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

Medicaid Section 1115 SUD Demonstrations
Monitoring Report Instructions Version 4.0

Medicaid Section 1115 Substance Use Disorder Demonstrations
Monitoring Report Instructions
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 9.75 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.

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Table of Contents
A. Instructions for completing a quarterly or annual monitoring report............................. 3
1.

Download Parts A, B and C from the Performance Metrics Database and
Analytics (PMDA) system. .................................................................................. 3

2.

Complete Parts A, B, and C of the customized template........................................ 3
2a) Complete Part A: Monitoring Report Workbook. ........................................... 4
2b) Complete Part B: Monitoring Report Template............................................... 8
2c) Complete Part C: Budget Neutrality Workbook ............................................ 13

3.

Submit Parts A, B, and C according to the instructions below. ............................ 13
3a) Name the files ............................................................................................. 13
3b) Upload the files using PMDA ...................................................................... 13

B. Instructions for completing a retrospective monitoring report .................................... 14
1.

Review customized Parts A and B...................................................................... 15

2.

Complete Parts A and B for the retrospective monitoring report. ......................... 15
2a) Complete Part A: Monitoring Report Workbook ........................................... 15
2b) Complete Part B: Monitoring Report Template............................................. 15

3.

Submit Parts A and B using PMDA. .................................................................. 16
3a) Name the retrospective monitoring reports. .................................................. 16
3b) Navigate to the deliverables page. ................................................................ 16

APPENDIX A: Guidelines for including Medicaid section 1115 SUD demonstrations
monitoring metrics and narrative information in monitoring reports ........................... 19
APPENDIX B: Calculating percent change for Medicaid section 1115 SUD
demonstrations monitoring metrics ........................................................................... 22

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A. Instructions for completing a quarterly or annual monitoring report
1. Download Parts A, B and C from the Performance Metrics Database and Analytics
(PMDA) system
The state can download the Monitoring Report Workbook (Part A), Monitoring Report
Template (Part B), and Budget Neutrality Workbook (Part C) from its state demonstration
dashboard on PMDA. This dashboard will list all section 1115 demonstrations associated
with the state. To download Parts A, B, and C, the state should navigate to the demonstration
name (name of the state’s stand-alone SUD demonstration or broader demonstration with a
SUD component). In the “Actions” column, select “Deliverables” from the drop-down menu
and click “Go,” which takes the state to its “Deliverables” page. From here, the state can
click the link in the top right-hand corner named “Download Templates and Instructions” to
navigate to the “Download Templates and Instructions” page where it can access the
reporting tools. A list of relevant templates for the monitoring report will appear on this page
(i.e., “Monitoring Report Workbook” and “Monitoring Report Template”).1
2. Complete Parts A, B, and C of the customized template
Note: If a state’s section 1115 SUD demonstration is part of a broader demonstration, the
Centers for Medicare & Medicaid Services (CMS) will work with the state to ensure there is
no duplication in the reporting requirements for different components of the demonstration.
For example, CMS may work with a state to avoid duplication in selecting metrics within
Part A and selecting reporting topics within Part B. The state may choose to include certain
reporting topics covered in Part B (SUD-related demonstration operations and policy, SUD
demonstration evaluation update, other demonstration reporting, and notable state
achievements and/or innovations) in either its monitoring report for the broader
demonstration or in Part B of its SUD demonstration monitoring report. The state should
always include narrative reporting on budget neutrality in its broader section 1115
demonstration monitoring report. If the state includes information applicable to the SUD
component of its demonstration in the broader demonstration’s monitoring report, the state
should note this in the corresponding section of Part B.
The state should provide information as requested in the instructions below for Part A and
Part B. Please note that embedded objects (e.g., documents, shapes, SmartArt, screenshots,
charts, tables) are not permitted in Part A and Part B. If necessary, a state may upload any
additional information as separate attachments and reference the attachment within Part A
1

For further technical assistance on downloading the reporting tools, the state should review the PMDA state user
manual. To access this manual, the state should navigate to the “Frequently Asked Questions” page by clicking the
“FAQ” button, which appears at the bottom of every page on PMDA. From here, the state should click on the
“Training and Support Materials” link found on the top right of the page to navigate to the “Training and Support
Materials” page. This page contains the PMDA state user manual as well as other resources.

