CMS-10398 #57 Monitoring Protocol Workbook

[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

SUD_MonProtocolWB.v6.0_PRA.xlsx

GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates

OMB: 0938-1148

Document [xlsx]
Download: xlsx | pdf

Overview

PRA disclosure statement
SUD planned metrics
SUD planned subpops
SUD reporting schedule

Sheet 1: PRA disclosure statement
Substance Use Disorder (SUD)
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 18.5 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.

Serious Mental Illness and Serious Emotional Disturbance (SMI/SED)
Note: PRA Disclosure Statement to be added here

end of worksheet

Sheet 2: SUD planned metrics
Medicaid Section 1115 SUD Demonstrations Monitoring Protocol (Part A) - Planned Metrics (Version 6.0)


















State [State Name - automatically populated]

















Demonstration Name [Demonstration Name - automatically populated]

















blank row


















Table: Substance Use Disorder Demonstration Planned Metrics


















Standard information on CMS-provided metrics Baseline, annual goals, and demonstration target Alignment with CMS-provided technical specifications manual Phased-in metrics reporting
Standard information on CMS-provided metrics
#		 Standard information on CMS-provided metrics
Metric name		 Standard information on CMS-provided metrics
Metric description		 Standard information on CMS-provided metrics
Milestone or reporting
topica		 Standard information on CMS-provided metrics
Metric type		 Standard information on CMS-provided metrics
Reporting
category		 Standard information on CMS-provided metrics
Data
source		 Standard information on CMS-provided metrics
Measurement
period		 Standard information on CMS-provided metrics
Reporting
frequency		 Standard information on CMS-provided metrics
Reporting
priority		 Standard information on CMS-provided metrics
State will
report (Y/N)		 Baseline, annual goals, and demonstration target
Baseline reporting
period (MM/DD/YYYY-MM/DD/YYYY)		 Baseline, annual goals, and demonstration target
Annual goal		 Baseline, annual goals, and demonstration target
Overall demonstration
target		 Alignment with CMS-provided technical specifications manual
Attest that planned
reporting matches the
CMS-provided
technical specifications manual (Y/N)		 Alignment with CMS-provided technical specifications manual
Explanation of any deviations from the CMS-provided
technical specifications manual (different data source, definition, codes, target
population, etc.)b,c		 Phased-in metrics reporting
State plans to phase in
reporting (Y/N)		 Phased-in metrics reporting
SUD monitoring report in which metric will be phased in (Format DY#Q#; e.g., DY1Q3)		 Phased-in metrics reporting
Explanation of any plans to phase in reporting over time
EXAMPLE:
1
(Do not delete or edit this row)		 EXAMPLE:
Assessed for SUD Treatment Needs Using a Standardized Screening Tool		 EXAMPLE:
Number of beneficiaries screened for SUD treatment needs using a standardized screening tool during the measurement period		 EXAMPLE:
Assessment of need and qualification for SUD treatment services		 EXAMPLE:
CMS-constructed		 EXAMPLE:
Other monthly and quarterly metrics		 EXAMPLE:
Medical record review or claims		 EXAMPLE:
Month		 EXAMPLE:
Quarterly		 EXAMPLE:
Recommended		 EXAMPLE:
Y		 EXAMPLE:
07/01/2018-06/30/2019		 EXAMPLE:
Increase		 EXAMPLE:
Increase		 EXAMPLE:
N		 EXAMPLE:
The Department will use state-defined procedure codes (list specific codes) to calculate this metric.		 EXAMPLE:
Y		 EXAMPLE:
DY2Q1		 EXAMPLE:
This measure requires an update to the Adult Needs and Strengths Assessment tool that reflects an ASAM level of treatment. The work is in the testing phase with anticipated go live in mid to late 2021.
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 Assessment of need and qualification for SUD treatment services CMS-constructed Other monthly and quarterly metrics Medical record review or claims Month Quarterly Recommended









2 Medicaid Beneficiaries with Newly Initiated SUD Treatment/Diagnosis Number of beneficiaries who receive MAT or a SUD-related treatment service with an associated SUD diagnosis during the measurement period but not in the three months before the measurement period Assessment of need and qualification for SUD treatment services CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Recommended









3 Medicaid Beneficiaries with SUD Diagnosis (monthly) Number of beneficiaries who receive MAT or a SUD-related treatment service with an associated SUD diagnosis during the measurement period and/or in the 11 months before the measurement period Assessment of need and qualification for SUD treatment services CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









