CMS-10398 #57 1115 SUD Metrics Template
Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
Copy of Copy of 1115 SUD Metrics Workbook 3_1 (version 4).xlsx
GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates
OMB: 0938-1148
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1148 can be found here:
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Monitoring protocol
Metrics report
Data and reporting issues
Version notes
Overview
PRA Disclosure StatementMonitoring protocol
Metrics report
Data and reporting issues
Version notes
Sheet 1: PRA Disclosure Statement
| PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid Services in program monitoring of Medicaid Section 1115 Substance Use Disorder Demonstrations. This mandatory information collection (42 CFR 431.428) will be used to support more efficient, timely and accurate review of states’ SUD 1115 demonstrations monitoring reports submissions to support consistency of monitoring and evaluation of SUD 1115 Demonstrations, increase in reporting accuracy, and reduce 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 #57). Public reporting burden for this collection of information is estimated to average 20 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. |
Sheet 2: Monitoring protocol
| Medicaid Section 1115 SUD Demonstration Monitoring Protocol | ||||||||||||||
| State | [Enter State Name] | |||||||||||||
| Demonstration Name | [Enter Demonstration Name] | |||||||||||||
| Submitted on | [Enter Date] (Format: MM/DD/YYYY) | |||||||||||||
| State will report (Y/N) | Reporting priority | # | Metric name | Metric description | Data source | Measurement period | Reporting frequency | Baseline Reporting Period (MM/DD/YYYY--MM/DD/YYYY) | Annual goal | Overall demonstration target | Attest that planned reporting matches the CMS-provided specification (Y/N) | Explanation of any deviations from the CMS-provided specifications (different data source, definition, codes, target population, etc.) | Demonstration Year (DY) and Quarter(Q) in which reporting will begin (Format: DY1Q3) | Explanation of any plans to phase in reporting over time |
| Assessment of need and qualification for SUD treatment services | ||||||||||||||
| Recommended | 1 | Assessed for SUD Treatment Needs Using a Standardized Screening Tool | Number of beneficiaries screened for SUD treatment needs using a standardized screening tool during the measurement period | Medical record review or claims | Month | Quarterly | ||||||||
| Recommended | 2 | Medicaid Beneficiaries with Newly Initiated SUD Treatment/Diagnosis | Number of beneficiaries with a SUD diagnosis and a SUD-related service during the measurement period but not in the three months before the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 3 | Medicaid Beneficiaries with SUD Diagnosis (monthly) | Number of beneficiaries with a SUD diagnosis and a SUD-related service during the measurement period and/or in the 11 months before the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 4 | Medicaid Beneficiaries with SUD Diagnosis (annually) | Number of beneficiaries with a SUD diagnosis and a SUD-related service during the measurement period and/or in the 12 months before the measurement period | Claims | Year | Annually | ||||||||
| Required | 5 | Medicaid Beneficiaries Treated in an IMD for SUD | Number of beneficiaries with a claim for residential treatment for SUD in an IMD during the reporting year | Claims | Year | Annually | ||||||||
| Milestone 1: Access to critical levels of care for OUD and other SUDs | ||||||||||||||
| Required | 6 | Any SUD Treatment | Number of beneficiaries enrolled in the measurement period receiving any SUD treatment service, facility claim, or pharmacy claim during the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 7 | Early Intervention | Number of beneficiaries who used early intervention services (such as procedure codes associated with SBIRT) during the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 8 | Outpatient Services | Number of beneficiaries who used outpatient services for SUD (such as outpatient recovery or motivational enhancement therapies, step down care, and monitoring for stable patients) during the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 9 | Intensive Outpatient and Partial Hospitalization Services | Number of unique beneficiaries who used intensive outpatient and/or partial hospitalization services