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and Part B. Instructions for how to upload documents using PMDA can be found in Section
A.3.
Annual versus quarterly monitoring reports: The annual and quarterly monitoring reports
use the same Part A and Part B templates. In Part A of annual monitoring reports, the state
should include applicable quarterly metrics for the demonstration and any annual metrics as
specified in its reporting schedule. Note that all metrics with annual measurement periods
will not necessarily be reported in the annual monitoring report, depending on their reporting
category. In Part B of annual monitoring reports, the state should include narrative
information on the several reporting topics that are applicable only to annual monitoring
reports.
Revisions to approved monitoring protocol post-approval: After the monitoring protocol
is approved, the state is expected to begin submitting metrics data to CMS. During the
reporting process, if the state finds that certain information in its approved monitoring
protocol is no longer feasible for reporting, the state should discuss the issue(s) and proposed
change(s) with its CMS demonstration team. In consultation with CMS, the state may be
required to submit an updated monitoring protocol using PMDA for CMS review. If an
updated monitoring protocol is accepted by CMS, it will be made available on Medicaid.gov.
Demonstration extensions: As described in the Monitoring Protocol Instructions, if a state
receives CMS approval for a demonstration extension, the state is expected to submit an
updated monitoring protocol for CMS approval. During the period in which the state is
updating its monitoring protocol—but prior to CMS approval of its updated monitoring
protocol for the demonstration extension period—the state should report monitoring metrics
in accordance with its previously approved monitoring protocol. The state should discuss
with its CMS demonstration team an appropriate timeline for monitoring report submission
while it is updating its reporting schedule in its monitoring protocol. If a state receives an
extension and continues to report metrics data before the updated monitoring protocol is
approved by CMS, the state should not need to submit a retrospective monitoring report.
2a) Complete Part A: Monitoring Report Workbook
CMS requires each state with a SUD demonstration to provide data on monitoring metrics for
different milestones or reporting topics (see Table 1 in Section 3). Part A includes a (1)
“SUD metrics” tab in which the state will report monitoring metrics, and a (2) “SUD
reporting issues” tab in which the state will report any data or reporting issues with specific
metrics. The instructions for these tabs are presented below according to the order of the
columns listed in each tab. In addition, Appendix A contains detailed instructions for
reporting monitoring metrics and narrative information.
•

“SUD metrics” tab. Report metrics’ values using the Medicaid Section 1115 Substance
Use Disorder Demonstrations: Technical Specifications for Monitoring Metrics (hereafter
referred to as “technical specifications manual”) provided by CMS. The technical
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specifications manual and the supplemental materials (such as associated value sets) that
accompany this manual can be accessed on PMDA on the “Reference Materials” page.2
The link to the “Reference Materials” page is available on the right side of the state's
demonstration dashboard. If the reporting schedule in Part A (“SUD reporting schedule”
tab) of a state’s approved monitoring protocol indicates a metric is not scheduled for
reporting or if the state did not propose reporting a metric in its approved monitoring
protocol (as indicated in the populated column “State will report (Y/N)” [column H]), the
state should leave that row blank and not insert any information (e.g., do not enter “n.a.”
or “0” in the row). Similarly, if a state does not plan to report a metric by subpopulation,
it should not enter any information in those columns.
-

Header information. PMDA will populate two of the header rows in the “SUD
metrics” tab (State and Demonstration Name). The state should fill out the remaining
header rows (listed below). This information will then populate in the other tab of
Part A (“SUD reporting issues”).
▪

SUD Demonstration Year (DY) (Format: DY1, DY2, DY3, etc.)

▪

Calendar dates for SUD DY (Format: MM/DD/YYYY - MM/DD/YYYY)

▪

SUD Reporting Period (Format: Q1, Q2, Q3, Q4)

▪

Calendar Dates for SUD Reporting Period (Format: MM/DD/YYYY MM/DD/YYYY)

If a state is approved for a SUD demonstration extension, the state should ideally
number the SUD DY and Q continuously from the previous approval period. For
example, if a state’s last monitoring report from the previous approval period was
submitted for SUD DY5Q4, the subsequent monitoring report should be named SUD
DY6Q1.
–

If the state’s approved monitoring protocol specifies that it will report on additional
state-specific subpopulations, that state should edit the titles of the provided columns
(in row 10 of columns AV-BJ) to reflect the approved state-specific subpopulation
names.