4 Medicaid Beneficiaries with SUD Diagnosis (annually) Number of beneficiaries who receive MAT or a SUD-related treatment service with an associated SUD diagnosis during the measurement period and/or in the 12 months before the measurement period Assessment of need and qualification for SUD treatment services CMS-constructed Other annual metrics Claims Year Annually Required









5 Medicaid Beneficiaries Treated in an IMD for SUD Number of beneficiaries with a claim for inpatient/residential treatment for SUD in an IMD during the measurement period. Milestone 2 CMS-constructed Other annual metrics Claims Year Annually 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 Milestone 1 CMS-constructed Other monthly and quarterly metrics 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 Milestone 1 CMS-constructed Other monthly and quarterly metrics 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 Milestone 1 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









9 Intensive Outpatient and Partial Hospitalization Services Number of 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 Milestone 1 CMS-constructed Other monthly and quarterly metrics 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 Milestone 1 CMS-constructed Other monthly and quarterly metrics 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 Milestone 1 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









12 Medication-Assisted Treatment Number of beneficiaries who have a claim for MAT for SUD during the measurement period Milestone 1 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









13 SUD Provider Availability The number of providers who were enrolled in Medicaid and qualified to deliver SUD services during the measurement period Milestone 4 CMS-constructed Other annual metrics 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 Milestone 4 CMS-constructed Other annual metrics Provider enrollment database; Claims; SAMHSA datasets Year Annually Required









15 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-AD)

[NCQA; NQF #0004; Medicaid Adult Core Set; Adjusted HEDIS measure]		 Percentage of beneficiaries age 18 and older with a new episode of alcohol or other drug (AOD) abuse or dependence who received the following:

• Initiation of AOD Treatment—percentage of beneficiaries who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or medication treatment within 14 days of the diagnosis
• Engagement of AOD Treatment—percentage of beneficiaries who initiated treatment and who were engaged in ongoing AOD treatment within 34 days of the initiation visit

The following diagnosis cohorts are reported for each rate: (1) Alcohol abuse or dependence, (2) Opioid abuse or dependence, (3) Other drug abuse or dependence, and (4) Total AOD abuse or dependence. A total of 8 separate rates are reported for this measure.		 Milestone 6 Established quality measure Annual metrics that are established quality measures Claims Year Annually Required









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]
 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.

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.		 Milestone 6 Established quality measure Annual metrics that are established quality measures Medical record review or claims Year Annually Recommended









17(1) Follow-up after Emergency Department Visit for Alcohol or Other Drug Dependence (FUA-AD)
[NCQA; NQF #3488; Medicaid Adult Core Set; Adjusted HEDIS measure]d
 Percentage of ED visits for beneficiaries age 18 and older with a principal diagnosis of AOD abuse or dependence who had a follow-up visit for AOD abuse or dependence. Two rates are reported:

- Percentage of ED visits for which the beneficiary received follow-up within 30 days of the ED visit (31 total days).
- Percentage of ED visits for which the beneficiary received follow-up within 7 days of the ED visit (8 total days).		 Milestone 6 Established quality measure Annual metrics that are established quality measures Claims Year Annually Required









17(2) Follow-up after Emergency Department Visit for Mental Illness (FUM-AD)
[NCQA; NQF #3489; Medicaid Adult Core Set; Adjusted HEDIS measure]e

 Percentage of ED visits for beneficiaries age 18 and older with a principal diagnosis of mental illness or intentional self-harm and who had a follow-up visit for mental illness. Two rates are reported:

- 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 of ED visits for mental illness for which the beneficiary received follow-up within 7 days of the ED visit (8 total days).		 Milestone 6 Established quality measure Annual metrics that are established quality measures Claims Year Annually Required









18 Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)
[PQA, NQF #2940; Medicaid Adult Core Set]		 Percentage of beneficiaries age 18 and older who received prescriptions for opioids with an average daily dosage greater than or equal to 90 morphine milligram equivalents (MME) over a period of 90 days or more. Beneficiaries with a cancer diagnosis, sickle cell disease diagnosis, or in hospice are excluded. Milestone 5 Established quality measure Annual metrics that are established quality measures Claims Year Annually Required









19 Use of Opioids from Multiple Providers in Persons without Cancer (OMP)
[PQA; NQF #2950]		 The percentage of individuals ≥18 years of age who received prescriptions for opioids from ≥4 prescribers AND ≥4 pharmacies within ≤180 days. Milestone 5 Established quality measure Annual metrics that are established quality measures Claims Year Annually Recommended









