedule for the duration of its
SMI/SED demonstration approval period.

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Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]

☐ The state has completed the table below according to the guidance in Appendix A of the instructions
document and attests to reporting metrics and narrative information in its quarterly and annual reports as
described.
☐ The state has reviewed Appendix A of the instructions document and completed the table below with
the following deviations: Insert narrative description of proposed changes to reporting. State should
provide justification for any proposed deviation.

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Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
Table A. [STATE] reporting in quarterly and annual monitoring reports
Dates of
reporting
quarter
EXAMPLE:

Broader
1115 DY (if
applicable)*
EXAMPLE:

January 1, 2019 – DY3 Q1
March 31, 2019

SMI/SED
DY

Report due
(per STCs
schedule)

Measurement period associated with SMI/SED
information in report, by reporting category

EXAMPLE:

EXAMPLE:

EXAMPLE:

DY1 Q1

5/30/2019

•
•
•
•
•

April 1, 2019 –
June 30, 2019

DY3 Q2

DY1 Q2

8/29/2019

•
•
•
•
•

July 1, 2019 –
September 30,
2019

DY3 Q3

DY1 Q3

11/29/2019

•
•
•
•
•

October 1, 2019 – DY4 Q4
December 31,
2019

DY1 Q4

4/1/2020

•
•
•
•
•

January 1, 2020 – DY4 Q1
March 31, 2020

DY2 Q1

5/30/2020

•
•
•
•
•

April 1, 2019 –
June 30, 2019

DY4 Q2

DY2 Q2

8/29/2020

•
•
•
•
•

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Narrative information: SMI/SED DY1 Q1
Grievances and appeals: SMI/SED DY1 Q1
Other monthly and quarterly metrics: None
Annual metrics that are established quality measures:
None
Other annual metrics: None
Narrative information: SMI/SED DY1 Q2
Grievances and appeals: SMI/SED DY1 Q2
Other monthly and quarterly metrics: SMI/SED DY1 Q1
Annual metrics that are established quality measures:
None
Other annual metrics: None
Narrative information: SMI/SED DY1 Q3
Grievances and appeals: SMI/SED DY1 Q3
Other monthly and quarterly metrics: SMI/SED DY1 Q2
Annual metrics that are established quality measures:
None
Other annual metrics: None
Narrative information: SMI/SED DY1 Q4
Grievances and appeals: SMI/SED DY1 Q4
Other monthly and quarterly metrics: SMI/SED DY1 Q3
Annual metrics that are established quality measures:
None**
Other annual metrics: None
Narrative information: SMI/SED DY2 Q1
Grievances and appeals: SMI/SED DY2 Q1
Other monthly and quarterly metrics: SMI/SED DY1 Q4
Annual metrics that are established quality measures:
None
Other annual metrics: SMI/SED DY1 (calculated for
DY1)
Narrative information: SMI/SED DY2 Q2
Grievances and appeals: SMI/SED DY2 Q2
Other monthly and quarterly metrics: SMI/SED DY2 Q1
Annual metrics that are established quality measures:
SMI/SED DY1 (calculated for CY 2019)
Other annual metrics: None

Medicaid Section 1115 SMI/SED Demonstration Monitoring Protocol – Part B
[State] [Demonstration Name]
Submitted on [Insert Date]
*In this example, the state’s SMI/SED demonstration was added to its broader 1115 demonstration by amendment at the start of
the broader 1115 demonstration’s third demonstration year. States that do not have a broader 1115 demonstration (i.e., that have a
SMI/SED demonstration only) should delete this column.
**In this example, the state reports its established quality measures in the second quarterly report following the annual report
because its demonstration year ends on 12/31; this lag allows adequate time for claims runout and other data completeness issues,
as well as time to incorporate annual measure steward updates to specifications. States with demonstration years that end January
31 or February 28 should instead report established quality measures in the first quarterly report following the annual report. All
other states should report established quality measures in the annual report.

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