CMS-10398 #59 Current Availability Assessment

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Overview

Introduction
Instructions
Definitions
Narrative Description
Availability Asesssment

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Sheet 1: Introduction

Introduction to the Assessment of the Availability of Mental Health Services

This template has four tabs: 1) Instructions, 2) Definitions, 3) Narrative Description, and 4) Availability Assessment.

States are expected to complete the Narrative Description once, at the beginning of the demonstration, and the Availability Assessment annually following the instructions on the Instructions tab

Questions should be directed to your CMS Project Officer

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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Sheet 2: Instructions

Instructions for Completing the Narrative Description ("Narrative Description" tab)

The state will provide a brief narrative of baseline conditions in place at the beginning of the demonstration in the Narrative Description tab. The state should provide a brief response in the space below each question. The state should complete this at the beginning of the demonstration only.

Instructions for Completing the Assessment of the Availability of Mental Health Services ("Availability Assessment" tab)

Before you begin:

The state will submit multiple availability assessments. The state will submit an initial assessment at the time of application and annual assessments thereafter.

The state should select a consistent month in each year to populate the information in the availability assessment (e.g. provide initial information based on counts covering August 2019, and update the information based on counts covering August 2020, August 2021, August 2022, and August 2023).

Enter the state name, data entry date(s), and time period reflected in the availability assessment in cells C1-3.

To add rows for additional geographic designations, click the "Add row" button.

Column

Instructions

B

In column B, enter each geographic designation starting in cell B8. Add rows as needed to capture all geographic designations. Geographic designation means a state-defined geographic unit for reporting data, such as county, region, or catchment area. The state should consider how it divides its mental health system into smaller units or catchment areas to select geographic designations that will yield meaningful, actionable information.

C

In column C, starting in cell C8, please select whether geographic designation entered in the corresponding cell in column B could be considered urban or rural. If the geographic designation should be categorized as something other than urban or rural, select "Other-please explain" and record an explanation in the notes box in column D. Urban is defined as a Metropolitan Statistical Area or a Metropolitan division (in the case where a Metropolitan Statistical Area is divided into Metropolitan Divisions), as defined by the Executive Office of Management and Budget (42 CFR § 412.64(b)) Rural is defined as any area outside an urban area as defined in 42 CFR § 412.64(b).

D

In column D, beginning in cell D8, please use this space to explain the state's response if the state selects 'Other-please explain' in column C.

E

In column E, starting in cell E8, enter the total number of adult Medicaid beneficiaries ages 18-20 in each geographic designation at the selected point in time. Medicaid beneficiary means a person who has been determined to be eligible to receive Medicaid services as defined at 42 CFR §400.200. Note: this age category is separate in order to avoid double counting beneficiaries in the residential treatment category and to facilitate the calculation of certain ratios in the assessment. See the note in the following cell for additional explanation

F

In column F, starting in cell F8, enter the number of adult Medicaid beneficiaries ages 18-20 with SMI in each geographic designation at the selected point in time. As defined on page 1 of the State Medicaid Directors Letter, serious mental illness means persons age 18 and over who currently, or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria, that has resulted in functional impairment which substantially interferes with or limits one or more major life activities. Note: in the State Medicaid Directors letter (SMDL #18-011), SMI is defined to include individuals age 18 years and older, and SED includes children younger than 18. However, the residential treatment section of the availability assessment requests data on PRTFs, and the federal definition for PRTFs includes facilities that serve individuals under the age of 21. In order to avoid double counting beneficiaries in the residential treatment category, the assessment requests data on beneficiaries age 0-17, 18-20, and 21 and older separately.

G

In column G, starting in cell G8, enter the total number of adult Medicaid beneficiaries age 21 and older in each geographic designation at the selected point in time.

H

In column H, starting in cell H8, enter the number of adult Medicaid beneficiaries age 21 and older with SMI in each geographic designation at the selected point in time. Note: in the SMDL, SMI is defined to include individuals age 18 years and older, and SED includes children younger than 18. However, the residential treatment section of the availability assessment requests data on PRTFs, and the federal definition for PRTFs includes facilities that serve individuals under the age of 21. In order to avoid double counting beneficiaries in the residential treatment category, the assessment requests data on beneficiaries age 0-17, 18-20, and 21 and older separately.

I

In column I, starting in cell I8, the availability assessment will automatically calculate the percent of adult Medicaid beneficiaries who have SMI in each geographic designation. The state should not input any values into this column or modify the formulas in this column.

J

In column J, starting in cell J8, enter the total number of Medicaid beneficiaries under the age of 18 in each geographic designation at the selected point in time.