for SUD (such as specialized outpatient SUD therapy or other clinical services) during the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 10 | Residential and Inpatient Services | Number of beneficiaries who use residential and/or inpatient services for SUD during the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 11 | Withdrawal Management | Number of beneficiaries who use withdrawal management services (such as outpatient, inpatient, or residential) during the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 12 | Medication Assisted Treatment | Number of beneficiaries who have a claim for MAT for SUD during the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 36 | Average Length of Stay in IMDs | The average length of stay for beneficiaries discharged from IMD residential treatment for SUD | Claims; State-specific IMD database | Year | Annually | ||||||||
| Milestone 2: Use of evidence-based, SUD-specific patient placement criteria | ||||||||||||||
| There are no CMS-provided metrics related to milestone 2. | ||||||||||||||
| Milestone 3: Use of nationally recognized SUD-specific program standards to set provider qualifications for residential treatment facilities | ||||||||||||||
| There are no CMS-provided metrics related to milestone 3. | ||||||||||||||
| Milestone 4: Sufficient provider capacity at critical levels of care including for medication assisted treatment for OUD | ||||||||||||||
| Required | 13 | SUD Provider Availability | The number of providers who were enrolled in Medicaid and qualified to deliver SUD services during the measurement period | Provider enrollment database; Claims | Year | Annually | ||||||||
| Required | 14 | SUD Provider Availability - MAT | The number of providers who were enrolled in Medicaid and qualified to deliver SUD services during the measurement period and who meet the standards to provide buprenorphine or methadone as part of MAT | Provider enrollment database; Claims; SAMHSA datasets | Year | Annually | ||||||||
| Milestone 5: Implementation of comprehensive treatment and prevention strategies to address opioid abuse and OUD | ||||||||||||||
| Required | 15 | Initiation and Engagement of Alcohol and Other Drug (AOD) Dependence Treatment (IET) [NCQA; NQF #0004; Medicaid Adult Core Set] |
1. Initiation of AOD Treatment—percentage of beneficiaries who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or MAT within 14 days of the diagnosis 2.Engagement of AOD Treatment—percentage of beneficiaries who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit |
Claims | Year | Annually | ||||||||
| Required | 18 | Use of Opioids at High Dosage in Persons Without Cancer [PQA, NQF #2940; Medicaid Adult Core Set] |
Rate per 1,000 beneficiaries age 18 and older included in the denominator without cancer who received prescriptions for opioids with a daily dosage greater than 120 morphine milligram equivalents for 90 consecutive days or longer. Patients in hospice are also excluded. | Claims | Year | Annually | ||||||||
| Recommended | 19 | Use of Opioids from Multiple Providers in Persons Without Cancer [PQA; NQF #2950] |
Rate per 1,000 beneficiaries included in the denominator without cancer who received prescriptions for opioids from four or more prescribers and four or more pharmacies. | Claims | Year | Annually | ||||||||
| Recommended | 20 | Use of Opioids at High Dosage from Multiple Providers in Persons Without Cancer [PQA, NQF #2951] | Rate per 1,000 beneficiaries included in the denominator without cancer who received prescriptions for opioids greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer, and from four or more prescribers and four or more pharmacies. | Claims | Year | Annually | ||||||||
| Required | 21 | Concurrent Use of Opioids and Benzodiazepines [PQA] |
Percentage of beneficiaries age 18 and older with concurrent use of prescription opioids and benzodiazepines. Patients with a cancer diagnosis or in hospice are excluded. | Claims | Year | Annually | ||||||||
| Required | 22 | Continuity of Pharmacotherapy for Opioid Use Disorder [RAND; NQF #3175] |
Percentage of adults in the denominator with pharmacotherapy for OUD who have at least 180 days of continuous treatment | Claims | Year | Annually | ||||||||
| Milestone 6: Improved care coordination and transitions between levels of care | ||||||||||||||
| Recommended | 16 | SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol and Other Drug Use Disorder Treatment at Discharge [Joint Commission; NQF #1664] |