20 Use of Opioids at High Dosage and from Multiple Providers in Persons Without Cancer (OHDMP) [PQA, NQF #2951] The percentage of individuals ≥18 years of age who received prescriptions for opioids with an average daily dosage of ≥90 morphine milligram equivalents (MME) AND who received prescriptions for opioids from ≥4 prescribers AND ≥4 pharmacies. Milestone 5 Established quality measure Annual metrics that are established quality measures Claims Year Annually Recommended









21 Concurrent Use of Opioids and Benzodiazepines (COB-AD)
[PQA, NQF #3389; Medicaid Adult Core Set]		 Percentage of beneficiaries age 18 and older with concurrent use of prescription opioids and benzodiazepines. Beneficiaries with a cancer diagnosis, sickle cell disease diagnosis, or in hospice are excluded. Milestone 5 Established quality measure Annual metrics that are established quality measures Claims Year Annually Required









22 Continuity of Pharmacotherapy for Opioid Use Disorder
[USC; NQF #3175]		 Percentage of adults 18 years of age and older with pharmacotherapy for OUD who have at least 180 days of continuous treatment Milestone 1 Established quality measure Annual metrics that are established quality measures Claims Year Annually 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 Milestone 5 CMS-constructed Other monthly and quarterly metrics 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 Other SUD-related metrics CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









25 Readmissions Among Beneficiaries with SUD The rate of all-cause readmissions during the measurement period among beneficiaries with SUD Milestone 6 CMS-constructed Other annual metrics 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. The state is encouraged to report the cause of overdose death as specifically as possible (for example, prescription vs. illicit opioid). Other SUD-related metrics CMS-constructed Other annual metrics 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. The state is encouraged to report the cause of overdose death as specifically as possible (for example, prescription vs. illicit opioid). Milestone 5 CMS-constructed Other annual metrics State data on cause of death Year Annually Required









28 SUD Spending Total Medicaid SUD spending during the measurement period. Other SUD-related metrics CMS-constructed Other annual metrics Claims Year Annually Recommended









29 SUD Spending Within IMDs Total Medicaid SUD spending on inpatient/residential treatment within IMDs during the measurement period. Other SUD-related metrics CMS-constructed Other annual metrics Claims Year Annually Recommended









30 Per Capita SUD Spending Per capita SUD spending during the measurement period Other SUD-related metrics CMS-constructed Other annual metrics Claims Year Annually Recommended









31 Per Capita SUD Spending Within IMDs Per capita SUD spending within IMDs during the measurement period Other SUD-related metrics CMS-constructed Other annual metrics Claims Year Annually Recommended









32 Access to Preventive/ Ambulatory Health Services for Adult Medicaid Beneficiaries with SUD [Adjusted HEDIS measure] The percentage of Medicaid beneficiaries with SUD who had an ambulatory or preventive care visit during the measurement period. Other SUD-related metrics Established quality measure Annual metrics that are established quality measures Claims Year Annually Required









33 Grievances Related to SUD Treatment Services Number of grievances filed during the measurement period that are related to SUD treatment services Other SUD-related metrics CMS-constructed Grievances and appealsf 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 Other SUD-related metrics CMS-constructed Grievances and appealsf 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 Other SUD-related metrics CMS-constructed Grievances and appealsf Administrative records Quarter Quarterly Recommended









36 Average Length of Stay in IMDs The average length of stay for beneficiaries discharged from IMD inpatient/residential treatment for SUD. Milestone 2 CMS-constructed Other annual metrics Claims; State-specific IMD database Year Annually Required









Q1 [Insert selected metric(s) for health IT question 1]
Health IT State-specific



Required









Q2 [Insert selected metric(s) for health IT question 2]
Health IT State-specific



Required









Q3 [Insert selected metric(s) for health IT question 3]
Health IT State-specific



Required









State-specific metrics blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank
[Insert row(s) for any additional state-specific metrics by right-clicking on row 51 and selecting "Insert"]












n.a. n.a.



blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank
aThere are no CMS-provided metrics related to milestone 3
















b If the state is not reporting a required metric (i.e., column K = “N”), enter explanation in corresponding row in column P.
















c The state should use column P to outline calculation methods for specific metrics as explained in Version 4.0 of the Medicaid Section 1115 Substance Use Disorder Demonstrations Monitoring Protocol Instructions.
