K

In column K, starting in cell K8, enter the number of beneficiaries under the age of 18 with SED in each geographic designation at the selected point in time. As defined on page 2 of the SMDL, individuals with SED are those from birth up to age 18 who currently, or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria that resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, or community activities. Functional impairment” is defined as difficulties that substantially interfere with or limit a child or adolescent from achieving or maintaining one or more developmentally-appropriate social, behavioral, cognitive, communicative, or adaptive skills.

L

In column L starting in cell L8, the availability assessment will automatically calculate the percent of beneficiaries under the age of 18 who have SED in each geographic designation. The state should not input any values into this column or modify the formulas in this column.

M

In column M, starting in cell M8, the availability assessment will automatically calculate the number of Medicaid beneficiaries (total) in each geographic designation.

N

In column N, starting in cell N8, the availability assessment will automatically calculate the percent with Medicaid beneficiaries with SMI or SED (total) in each geographic designation.

O

In column O, starting in cell O8, the availability assessment will automatically calculate the percent with SMI or SED (total) in each geographic designation.

P

In column P, beginning in cell P8, please use this space to provide notes about or qualifications to beneficiary data. For example, use this cell to explain data limitations or missing data.

Q

In column Q, starting in cell Q8, enter the number of psychiatrists or other practitioners who are authorized to prescribe in each geographic designation. A psychiatrist is any psychiatrist licensed to practice in the state under state licensure laws. Other prescribers authorized to prescribe means the number of mental health practitioners other than psychiatrists who are authorized to prescribe as defined by state licensure laws.

R

In column R, starting in cell R8, enter the number of Medicaid-enrolled psychiatrists or other practitioners who are authorized to prescribe in each geographic designation. Medicaid-enrolled means any provider enrolled in Medicaid to obtain Medicaid billing privileges, as defined in 42 CFR §455.410.

S

In column S, starting in cell S8, enter the number of Medicaid-enrolled psychiatrists or other practitioners who are authorized to prescribe and are accepting new Medicaid patients in each geographic designation. Accepting new Medicaid patients means any provider enrolled in Medicaid to obtain Medicaid billing privileges who will treat new Medicaid-enrolled patients.

T-V

In columns T-V, starting in cell T8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

W

In column W, beginning in cell W8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

X

In column X, starting in cell X8, enter the number of other practitioners certified or licensed to independently treat mental illness in each geographic designation. Other types of practitioners certified or licensed to independently treat mental illness means non-psychiatrist mental health providers who are certified or licensed to independently treat mental illness as defined by state licensure laws. This may include, but is not limited to, licensed psychologists, clinical social workers, and professional counselors.

Y

In column Y, starting in cell Y8, enter the number of Medicaid-enrolled other types of practitioners certified and licensed to independently treat mental illness in each geographic designation.

Z

In column Z, starting in cell Z8, enter the number of Medicaid-enrolled other types of practitioners certified and licensed to independently treat mental illness accepting new Medicaid patients in each geographic designation.

AA-AC

In columns AA-AC, starting in cell AA8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

AD

In column AD, beginning in cell AD8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

AE

In column AE, starting in cell AE8, enter the number of community mental health centers (CMHCs) in each geographic designation. A community mental health center is an entity that provides outpatient mental health services, 24 hour emergency care services, day treatment, screenings, and consultation and educational services, as defined at 42 CFR §410.2.

AF

In column AF, starting in cell AF8, enter the number of Medicaid-enrolled CMHCs in each geographic designation.

AG

In column AG, starting in cell AG8, enter the number of Medicaid-enrolled CMHCs accepting new Medicaid patients in each geographic designation.

AH-AJ

In columns AH-AJ, starting in cell AH8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

AK

In column AK, beginning in cell AK8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

AL

In column AL, starting in cell AL8, enter the number of intensive outpatient/partial hospitalization providers in each geographic designation. Partial hospitalization or intensive outpatient services means a distinct and organized intensive ambulatory treatment program that offers less than 24-hour daily care other than in an individual's home or in an inpatient or residential setting.

AM

In column AM, starting in cell AM8, enter the number of Medicaid-enrolled intensive outpatient/partial hospitalization providers in each geographic designation.

AN

In column AN, starting in cell AN8, enter the number of Medicaid-enrolled intensive outpatient/partial hospitalization providers accepting new Medicaid patients in each geographic designation.