SUB-3 rate: Patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. SUB-3a rate: Patients who are identified with alcohol or drug disorder who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. |
Medical record review or claims | Year | Annually | ||||||||
| Required | 17 | Follow-up after Discharge from the Emergency Department for Mental Health or Alcohol or Other Drug Dependence§ [NCQA; NQF #2605; Medicaid Adult Core Set] |
Percentage of ED visits for beneficiaries who have a principal diagnosis of mental illness or AOD abuse or dependence and who had a follow-up visit for mental illness or AOD. Four rates are reported: Percentage 1. Percentage of ED visits for mental illness for which the beneficiary received follow-up within 7 days of the ED visit (8 total days). Percentage 2. Percentage of ED visits for mental illness for which the beneficiary received follow-up within 30 days of the ED visit (31 total days) Percentage 3. Percentage of ED visits for which the beneficiary received a follow-up visit for mental illness or AOD within 30 days of the ED visit (31 total days) Percentage 4. Percentage of ED visits for which the beneficiary received a follow-up visit for mental illness or AOD within 7 days of the ED visit (8 total days) |
Claims | Year | Annually | ||||||||
| SUD health information technology (SUD health IT) (Insert at least one selected metric per key health IT question 1-3. See instructions document for further guidance.) | ||||||||||||||
| Required | Q1 | [Insert selected metric(s) for health IT question 1] | ||||||||||||
| Required | Q2 | [Insert selected metric(s) for health IT question 2] | ||||||||||||
| Required | Q3 | [Insert selected metric(s) for health IT question 3] | ||||||||||||
| Other SUD-related metrics | ||||||||||||||
| Required | 23 | Emergency Department Utilization for SUD per 1,000 Medicaid Beneficiaries | Total number of ED visits for SUD per 1,000 beneficiaries in the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 24 | Inpatient Stays for SUD per 1,000 Medicaid Beneficiaries | Total number of inpatient stays per 1,000 beneficiaries in the measurement period | Claims | Month | Quarterly | ||||||||
| Required | 25 | Readmissions Among Beneficiaries with SUD | The number of acute inpatient stays among beneficiaries with SUD during the measurement period followed by an acute readmission within 30 days. | Claims | Year | Annually | ||||||||
| Required | 26 | Overdose Deaths (count) | Number of overdose deaths during the measurement period among Medicaid beneficiaries living in a geographic area covered by the demonstration. States are encouraged to report the cause of overdose death as specifically as possible (for example, prescription vs. illicit opioid). | State data on cause of death | Year | Annually | ||||||||
| Required | 27 | Overdose Deaths (rate) | Rate of overdose deaths during the measurement period among adult Medicaid beneficiaries living in a geographic area covered by the demonstration. States are encouraged to report the cause of overdose death as specifically as possible (for example, prescription vs. illicit opioid). | State data on cause of death | Year | Annually | ||||||||
| Recommended | 28 | SUD Spending | Total Medicaid SUD spending during the measurement period. | Claims | Year | Annually | ||||||||
| Recommended | 29 | SUD Spending Within IMDs | Total Medicaid SUD spending on residential treatment within IMDs during the measurement period | Claims | Year | Annually | ||||||||
| Recommended | 30 | Per Capita SUD Spending | Per capita SUD spending during the measurement period | Claims | Year | Annually | ||||||||
| Recommended | 31 | Per Capita SUD Spending Within IMDs | Per capita SUD spending within IMDs during the measurement period | Claims | Year | Annually | ||||||||
| Required | 32 | Access to Preventive/ Ambulatory Health Services for Adult Medicaid Beneficiaries with SUD | The percentage of Medicaid beneficiaries with SUD who had an ambulatory or preventive care visit during the measurement period. | Claims | Year | Annually | ||||||||
| Recommended | 33 | Grievances Related to SUD Treatment Services | Number of grievances filed during the measurement period that are related to SUD treatment services | Administrative records | Quarter | Quarterly | ||||||||