− Standard information on CMS-provided metrics. The following columns in the
“SUD metrics” tab (columns A-J and M) will be populated with information from a
state’s approved monitoring protocol, including:
▪

Number (#)

The technical specifications manual can be accessed on PMDA on the “Reference Materials” page after the state
completes the National Measure Stewards Terms and Conditions ‘Point and Click’ Agreement. The state can access
this agreement by clicking on the technical specifications manual it wishes to download. A pop-up will appear that
allows the state to download and read the ‘Point and Click’ Agreement directly, or to receive it by email.
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▪

Metric name

▪

Metric description

▪

Milestone or reporting topic3

▪

Metric type

▪

Reporting category

▪

Data source

▪

State will report (Y/N)

▪

Approved monitoring protocol indicates that reporting matches the CMSprovided technical specifications manual (Y/N)

▪

Deviations from CMS-provided technical specifications manual in approved
monitoring protocol

▪

Measurement period (month, quarter, year)

The state should verify the content of the “SUD metrics” tab against the information
in its approved monitoring protocol.
The state should note that cells containing standard information for all metrics (in
columns A-G) as well as cells populated from the state’s approved monitoring
protocol (in columns H-J), are locked for editing and cannot be altered by the state.
The state can edit the “SUD metrics” tab starting with the column “Technical
specifications manual version” (column K).
–

Technical specifications manual version. The state should indicate the version of
the technical specifications manual used to report each metric, using the drop -down
options (Version 1.1, Version 2.0, Version 3.0, or Version 4.0) in the column
“Technical specifications manual version” (column K). The state should consult the
technical specifications manual (Chapter I, “Manual version” section) for more
information regarding the appropriate version for calculating each monitoring metric.
If a state uses a version of the technical specifications that differs from the
expectations outlined in the current technical specifications manual, it should indicate
Y in the column “Reporting issue (Y/N)” (column L) and provide an explanation in
the “SUD reporting issues” tab.

–

Reporting issues. In the column “Reporting issue (Y/N)” (column L), the state
should indicate whether any data or reporting issues affected the state’s ability to
report metrics as described in the approved monitoring protocol (e.g., difficulty

3

The milestones correspond with those listed in State Medicaid Director Letter #17-003, which announced the SUD
demonstration opportunity. The full letter is available here: https://www.medicaid.gov/sites/default/files/federalpolicy-guidance/downloads/smd17003.pdf

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obtaining necessary data or calculating a metric the state planned to report ). For any
identified issues, the state should provide further detail in the “SUD reporting issues”
tab described below.
–

Dates covered by measurement period. The state should use the column “Dates
covered by measurement period” (column N) to provide the calendar dates associated
with the measurement period (data collection timeframe). See the technical
specifications manual for additional instructions on determining the measurement
period for each metric.

–

Presenting data for counts. The denominator and rate/percentage columns are
shaded grey for any metrics that are reported as counts. For each count metric, the
state should report the numerator (outlined in the corresponding metric’s technical
specification) in the numerator column, leaving the denominator and the
rate/percentage columns grey. The state should report separately for the overall
demonstration and for any subpopulations reported, using the columns provided.

–

Presenting data for rates or percentages. The state should populate both the
denominator and numerator columns for metrics that are reported as rates or
percentages. After these values are entered, the “rate/percentage” cells—which are
locked for editing—will calculate the associated rate or percentage. The state should
report separately for the overall demonstration and for any subpopulations reported,
using the columns provided.
Please note that if a state reports state-specific metrics (including health IT metrics)
as rates or percentages, the state should populate both the denominator and numerator
cells. For these metrics, the state should also enter a formula into the
“rate/percentage” cells (which are unlocked) to calculate the rates or percentages.

–

•

Reporting annual metrics. The state should report data for annual metrics (CMSconstructed and established quality measures) in the quarterly or annual monitoring
report according to the reporting schedule in Part A in its approved monitoring
protocol. The annual metric reporting columns should remain blank in other
quarterly monitoring reports, as noted within the tab.