AO-AQ

In column AO-AQ, starting in cell AO8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

AR

In column AR, beginning in cell AR8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

AS

In column AS, starting in cell AS8, enter the number of residential mental health treatment facilities (adult) in each geographic designation. A residential mental health treatment facilities (adult) is a facility not licensed as a psychiatric hospital, whose primary purpose is to provide individually planned programs of mental health treatment services in a residential care setting for adults as defined for SAMHSA's N-MHSS. Please exclude residential SUD treatment facilities.

AT

In column AT, starting in cell AT8, enter the number of Medicaid-enrolled residential mental health treatment facilities (adult) in each geographic designation.

AU

In column AU, starting in cell AU8, enter the number of Medicaid-enrolled residential mental health treatment facilities (adult) accepting new Medicaid patients in each geographic designation.

AV-AX

In column AV-AX, starting in cell AV8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

AY

In column AY, starting in cell AY8, enter the total number of residential mental health treatment facility beds (adult) in each geographic designation.

AZ

In column AZ, starting in cell AZ8, enter the total number of Medicaid-enrolled residential mental health treatment beds (adult) in each geographic designation.

BA

In column BA, starting in cell BA8, enter the total number of Medicaid-enrolled residential mental health treatment beds available to adult Medicaid patients in each geographic designation. Available to Medicaid adult Medicaid patients means any facility or bed available to serve Medicaid patients over the age of 18.

BB-BD

In column BB-BD, starting in cell BB8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

BE

In column BE, beginning in cell BE8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

BF

In column BF, starting in cell BF8, enter the number of psychiatric residential treatment facilities (PRTF) in each geographic designation. A PRTF is a non-hospital facility with a provider agreement with a state Medicaid agency to provide the inpatient psychiatric services to individuals under age 21 benefit (psych under 21 benefit). The facility must be accredited by the Joint Commission, the Council on Accreditation of Services for Families and Children, the Commission on Accreditation of Rehabilitation Facilities, or any other accrediting organization with comparable standards recognized by the State. PRTFs must also meet the requirements at 42 CFR §441.151 - §441.182, and 42 CFR §483.350 – §483.376.

BG

In column BG, starting in cell BG8, enter the number of Medicaid-enrolled PRTFs in each geographic designation.

BH

In column BH, starting in cell BH8, enter the number of Medicaid-enrolled PRTFs accepting new Medicaid patients in each geographic designation.

BI-BK

In column BI-BK, starting in cell BI8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

BL

In column BL, starting in cell BL8, enter the total number of PRTF beds in each geographic designation.

BM

In column BM, starting in cell BM8, enter the number of Medicaid-enrolled PRTF beds in each geographic designation.

BN

In column BN, starting in cell BN8, enter the number of Medicaid-enrolled PRTF beds available to Medicaid patients in each geographic designation. Available to Medicaid patients means any facility or bed available to serve Medicaid patients.

BO-BQ

In column BO-BQ, starting in cell BO8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

BR

In column BR, beginning in cell BR8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

BS

In column BS, starting in cell BS8, enter the number of psychiatric hospitals in each geographic designation. A psychiatric hospital is an institution which provides diagnosis and treatment of mentally ill persons, as defined at 42 USC §1395x.

BT

In column BT, starting in cell BT8, enter the number of psychiatric hospitals available to Medicaid patients in each geographic designation.

BU-BV

In column BU-BV, starting in cell BU8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

BW

In column BW, beginning in cell BW8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

BX

In column BX, starting in cell BX8, enter the number of psychiatric units in acute care hospitals in each geographic designation. A psychiatric unit is a separate inpatient psychiatric unit of a general hospital that provides inpatient mental health services and has specifically allocated staff and space (beds) for the treatment of persons with mental illness, as defined for SAMHSA's N-MHSS.

BY

In column BY, starting in cell BY8, enter the number of psychiatric units in critical access hospitals (CAHs) in each geographic designation. A critical access hospital is a small facility that provides 24-hour emergency care, outpatient services, as well as inpatient services to people in rural areas, as defined in 42 CFR §485.606.

BZ

In column BZ, starting in cell BZ8, enter the number of Medicaid-enrolled psychiatric units in acute care hospitals in each geographic designation.

CA

In column CA, starting in cell CA8, enter the number of Medicaid-enrolled psychiatric units in CAHs in each geographic designation.

CB

In column CB, starting in cell CB8, enter the number of Medicaid-enrolled psychiatric units in acute care hospitals accepting new Medicaid patients in each geographic designation.

CC

In column CC starting in cell CC8, enter the number of Medicaid-enrolled psychiatric units in CAHs accepting new Medicaid patients in each geographic designation.