| Recommended | 34 | Appeals Related to SUD Treatment Services | Number of appeals filed during the measurement period that are related to SUD treatment services | Administrative records | Quarter | Quarterly | ||||||||
| Recommended | 35 | Critical Incidents Related to SUD Treatment Services | Number of critical incidents filed during the measurement period that are related to SUD treatment services | Administrative records | Quarter | Quarterly | ||||||||
Sheet 3: Metrics report
| Medicaid Section 1115 SUD Demonstration Monitoring Report | ||||||||||||||||||||||||||||||||||||||||||||||
| State | [Enter State Name] | |||||||||||||||||||||||||||||||||||||||||||||
| Demonstration Name | [Enter Demonstration Name] | |||||||||||||||||||||||||||||||||||||||||||||
| Demonstration Year | [Enter Demonstration Year] (Format: DY1, DY2, DY3, etc.) | |||||||||||||||||||||||||||||||||||||||||||||
| Calendar Dates for Demonstration Year | [Enter Calendar Dates for Demonstration Year] (Format: MM/DD/YYYY - MM/DD/YYYY) | |||||||||||||||||||||||||||||||||||||||||||||
| Reporting Period | [Enter Reporting Period] (Format: Q1, Q2, Q3, Q4) | |||||||||||||||||||||||||||||||||||||||||||||
| Calendar Dates for Reporting Period | [Enter Calendar Dates for Reporting Period (Format: MM/DD/YYYY - MM/DD/YYYY) | |||||||||||||||||||||||||||||||||||||||||||||
| Submitted on | [Enter Date] (Format: MM/DD/YYYY) | |||||||||||||||||||||||||||||||||||||||||||||
| Substance Use Disorder (SUD) Metricsa | ||||||||||||||||||||||||||||||||||||||||||||||
| Demonstration | Modeld | OUD subpopulation | Age < 18 | Age 18-64 | Age 65+ | Dual eligible (Medicare-Medicaid eligible) | Medicaid only | Pregnant | Not pregnant | Criminally involved | Not criminally involved | New modeld | ||||||||||||||||||||||||||||||||||
| # | Metric name | Metric description | Data source | Attest that reporting matches CMS-provided specification (Y/N) | Describe any deviations from CMS-provided measure specifications | Reporting issue (Y/N) (further describe in data and reporting issues tab) |
Measurement period (month, quarter, yearb) | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec | Denominator | Numerator or count | Rate/Percentagec |
| Assessment of need and qualification for SUD treatment services | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Assessed for SUD Treatment Needs Using a Standardized Screening Tool | Number of beneficiaries screened for SUD treatment needs using a standardized screening tool during the measurement period | Medical record review or claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 2 | Medicaid Beneficiaries with Newly Initiated SUD Treatment/Diagnosis | Number of beneficiaries with a SUD diagnosis and a SUD-related service during the measurement period but not in the three months before the measurement period | Claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3 | Medicaid Beneficiaries with SUD Diagnosis (monthly) | Number of beneficiaries with a SUD diagnosis and a SUD-related service during the measurement period and/or in the 11 months before the measurement period | Claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 4 | Medicaid Beneficiaries with SUD Diagnosis (annually) | Number of beneficiaries with a SUD diagnosis and a SUD-related service during the measurement period and/or in the 12 months before the measurement period | Claims | Year | ||||||||||||||||||||||||||||||||||||||||||
| 5 | Medicaid Beneficiaries Treated in an IMD for SUD | Number of beneficiaries with a claim for residential treatment for SUD in an IMD during the reporting year | Claims | Year | ||||||||||||||||||||||||||||||||||||||||||
| Milestone 1: Access to critical levels of care for OUD and other SUDs | ||||||||||||||||||||||||||||||||||||||||||||||
| 6 | Any SUD Treatment | Number of beneficiaries enrolled in the measurement period receiving any SUD treatment service, facility claim, or pharmacy claim during the measurement period | Claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Early Intervention | Number of beneficiaries who used early intervention services (such as procedure codes associated with SBIRT) during the measurement period | Claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Outpatient Services | Number of beneficiaries who used outpatient services for SUD (such as outpatient recovery or motivational enhancement therapies, step down care, and monitoring for stable patients) during the measurement period | Claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Intensive Outpatient and Partial Hospitalization Services | Number of unique beneficiaries who used intensive outpatient and/or partial hospitalization services for SUD (such as specialized outpatient SUD therapy or other clinical services) during the measurement period | Claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 10 | Residential and Inpatient Services | Number of beneficiaries who use residential and/or inpatient services for SUD during the measurement period | Claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Withdrawal Management | Number of beneficiaries who use withdrawal management services (such as outpatient, inpatient, or residential) during the measurement period | Claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 12 | Medication Assisted Treatment (MAT) | Number of beneficiaries who have a claim for MAT for SUD during the measurement period | Claims | Month 1 | ||||||||||||||||||||||||||||||||||||||||||
| Month 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Month 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| 36 | Average Length of Stay in IMDs | The average length of stay for beneficiaries discharged from IMD residential treatment for SUD | Claims; State-specific IMD database | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| Milestone 2: Use of evidence-based, SUD-specific patient placement criteria | ||||||||||||||||||||||||||||||||||||||||||||||
| There are no CMS-provided metrics related to milestone 2. | -- | |||||||||||||||||||||||||||||||||||||||||||||
| Milestone 3: Use of nationally recognized SUD-specific program standards to set provider qualifications for residential treatment facilities | ||||||||||||||||||||||||||||||||||||||||||||||
| There are no CMS-provided metrics related to milestone 3. | -- | |||||||||||||||||||||||||||||||||||||||||||||
| Milestone 4: Sufficient provider capacity at critical levels of care including for medication assisted treatment for OUD | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | SUD Provider Availability | The number of providers who were enrolled in Medicaid and qualified to deliver SUD services during the measurement period | Provider enrollment database; Claims | Year | ||||||||||||||||||||||||||||||||||||||||||
| 14 | SUD Provider Availability - MAT | The number of providers who were enrolled in Medicaid and qualified to deliver SUD services during the measurement period and who meet the standards to provide buprenorphine or methadone as part of MAT | Provider enrollment database, SAMHSA datasets | Year | ||||||||||||||||||||||||||||||||||||||||||
| Milestone 5: Implementation of comprehensive treatment and prevention strategies to address opioid abuse and OUD | ||||||||||||||||||||||||||||||||||||||||||||||
| 15 | Initiation and Engagement of Alcohol and Other Drug (AOD) Dependence Treatment (IET) [NCQA; NQF #0004; Medicaid Adult Core Set] |
There are two percentages. Percentage of beneficiaries with a new episode of (AOD) abuse or dependence who received the following: | -- | |||||||||||||||||||||||||||||||||||||||||||
| Percentage 1. Initiation of AOD Treatment—percentage of beneficiaries who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or MAT within 14 days of the diagnosis | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | ||||||||||||||||||||||||||||||||||||||||
| Percentage 2. Engagement of AOD Treatment—percentage of beneficiaries who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | ||||||||||||||||||||||||||||||||||||||||
| 18 | Use of Opioids at High Dosage and from Multiple Providers in Persons Without Cancer [PQA; NQF #2951] |
Rate per 1,000 beneficiaries age 18 and older included in the denominator without cancer who received prescriptions for opioids with a daily dosage greater than 120 morphine milligram equivalents for 90 consecutive days or longer. Patients in hospice are also excluded. | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| 19 | Use of Opioids from Multiple Providers in Persons Without Cancer [PQA; NQF #2950] |