d Rates 1 and 2 reported for Metric #17(1) correspond to rates 2 and 3 for Metric #17 from Version 1.1 of the the Medicaid Section 1115 Substance Use Disorder Demonstrations: Technical Specifications for Monitoring Metrics
















e Rates 1 and 2 reported for Metric #17(2) correspond to rates 1 and 2 for Metric #17 from Version 1.1 of the the Medicaid Section 1115 Substance Use Disorder Demonstrations: Technical Specifications for Monitoring Metrics
















f While grievances and appeals metrics are recommended for reporting, the state is required, per 42 CFR 431.428(a)5, to provide updates on the results of beneficiary satisfaction surveys, if conducted during the reporting year, including updates on grievances and appeals from beneficiaries, in in its annual (Q4) monitoring report.
















end of worksheet


















Sheet 3: SUD planned subpops
Medicaid Section 1115 SUD Demonstrations Protocol (Part A) - Planned Subpopulations (Version 6.0)








State [State Name - automatically populated]







Demonstration Name [Demonstration Name - automatically populated]







blank








Table: Substance Use Disorder Demonstration Planned Subpopulations








Planned subpopulation reporting Alignment with CMS-provided technical specifications manual
blank Subpopulations Relevant metrics
Planned subpopulation reporting
Subpopulation category		 Planned subpopulation reporting
Subpopulations		 Planned subpopulation reporting
Reporting priority		 Planned subpopulation reporting
Relevant metrics 		Planned subpopulation reporting
Subpopulation type		 Planned subpopulation reporting
State will report (Y/N)		 Subpopulations
Attest that planned subpopulation reporting within each category matches the description in the CMS-provided technical specifications manual (Y/N)		 Subpopulations
If the planned reporting of subpopulations does not match (i.e., column G = “N”), list the subpopulations state plans to report (Format comma separated)a,b,c		 Relevant metrics
Attest that metrics reporting for subpopulation category matches CMS-provided technical specifications manual (Y/N) 		Relevant metrics
If the planned reporting of relevant metrics does not match (i.e., column I = "N"), list the metrics for which state plans to report for each subpopulation category (Format metric number, comma separated)
EXAMPLE:
Age group
(Do not delete or edit this row)		 EXAMPLE:
Children <18, adults 18–64, and older adults 65+		 EXAMPLE:
Required		 EXAMPLE:
Metrics #1-3, 6-12, 23, 24, 26, 27		 EXAMPLE:
CMS-provided		 EXAMPLE:
Y		 EXAMPLE:
N		 EXAMPLE:
Children/Young adults 12-21, Adults 21-65		 EXAMPLE:
N		 EXAMPLE:
1, 2, 3
Age group Children <18, adults 18–64, and older adults 65+ Required Metrics #1-3, 6-12, 23, 24, 26, 27 CMS-provided




Dual–eligible status Dual-eligible (Medicare-Medicaid eligible), Medicaid only Required Metrics #1-3, 6-12 CMS-provided




Pregnancy status Pregnant, Not pregnant Required Metrics #1-3, 6-12 CMS-provided




Criminal justice status Criminally involved, Not criminally involved Required Metrics #1-3, 6-12 CMS-provided




OUD population Opioid diagnosis Recommended Metrics #2-12, 23, 24, 26, 27, 36 CMS-provided




[Insert row(s) for any state-specific subpopulation(s)]








blank blank blank blank blank blank blank blank blank blank
a If the state is not reporting a required subpopulation category (i.e., column F = “N”), enter explanation in corresponding row in column H.





b If the state is reporting on the Dual-eligible status, Pregnancy status, Criminal justice status, and OUD population subpopulation categories, the state should use column H to outline its subpopulation identification approach as explained in Version 4.0 of the Medicaid Section 1115 Substance Use Disorder Demonstrations Monitoring Protocol Instructions.





c If the state is planning to phase in the reporting of any of the subpopulation categories, the state should (1) select N in column G and (2) provide an explanation and the report (SUD DY and Q) in which it will begin reporting the subpopulation category in column H.





end of worksheet








Sheet 4: SUD reporting schedule
Medicaid Section 1115 SUD Demonstrations Monitoring Protocol (Part A) - Reporting Schedule (Version 6.0)


























State [Enter State Name - automatically populated]

























Demonstration Name [Enter Demonstration Name - automatically populated]

























blank row


























Instructions:























(1) In the reporting periods input table (Table 1), use the prompt in column A to enter the requested information in the corresponding row of column B. All monitoring report names and reporting periods should use the format DY#Q# or CY# and all dates should use the format MM/DD/YYYY with no spaces in the cell. The information entered in these cells will auto-populate the SUD demonstration reporting schedule in Table 2. All cells in the input table must be completed in entirety for the standard reporting schedule to be accurately auto-populated.