CD-CI

In column CD-CI, starting in cell CD8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

CJ

In column CJ, beginning in cell CJ8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

CK

In column CK, starting in cell CK8, enter the number of licensed psychiatric hospital beds (psychiatric hospital + psychiatric units) in each geographic designation. Please enter the number of licensed psychiatric hospital beds as defined by state licensure requirements.

CL

In column CL, starting in cell CL8, enter the number of licensed psychiatric hospital beds (psychiatric hospital + psychiatric units) available to Medicaid patients in each geographic designation.

CM-CN

In column CM-CN, starting in cell CM8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

CO

In column CO, beginning in cell CO8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

CP

In column CP, starting in cell CP8, enter the number of residential mental health treatment facilities (adult) that qualify as an institution for mental diseases (IMDs) in each geographic designation. An IMD is a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services per section 1905(i) of the Social Security Act. See also 42 CFR §435.1010 and section 4390 of the State Medicaid Manual.

CQ

In column CQ, starting in cell CQ8, enter the number of Medicaid-enrolled residential mental health treatment facilities (adult) that qualify as IMDs in each geographic designation.

CR

In column CR, starting in cell CR8, enter the number of Medicaid-enrolled residential mental health treatment facilities (adult) that qualify as IMDs accepting Medicaid patients in each geographic designation.

CS-CU

In column CS-CU, starting in cell CS8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

CV

In column CV, starting in cell CV8, enter the number of psychiatric hospitals that qualify as IMDs in each geographic designation.

CW

In column CW, starting in cell CW8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

CX

In column CX, beginning in cell CX8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

CY

In column CY, starting in cell CY8, enter the number of crisis call centers in each geographic designation. Please enter the number of crisis call centers as defined by the state.

CZ

In column CZ, starting in cell CZ8, enter the number of mobile crisis units in each geographic designation. A mobile crisis unit is a team that intervenes during mental health crises, as defined by the state.

DA

In column DA, starting in cell DA8, enter the number of crisis observation/ assessment centers in each geographic designation. Please enter the number of observation or assessment centers as defined by the state.

DB

In column DB, starting in cell DB8, enter the number of crisis stabilization units in each geographic designation. Crisis stabilization units offer medically monitored short-term crisis stabilization services, as defined by the state.

DC

In column DC, starting in cell DC8, enter the number of coordinated community crisis response teams in each geographic designation. Coordinated community crisis response means a community-based program or entity that manages crisis response across various community entities or programs, as defined by the state.

DD-DH

In column DD-DH, starting in cell DD8, the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

DI

In column DI, beginning in cell DI8, please use this space to provide notes about or qualifications to category data. For example, use this cell to explain data limitations or missing data.

DJ

In column DJ, starting in cell DJ8, enter the number FQHCs that offer behavioral health services in each geographic designation. Federally qualified health center (FQHC) means an entity that has entered into an agreement with CMS to meet Medicare program requirements under 42 CFR §405.2434 and 42 CFR §405.2401.

DK

In column DK, starting in cell DK8,the availability assessment will automatically calculate the ratios in each geographic designation. The state should not input any values into these columns or modify the formulas in these columns.

DL

In column DL, beginning in cell DL8, please use this space to provide notes about or qualifications to category data.

DM

Beginning in column DM, add additional counts and ratios for provider and setting types that the state considers important to its mental health system. The state should not modify any of the previous columns.