Rate per 1,000 beneficiaries included in the denominator without cancer who received prescriptions for opioids from four or more prescribers and four or more pharmacies. | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| 20 | Use of Opioids at High Dosage from Multiple Providers in Persons Without Cancer [PQA, NQF #2951] | Rate per 1,000 beneficiaries included in the denominator without cancer who received prescriptions for opioids greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer, and from four or more prescribers and four or more pharmacies. | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| 21 | Concurrent Use of Opioids and Benzodiazepines [PQA] |
Percentage of beneficiaries age 18 and older with concurrent use of prescription opioids and benzodiazepines. Patients with a cancer diagnosis or in hospice are excluded. | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| 22 | Continuity of Pharmacotherapy for Opioid Use Disorder [RAND; NQF #3175] |
Percentage of adults in the denominator with pharmacotherapy for OUD who have at least 180 days of continuous treatment | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| Milestone 6: Improved care coordination and transitions between levels of care | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge, SUB-3a Alcohol and Other Drug Use Disorder Treatment at Discharge [Joint Commission; NQF #1664] |
SUB-3: Patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. | Medical record review or claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| SUB-3a: Patients who are identified with alcohol or drug disorder who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. | Medical record review or claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||||
| 17 | Follow-up after Discharge from the Emergency Department for Mental Health or Alcohol or Other Drug Dependence§ [NCQA; NQF #2605; Medicaid Adult Core Set] |
Percentage of ED visits for beneficiaries who have a principal diagnosis of mental illness or AOD abuse or dependence and who had a follow-up visit for mental illness or AOD. Four rates are reported: | -- | |||||||||||||||||||||||||||||||||||||||||||
| Percentage 1. Percentage of ED visits for mental illness for which the beneficiary received follow-up within 7 days of the ED visit (8 total days). | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||||
| Percentage 2. Percentage of ED visits for mental illness for which the beneficiary received follow-up within 30 days of the ED visit (31 total days). | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||||
| Percentage 3. Percentage of ED visits for which the beneficiary received a follow-up visit for mental illness or AOD within 30 days of the ED visit (31 total days) | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||||
| Percentage 4. Percentage of ED visits for which the beneficiary received a follow-up visit for mental illness or AOD within 7 days of the ED visit (8 total days) | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||||
| SUD health information technology (SUD health IT) | ||||||||||||||||||||||||||||||||||||||||||||||
| Insert selected metric(s) related to key health IT question 1 | ||||||||||||||||||||||||||||||||||||||||||||||
| Insert selected metric(s) related to key health IT question 2 | ||||||||||||||||||||||||||||||||||||||||||||||
| Insert selected metric(s) related to key health IT question 3 | ||||||||||||||||||||||||||||||||||||||||||||||
| Other SUD-related metrics | ||||||||||||||||||||||||||||||||||||||||||||||
| 23 | Emergency Department Utilization for SUD per 1,000 Medicaid Beneficiaries | Total number of ED visits for SUD per 1,000 beneficiaries in the measurement period | Claims | Month 1 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||
| Month 2 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| Month 3 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| 24 | Inpatient Stays for SUD per 1,000 Medicaid Beneficiaries | Total number of inpatient stays per 1,000 beneficiaries in the measurement period | Claims | Month 1 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||
| Month 2 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| Month 3 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| 25 | Readmissions Among Beneficiaries with SUD | The number of acute inpatient stays among beneficiaries with SUD during the measurement period followed by an acute readmission within 30 days. | Claims | Year | ||||||||||||||||||||||||||||||||||||||||||
| 26 | Overdose Deaths (count) | Number of overdose deaths during the measurement period among Medicaid beneficiaries living in a geographic area covered by the demonstration. States are encouraged to report the cause of overdose death as specifically as possible (for example, prescription vs. illicit opioid). | State data on cause of death | Year | ||||||||||||||||||||||||||||||||||||||||||