(2) Review the state's reporting schedule in the SUD demonstration reporting schedule table (Table 2). For each of the reporting categories listed in column F, select Y or N in column H, "Deviation from standard reporting schedule (Y/N)" to indicate whether the state plans to report according to the standard reporting schedule. If a state's planned reporting does not match the standard reporting schedule for any quarter and/or reporting category (i.e., column H=“Y”), the state should describe these deviations in column I, "Explanation for deviations (if column H="Y")" and use column J, “Proposed deviations from standard reporting schedule,” to indicate the SUD measurement periods with which it wishes to overwrite the standard schedule (column G). All other columns are locked for editing and should not be altered by the state.























blank























Table 1. Substance Use Disorder Demonstration Reporting Periods Input Table























Column A Demonstration reporting periods/dates

























Dates of first SUD demonstration year blank

























Start date (MM/DD/YYYY)


























End date (MM/DD/YYYY)


























Dates of first quarter of the baseline reporting period for CMS-constructed metrics blank

























Reporting period (SUD DY and Q)
(Format DY#Q#; e.g., DY1Q1)


























Start date (MM/DD/YYYY)a


























End date (MM/DD/YYYY)

























Broader section 1115 demonstration reporting period corresponding with the first SUD reporting quarter, if applicable. If there is no broader demonstration, fill in the first SUD reporting period.
(Format DY#Q#; e.g., DY3Q1)


























First SUD monitoring report due date (per STCs) (MM/DD/YYYY)


























First SUD monitoring report in which the state plans to report annual metrics that are established quality measures (EQMs) blank

























Baseline period for EQMs
(Format CY#; e.g., CY2019)


























SUD DY and Q associated with monitoring report
(Format DY#Q#; e.g., DY1Q1)


























Start date (MM/DD/YYYY)


























End date (MM/DD/YYYY)


























Dates of last SUD reporting quarter: blank

























Start date (MM/DD/YYYY)


























End date (MM/DD/YYYY)


























end of table


























Table 2. Substance Use Disorder Demonstration Reporting Schedule























SUD reporting quarter start date
(MM/DD/YYYY)		 SUD reporting quarter end date
(MM/DD/YYYY)		 Monitoring report due
(per STCs)
(MM/DD/YYYY)		 Broader section 1115 reporting period, if applicable; else SUD reporting period
(Format DY#Q#; e.g., DY1Q3)		 SUD reporting period
(Format DY#Q#; e.g., DY1Q3)		 Reporting category For each reporting category, measurement period for which information is captured in monitoring report per standard reporting schedule (Format DY#Q#; e.g., DY1Q3)b
SUD		 Deviation from standard reporting schedule
(Y/N/n.a.)		 Explanation for deviations
(if column H="Y") 		Proposed deviation in measurement period from standard reporting schedule in column G
(Format DY#Q#; e.g., DY1Q3)






















Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics




















blank blank blank blank blank Annual metrics that are established quality measures




















blank blank blank blank blank Other annual metrics


























Narrative information




















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics





















[Add rows for all additional demonstration reporting quarters]


























blank blank blank blank
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a SUD demonstration start date: For monitoring purposes, CMS defines the start date of the demonstration as the effective date listed in the state’s STCs at time of SUD demonstration approval. For example, if the state’s STCs at the time of SUD demonstration approval note that the demonstration is effective January 1, 2020 – December 31, 2025, the state should consider January 1, 2020 to be the start date of the demonstration. Note that that the effective date is considered to be the first day the state may begin its SUD demonstration. In many cases, the effective date is distinct from the approval date of a demonstration; that is, in certain cases, CMS may approve a section 1115 demonstration with an effective date that is in the future. For example, CMS may approve an extension request on December 15, 2020, with an effective date of January 1, 2021 for the new demonstration period. In many cases, the effective date also differs from the date a state begins implementing its demonstration. To generate an accurate reporting schedule, the start date as listed in Table 1 of the “SUD reporting schedule tab” should align with the first day of a month. If a state’s SUD demonstration begins on any day other than the first day of the month, the state should list its start date as the first day of the month in which the effective date occurs. For example, if a state’s effective date is listed as January 15, 2020, the state should indicate "01/01/2020" as the start date in Table 1 of the “SUD reporting schedule” tab. Please see Appendix A for more information on determining demonstration quarter timing.


















b The auto-populated reporting schedule in Table 2 outlines the data the state is expected to report for each demonstration year and quarter. However, states are not expected to begin reporting any metrics data until after monitoring protocol approval. The state should see Section B of the Monitoring Report Instructions for more information on retrospective reporting of data following protocol approval.


















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