End of worksheet

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Sheet 3: Definitions

Definitions of terms used in the Availability Assessment
Term	Definition
Accepting new Medicaid patients	Accepting new Medicaid patients means any provider enrolled in Medicaid to obtain Medicaid billing privileges who will treat new Medicaid-enrolled patients.
Available to Medicaid patients	Available to Medicaid patients means any facility or bed available to serve Medicaid patients.
Adult	An adult is a person age 18 and over [SMDL].
Community mental health center (CMHC)	A community mental health center (CMHC) is an entity that provides outpatient mental health services, 24 hour emergency care services, day treatment, screenings, and consultation and educational services, as defined at 42 CFR §410.2.
Coordinated community crisis response	Coordinated community crisis response means a community-based program or entity that manages crisis response across various community entities or programs, as defined by the state.
Crisis call center	Crisis call centers are defined by the state.
Crisis stabilization unit	Crisis stabilization units offer medically monitored short-term crisis stabilization services, as defined by the state.
Critical access hospital	A critical access hospital is a small facility that provides 24-hour emergency care, outpatient services, as well as inpatient services to people in rural areas, as defined in 42 CFR §485.606.
Federally qualified health center	Federally qualified health center (FQHC) means an entity that has entered into an agreement with CMS to meet Medicare program requirements under 42 CFR §405.2434 and 42 CFR §405.2401
Geographic designation	Geographic designation means a state-defined geographic unit for reporting data, such as county, region, or catchment area.
Institution for mental diseases (IMD)	An institution for mental diseases is a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services per section 1905(i) of the Social Security Act. See also 42 CFR §435.1010 and section 4390 of the State Medicaid Manual.
Intensive outpatient services or partial hospitalization	Intensive outpatient services or partial hospitalization means a distinct and organized intensive ambulatory treatment program that offers less than 24-hour daily care other than in an individual's home or in an inpatient or residential setting.
Licensed psychiatric hospital bed	Licensed psychiatric hospital bedsare defined by state licensure requirements.
Medicaid beneficiary	Medicaid beneficiary means a person who has been determined to be eligible to receive Medicaid services as defined at 42 CFR §400.200.
Medicaid-enrolled	Medicaid-enrolled means any provider enrolled in Medicaid to obtain Medicaid billing privileges, as defined in 42 CFR §455.410.
Mobile crisis unit	A mobile crisis unit is a team that intervenes during mental health crises, as defined by the state.
Mental health practitioners other than psychiatrists who are authorized to prescribe	Mental health practitioners other than psychiatrists who are authorized to prescribe are defined by state licensure laws.
Mental health practitioners other than psychiatrists who are certified or licensed by the state to independently treat mental illness.	Mental health practitioners other than psychiatrists who are certified or licensed to treat mental illness are non-psychiatrist mental health providers who are certified or licensed to independently treat mental illness as defined by state licensure laws. This may include, but is not limited to, licensed psychologists, clinical social workers, and professional counselors .
Observation or assessment centers	Observation or assessment centers are defined by the state.
Psychiatric hospital	A psychiatric hospital is an institution which provides diagnosis and treatment of mentally ill person, as defined at 42 USC §1395x.
Psychiatric residential treatment facility (PRTF)	A psychiatric residential treatment facility is a non-hospital facility with a provider agreement with a state Medicaid agency to provide the inpatient psychiatric services to individuals under age 21 benefit (psych under 21 benefit). The facility must be accredited by the Joint Commission, the Council on Accreditation of Services for Families and Children, the Commission on Accreditation of Rehabilitation Facilities, or any other accrediting organization with comparable standards recognized by the State. PRTFs must also meet the requirements at 42 CFR §441.151 - §441.182, and 42 CFR §483.350 – §483.376.
Psychiatric unit	A psychiatric unit is a separate inpatient psychiatric unit of a general hospital that provides inpatient mental health services and has specifically allocated staff and space (beds) for the treatment of persons with mental illness, as defined for SAMHSA's National Mental Health Services Survey (N-MHSS).
Psychiatrist	A psychiatrist is any psychiatrist licensed to practice in the state under state licensure laws
Residential mental health treatment facilities (adult)	A residential mental health treatment facilities (adult) is a facility not licensed as a psychiatric hospital, whose primary purpose is to provide individually planned programs of mental health treatment services in a residential care setting for adults as defined for SAMHSA's N-MHSS. Please exclude residential SUD treatment facilities.
Rural	Rural means any area outside an urban area as defined in 42 CFR § 412.64(b)
Serious emotional disturbance	Persons withserious emotional disturbance means individuals from birth up to age 18 who currently, or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria that resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, or community activities. Functional impairment” is defined as difficulties that substantially interfere with or limit a child or adolescent from achieving or maintaining one or more developmentally-appropriate social, behavioral, cognitive, communicative, or adaptive skills [SMDL].
Serious mental illness	Persons with serious mental illness means individuals, age 18 and over, who currently, or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria, that has resulted in functional impairment which substantially interferes with or limits one or more major life activities. [SMDL] Note: in the SMDL, SMI is defined to include individuals age 18 years and older, and SED includes children younger than 18. However, the residential treatment section of the availability assessment requests data on PRTFs, and the federal definition for PRTFs includes facilities that serve individuals under the age of 21. In order to avoid double counting beneficiaries in the residential treatment category, the assessment requests data on beneficiaries age 0-17, 18-20, and 21 and older separately.
Urban	Urban means a Metropolitan Statistical Area or a Metropolitan division (in the case where a Metropolitan Statistical Area is divided into Metropolitan Divisions), as defined by the Executive Office of Management and Budget (42 CFR § 412.64(b)).
End of worksheet

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Sheet 4: Narrative Description

Narrative Description (to be completed at baseline)