| 27 | Overdose Deaths (rate) | Rate of overdose deaths during the measurement period among adult Medicaid beneficiaries living in a geographic area covered by the demonstration. States are encouraged to report the cause of overdose death as specifically as possible (for example, prescription vs. illicit opioid). | State data on cause of death | Year | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||
| 28 | SUD Spending | Total Medicaid SUD spending during the measurement period. | Claims | Year | ||||||||||||||||||||||||||||||||||||||||||
| 29 | SUD Spending within IMDs | Total Medicaid SUD spending on residential treatment within IMDs during the measurement period | Claims | Year | ||||||||||||||||||||||||||||||||||||||||||
| 30 | Per Capita SUD Spending | Per capita SUD spending during the measurement period | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| 31 | Per Capita SUD Spending within IMDs | Per capita SUD spending within IMDs during the measurement period | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| 32 | Access to Preventive/ Ambulatory Health Services for Adult Medicaid Beneficiaries with SUD | The percentage of Medicaid beneficiaries with SUD who had an ambulatory or preventive care visit during the measurement period. | Claims | Year | #DIV/0! | #DIV/0! | #DIV/0! | |||||||||||||||||||||||||||||||||||||||
| 33 | Grievances Related to SUD Treatment Services | Number of grievances filed during the measurement period that are related to SUD treatment services | Administrative records | Quarter | ||||||||||||||||||||||||||||||||||||||||||
| 34 | Appeals Related to SUD Treatment Services | Number of appeals filed during the measurement period that are related to SUD treatment services | Administrative records | Quarter | ||||||||||||||||||||||||||||||||||||||||||
| 35 | Critical Incidents Related to SUD Treatment Services | Number of critical incidents filed during the measurement period that are related to SUD treatment services | Administrative records | Quarter | ||||||||||||||||||||||||||||||||||||||||||
| a States should create a new metrics report for each reporting quarter | ||||||||||||||||||||||||||||||||||||||||||||||
| b Report metrics that are one annual value for a demonstration year only in the annual report. | ||||||||||||||||||||||||||||||||||||||||||||||
| c If applicable. See CMS-provided technical specifications. | ||||||||||||||||||||||||||||||||||||||||||||||
| dEnter any new models that will be reported after column AR; create new columns as needed | ||||||||||||||||||||||||||||||||||||||||||||||
| Checks: | ||||||||||||||||||||||||||||||||||||||||||||||
| Numerator in #27 should equal the numerator in #26. | ||||||||||||||||||||||||||||||||||||||||||||||
| Denominator in #30 should equal the numerator in #4. | ||||||||||||||||||||||||||||||||||||||||||||||
| Numerator in #30 should equal the numerator in #28. | ||||||||||||||||||||||||||||||||||||||||||||||
| Denominator in #31 should equal the numerator in #5. | ||||||||||||||||||||||||||||||||||||||||||||||
| Numerator in #31 should equal the numerator in #29. | ||||||||||||||||||||||||||||||||||||||||||||||
| Counts for a subpopulation (e.g. pregnant, not pregnant) should sum approximately to counts for the overall demonstration. | ||||||||||||||||||||||||||||||||||||||||||||||
Sheet 4: Data and reporting issues
| Medicaid Section 1115 SUD Demonstration Monitoring Report | |||||
| State | [Enter State Name] | ||||
| Demonstration Name | [Enter Demonstration Name] | ||||
| Demonstration Year | [Enter Demonstration Year] (Format: DY1, DY2, DY3, etc.) | ||||
| Calendar Dates for Demonstration Year | [Enter Calendar Dates for Demonstration Year] (Format: MM/DD/YYYY - MM/DD/YYYY) | ||||
| Reporting Period | [Enter Reporting Period] (Format: Q1, Q2, Q3, Q4) | ||||
| Calendar Dates for Reporting Period | [Enter Calendar Dates for Reporting Period (Format: MM/DD/YYYY - MM/DD/YYYY) | ||||
| Submitted on | [Enter Date] (Format: MM/DD/YYYY) | ||||
| Metric(s) impacted | Summary of issue | Date and report in which issue was first reported | Estimated number of impacted beneficiaries | Known or suspected cause(s) of issue (if applicable) | Remediation plan and timeline for resolution (if applicable)/status update if issue previously reporteda |