1. In the space below, describe the mental health service needs (e.g. prevalence and distribution of SMI/SED) of Medicaid beneficiaries with SMI/SED in the state at the beginning of the demonstration. [Limit responses to 500 words if possible]

2. In the space below, describe the organization of the state’s Medicaid behavioral health service delivery system at the beginning of the demonstration. [Limit responses to 500 words if possible]

3. In the space below, describe the availability of mental health services for Medicaid beneficiaries with SMI/SED in the state at the beginning of the demonstration. At minimum, explain any variations across the state in the availability of the following: inpatient mental health services; outpatient and community-based services; crisis behavioral health services; and care coordination and care transition planning. [Limit responses to 1000 words if possible]

4. In the space below, describe any gaps the state identified in the availability of mental health services or service capacity while completing the Availability Assessment. [Limit responses to 500 words if possible]

5. In the space below, describe any gaps in the availability of mental health services or service capacity NOT reflected in the Availability Assessment. [Limit responses to 500 words if possible]

End of worksheet

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Sheet 5: Availability Asesssment

	State Name
	Date of Assessment
	Time Period Reflected in Assessment
	Geographic Designation			Beneficiaries												Providers														Community Mental Health Centers							Intensive Outpatient or Partial Hospitalization Providers							Residential Mental Health Treatment Facilities																										Inpatient																							Institutions for Mental Diseases									Crisis Stabilization Services											Federally Qualified Health Centers
				Adult					Children			Total				Psychiatrists or Other Practitioners Who Are Authorized to Prescribe							Other Practitioners Certified and Licensed to Independently Treat Mental Illness																					Residential Mental Health Treatment Facilities (Adult)													Psychiatric Residential Treatment Facilities													Psychiatric Hospitals					Psychiatric Units													Psychiatric Beds					Residential Treatment Facilities That Qualify As IMDs						Psychiatric Hospitals That Qualify As IMDs
	Geographic designation	Is this geographic designation primarily urban or rural?	Geographic Designation Notes	Number of adult Medicaid beneficiaries (18 - 20)	Number of adult Medicaid beneficiaries with SMI (18 - 20)	Number of adult Medicaid beneficiaries (21+)	Number of adult Medicaid beneficiaries with SMI (21+)	Percent with SMI (Adult)	Number of Medicaid beneficiaries (0 - 17)	Number of Medicaid beneficiaries with SED (0 - 17)	Percent with SED (0-17)	Number of Medicaid beneficiaries (Total)	Number of Medicaid beneficiaries with SMI or SED (Total)	Percent with SMI or SED (Total)	Beneficiary Category Notes	Number of Psychiatrists or Other Practitioners Who Are Authorized to Prescribe	Number of Medicaid-Enrolled Psychiatrists or Other Practitioners Who Are Authorized to Prescribe	Number of Medicaid-Enrolled Psychiatrists or Other Practitioners Who Are Authorized to Prescribe Accepting New Medicaid Patients	Ratio of Medicaid beneficiaries with SMI/SED to Medicaid-Enrolled Psychiatrists or Other Prescribers	Ratio of Total Psychiatrists or Other Prescribers to Medicaid-Enrolled Psychiatrists or Other Prescribers	Ratio of Medicaid-Enrolled Psychiatrists or Other Prescribers to Medicaid-Enrolled Psychiatrists or Other Prescribers Accepting New Medicaid Patients	Psychiatrists or Other Practitioners Who Are Authorized to Prescribe Category Notes	Number of Other Practitioners Certified or Licensed to Independently Treat Mental Illness	Number of Medicaid-Enrolled Other Practitioners Certified or Licensed to Independently Treat Mental Illness	Number of Medicaid-Enrolled Other Practitioners Certified or Licensed to Independently Treat Mental Illness Accepting New Medicaid Patients	Ratio of Medicaid Beneficiaries with SMI/SED to Medicaid-Enrolled Other Practitioners Certified or Licensed to Independently Treat Mental Illness	Ratio of Other Practitioners Certified or Licensed to Independently Treat Mental Illness to Medicaid-Enrolled Other Practitioners Certified or Licensed to Independently Treat Mental Illness	Ratio of Medicaid-Enrolled Other Practitioners Certified and Licensed to Independently Treat Mental Illness to Medicaid-Enrolled Other Practitioners Certified and Licensed to Independently Treat Mental Illness Accepting New Patients	Other Practitioner Category Notes	Number of CMHCs	Number of Medicaid- Enrolled CMHCs	Number of Medicaid-Enrolled CMHCs Accepting New Medicaid Patients	Ratio of Medicaid Beneficiaries with SMI/SED to Medicaid- Enrolled CMHCs	Ratio of Total CMHCs to Medicaid- Enrolled CMHCs	Ratio of Medicaid-Enrolled CMHCs to Medicaid-Enrolled CMHCs Accepting New Patients	CMHC Category Notes	Number of Intensive Outpatient/ Partial Hospitalization Providers	Number of Medicaid-Enrolled Intensive Outpatient/ Partial Hospitalization Providers	Number of Medicaid-Enrolled Intensive Outpatient/Partial Hospitalization Providers Accepting New Medicaid Patients	Ratio of Medicaid Beneficiaries with SMI/SED to Medicaid- Enrolled Intensive Outpatient/ Partial Hospitalization Providers	Ratio of Total Partial Hospitalization/ Day Treatment Providers to Medicaid-Enrolled Intensive Outpatient/ Partial Hospitalization Providers	Ratio of Medicaid-Enrolled Partial Hospitalization/ Day Treatment Providers to Medicaid- Enrolled Intensive Outpatient/ Partial Hospitalization Providers Accepting New Medicaid Patients	Intensive Outpatient/ Partial Hospitalization Category Notes	Number of Residential Mental Health Treatment Facilities (Adult)	Number of Medicaid- Enrolled Residential Mental Health Treatment Facilities (Adult)	Number of Medicaid-Enrolled Residential Mental Health Treatment Facilities Accepting New Medicaid Patients (Adult)	Ratio of Medicaid Beneficiaries with SMI (Adult) to Medicaid- Enrolled Residential Mental Health Treatment Facilities (Adult)	Ratio of Total Residential Mental Health Treatment Facilities (Adult) to Medicaid-Enrolled Residential Mental Health Treatment Facilities (Adult)	Ratio of Medicaid-Enrolled Residential Mental Health Treatment Facilities (Adult) to Medicaid- Enrolled Residential Mental Health Treatment Facilities (Adult) Accepting New Patients	Total Number of Residential Mental Health Treatment Facility Beds (Adult)	Total Number of Medicaid- Enrolled Residential Mental Health Treatment Beds (Adult)	Total Number of Medicaid-Enrolled Residential Mental Health Treatment Beds Available to Adult Medicaid Patients	Ratio of Medicaid Beneficiaries with SMI (Adult) to Medicaid-Enrolled Residential Mental Health Treatment Beds	Ratio of Total Residential Mental Health Treatment Beds to Medicaid-Enrolled Residential Mental Health Treatment Beds	Ratio of Medicaid-Enrolled Residential Mental Health Treatment Beds to Medicaid- Enrolled Residential Mental Health Treatment Beds Available to Medicaid Patients	Residential Mental Health Treatment Facility Category Notes (Adult)	Number of Psychiatric Residential Treatment Facilities (PRTF)	Number of Medicaid- Enrolled PRTFs	Number of Medicaid-Enrolled PRTFs Accepting New Medicaid Patients	Ratio of Medicaid Beneficiaries with SED to Medicaid-Enrolled PTRFs	Ratio of Total PTRFs to Medicaid- Enrolled PRTFs	Ratio of Medicaid-Enrolled PRTFs to Medicaid-Enrolled PRTFs Accepting New Medicaid Patients	Total Number of PRTF Beds	Number of Medicaid-Enrolled PRTF Beds	Number of Medicaid-Enrolled PRTF Beds Available to Medicaid Patients	Ratio of Medicaid Beneficiaries with SED to Medicaid-Enrolled PRTF Beds Available to Medicaid Patients	Ratio of Total Number of PRTF Beds to Medicaid- Enrolled PRTF Beds	Ratio of Medicaid- Enrolled PRTF Beds to Medicaid- Enrolled PRTFs Available to Medicaid Patients	Psychiatric Residential Treatment Facility (Under 21) Category Notes	Number of Psychiatric Hospitals	Psychiatric Hospitals Available to Medicaid Patients	Ratio of Medicaid Beneficiaries with SMI/SED to Psychiatric Hospitals Available to Medicaid Patients	Ratio of Psychiatric Hospitals to Psychiatric Hospitals Available to Medicaid Patients	Psychiatric Hospital Category Notes	Number of Psychiatric Units in Acute Care Hospitals	Number of Psychiatric Units in Critical Access Hospitals (CAHs)	Number of Medicaid- Enrolled Psychiatric