| Assessment of need and qualification for SUD services | |||||
| EXAMPLE 1: Assessed for SUD treatment needs |
EXAMPLE Difficulty with collecting data for X metric (i.e., lack of EHR data or need for hybrid data) |
EXAMPLE 9/1/17; DY 2 Qtr. 3 |
EXAMPLE 75000 |
EXAMPLE Demonstration site in process of updating EHR, to be completed X date |
EXAMPLE Currently reporting X measure by deviating from current metric specifications in order to adhere to demonstration reporting requirement |
| [Add rows as needed] | |||||
|
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| [Add rows as needed] | |||||
|
|||||
| [Add rows as needed] | |||||
|
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| Milestone 3: Use of nationally recognized SUD-specific program standards to set provider qualifications for residential treatment facilities | |||||
| [Add rows as needed] | |||||
|
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| Milestone 4: Sufficient provider capacity at critical levels of care including for medication assisted treatment for OUD | |||||
| [Add rows as needed] | |||||
|
|||||
| Milestone 5: Implementation of comprehensive treatment and prevention strategies to address opioid abuse and OUD | |||||
| [Add rows as needed] | |||||
|
|||||
| Milestone 6: Improved care coordination and transitions between levels of care | |||||
| [Add rows as needed] | |||||
|
|||||
| SUD health information technology (SUD health IT) | |||||
| [Add rows as needed] | |||||
|
|||||
| Other SUD-related metrics | |||||
| [Add rows as needed] | |||||
|
|||||
| aThe state should also use this column to provide updates on any data or reporting issues described in previous reports. When applicable, the state should note when issues are resolved. If an issue was noted as resolved in the previous report, it should not be reported in the current report. | |||||
Sheet 5: Version notes
| Version 2.0 does not change the metrics for reporting or substantively modify their content. | |
| Version 2.0 updates the original metrics workbook in the following ways: | |
| Renumbers metrics using consecutive numbers | |
| Updates titles of metrics 5, 22 and 23 | |
| Edits descriptions of metrics 2, 3, 4, 5, 6, 12, 17, 18, 19, 22, 23, 24, 25, 34 | |
| Updates subpopulations for reporting under metrics 6, 7, 8, 9, 10, 11, 12 and 23 | |
| Clarifies data source for metrics 1, 16, 34 | |
| Adds footnote "d" of the Metrics Reporting tab, instructing users to add columns as necessary to report on additional models | |
| Removes metrics formerly named 26 and 27, which are not yet included in reporting | |
| Version 3.0 updates metrics workbook 2.0 in the following ways: | |
| Adds two recommended metrics for reporting: 'Use of Opioids from Multiple Providers in Persons Without Cancer' (metric 19) and 'Use of Opioids at High Dosage and from Multiple Providers in Persons Without Cancer' (metric 20) | |
| Renumbers current metrics 21-36 to accommodate addition | |
| Edits description of metric 3, 'Medicaid Beneficiaries with SUD Diagnosis (monthly)', to reflect a lookback period of 11 months | |
| Reformats headers on all tabs so column A = label and column B = user entry | |
| Reformats Baseline Reporting Period to MM/DD/YYYY on monitoring protocol tab | |
| Updates column N title on monitoring protocol tab to 'Demonstration Year (DY) and Quarter(Q) in which reporting will begin (Format: DY1 Q3) | |
| Edits footnote "a" of the metrics reporting tab, instructing users to create a new metrics report for each reporting quarter | |
| Edits footnote "d" of the metrics reporting tab, instructing users to enter any new models that will be reported after column AR | |
| Adds columns AS, AT, and AU for state-identified models on the metrics reporting tab | |
| Changes the name of the "metrics reporting" tab to the "metrics report" tab | |
| On the metrics report tab, edits "numerator" headers to "numerator or count" | |
| Version 3.1 updates metrics workbook 3.0 in the following ways: | |
| Assigns metric IDs Q1, Q2, Q3 to the SUD health information technology (SUD health IT) section on the Monitoring protocol tab | |
| Adds data validation checks to ensure numerator and denominator values are numeric values | |
| Locks down the Monitoring protocol, Metrics report and Data and reporting issues tabs |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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