Units in Acute Care Hospitals	Number of Medicaid-Enrolled Psychiatric Units in CAHs	Number of Medicaid-Enrolled Psychiatric Units in Acute Care Hospitals Accepting New Medicaid Patients	Number of Medicaid-Enrolled Psychiatric Units in CAHs Accepting New Medicaid Patients	Ratio of Medicaid Beneficiaries with SMI/SED to Medicaid-Enrolled Psychiatric Units in Acute Care Hospitals	Ratio of Medicaid Beneficiaries with SMI/SED to Medicaid-Enrolled Psychiatric Units in CAHs	Ratio of Psychiatric Units in Acute Care Hospitals to Medicaid-Enrolled Psychiatric Units in Acute Care Hospitals	Ratio of Psychiatric Units in CAHs to Medicaid-Enrolled Psychiatric Units in CAHs	Ratio of Medicaid-Enrolled Psychiatric Units in Acute Care Hospitals to Medicaid-Enrolled Psychiatric Units in Acute Care Hospitals Accepting New Medicaid Patients	Ratio of Medicaid-Enrolled Psychiatric Units in CAHs to Medicaid-Enrolled Psychiatric Units in CAHs Accepting New Medicaid Patients	Psychiatric Unit Category Notes	Number of Licensed Psychiatric Hospital Beds (Psychiatric Hospital + Psychiatric Units)	Number of Licensed Psychiatric Hospital Beds (Psychiatric Hospital + Psychiatric Units) Available to Medicaid Patients	Ratio of Medicaid Beneficiaries with SMI/SED to Licensed Psychiatric Hospital Beds Available to Medicaid Patients	Ratio of Licensed Psychiatric Hospital Beds to Licensed Psychiatric Hospital Beds Available to Medicaid Patients	Psychiatric Beds Category Notes	Number of Residential Mental Health Treatment Facilities (Adult) that Qualify as IMDs	Number of Medicaid- Enrolled Residential Mental Health Treatment Facilities (Adult) that Qualify as IMDs	Number of Medicaid- Enrolled Residential Mental Health Treatment Facilities (Adult) that Qualify as IMDs Accepting Medicaid Patients	Ratio of Medicaid Beneficiaries with SMI (Adult) to Medicaid- Enrolled Residential Mental Health Treatment Facilities that Qualify as IMDs	Ratio of Total Residential Mental Health Treatment Facilities (Adult) that Qualify as IMDs to Medicaid-Enrolled Residential Mental Health Treatment Facilities (Adult) that Qualify as IMDs	Ratio of Medicaid-Enrolled Residential Mental Health Treatment Facilities (Adult) that Qualify as IMDs to Medicaid- Enrolled Residential Mental Health Treatment Facilities (Adult) that Qualify as IMDs Accepting New Medicaid Patients	Number of Psychiatric Hospitals that Qualify as IMDs	Ratio of Medicaid Beneficiaries with SMI/SED to Psychiatric Hospitals that Qualify as IMDs	Facilities That Qualify As IMDs Category Notes	Number of Crisis Call Centers	Number of Mobile Crisis Units	Number of Crisis Observation/ Assessment Centers	Number of Crisis Stabilization Units	Number of Coordinated Community Crisis Response Teams	Ratio of Medicaid Beneficiaries with SMI/SED to Crisis Call Centers	Ratio of Medicaid Beneficiaries with SMI/SED to Mobile Crisis Units	Ratio of Medicaid Beneficiaries with SMI/SED to Crisis Observation/ Assessment Centers	Ratio of Medicaid Beneficiaries with SMI/SED to Crisis Stabilization Units	Ratio of Medicaid Beneficiaries with SMI/SED to Coordinated Community Crisis Response Teams	Crisis Stabilization Services Category Notes	Number FQHCs that Offer Behavioral Health Services	Ratio of Medicaid Beneficiaries with SMI/SED to FQHCs that Offer Behavioral Health Services	FQHC Category Notes
1.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
2.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
3.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
4.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
5.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
6.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
7.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
8.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
9.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
10.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
11.								-			-	0	0	-					-	-	-					-	-	-					-	-	-					-	-	-					-	-	-				-	-	-					-	-	-				-	-	-				-	-								-	-	-	-	-	-				-	-					-	-	-		-							-	-	-	-	-			-
	Total			0	0	0	0	-	0	0	-	0	0	-		0	0	0	-	-	-		0	0	0	-	-	-		0	0	0	-	-	-		0	0	0	-	-	-		0	0	0	-	-	-	0	0	0	-	-	-		0	0	0	-	-	-	0	0	0	-	-	-		0	0	-	-		0	0	0	0	0	0	-	-	-	-	-	-		0	0	-	-		0	0	0	-	-	-	0	-		0	0	0	0	0	-	-	-	-	-		0	-