“SUD reporting issues” tab. In the “SUD reporting issues” tab, the state should provide
detailed information about any data or reporting issues indicated in the column
“Reporting issue (Y/N)” (column L) of the “SUD metrics” tab. The state should report
any issue that prevents reporting in alignment with its approved monitoring protocol. In
addition, the state should include all data and reporting issues identified in its last SUD
monitoring report, even if those issue have been resolved.

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This tab will include all the metrics the state plans to report (including state-specific
metrics) as indicated in its approved monitoring protocol. The state only needs to
complete the “SUD reporting issues” tab for metrics that have a data or reporting issue.
The state may use the filter feature function in column A (“#”) to select the applicable
metrics, if desired.
− Instructions for reporting new issues. The state should complete columns D-G for
new issues:
▪

Summary of issue: The summary should include known or suspected causes of the
issue, if applicable.

▪

Date and monitoring report in which issue was first reported: The state should
enter the current report period for new issues.

▪

Remediation plan and timeline for resolution

▪

Status: The state should select New from the drop-down.

− Instructions for reporting updates on ongoing issues. The state should provide
updates on any data or reporting issues described in previous monitoring reports with
status New or Ongoing in columns G and H described below. The state should also
copy the information entered into columns D-F from the previous monitoring report
into its current monitoring report.
▪

Status: If any data and reporting issues described in a previous monitoring report
are unresolved, the state should select “Ongoing” from the drop-down. For any
resolved data and reporting issue, the state should select “Resolved” from the
drop-down.

▪

Update(s) to issue summary, remediation plan, and/or timeline for resolution, if
issue previously reported: The state should include updates to the remediation
plan and timeline, or any other new information the state deems relevant in the
column. For resolved data and reporting issues, the state should provide an
update on how the issue was resolved. Please note that a resolved issue should be
reported with N in the column “Reporting issue (Y/N)” (column K) in the “SUD
metrics” tab. Any issues reported as resolved should not be reported in
subsequent monitoring reports.

2b) Complete Part B: Monitoring Report Template
The instructions below describe the four sections of Part B, which includes:
•

Section 1. Title page. The title page is a brief form that the state completed as part of its
monitoring protocol. The state should submit this form as the title page for all

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monitoring reports. The title page will be populated with the information from the state’s
approved monitoring protocol, except for the following two rows:
− SUD demonstration year and quarter. The state will enter the section 1115 SUD
demonstration year (DY) and quarter (Q) associated with the submitted monitoring
report. This should align with the reporting schedule in the state’s approved
monitoring protocol.
− Reporting period. The state will enter the calendar dates for the current reporting
period (i.e., for the quarter or year). This should align with the reporting schedule in
the state’s approved monitoring protocol.
•

Section 2. Executive summary. The state should provide a brief, targeted executive
summary to communicate key achievements, highlights, issues, and/or risks identified
during the current reporting period for the SUD demonstration or the SUD component of
a broader section 1115 demonstration. This summary should also identify: (1) key
changes since the last monitoring report, including the implementation of new program
components; (2) programmatic improvements (e.g., increased outreach or any beneficiary
or provider education efforts); and (3) highlights of unexpected changes (e.g., unexpected
increases or decreases in enrollment or complaints, etc.), which may include changes
related to the 2019 coronavirus (COVID-19) pandemic. Historical background or general
descriptions of the waiver components should not be included. The word count should
not exceed 500.

•

Section 3. Narrative information on implementation, by milestone and reporting
topic. The state should report narrative information in this table following the detailed
prompts for each reporting topic. Any narrative/summary text provided in Section 3
should be brief and not exceed 250 words (2-3 paragraphs). The state should remove the
provided example text from the table and provide a response for each reporting topic.
The narrative information for each reporting topic is organized into two subsections:
− Subsection 1. Metrics trends. The state should discuss any relevant trends that the
data shows related to each milestone or reporting topic, including trends in statespecific metrics. Describe and explain changes (+ or -) greater than two percent in
the “State response” column. The state should also describe any changes that are
possibly due to the impact of the COVID-19 pandemic. The state should insert the
metric related to the trend reported in the column “Related metric(s) (if any),” and
should not enter any text in the column “State has no trends/update to report.” CMS
will continuously review the threshold (currently +/- 2%) and ensure that it is a
helpful threshold for monitoring purposes. Appendix B contains detailed instructions
for calculating the percent change for metrics trends reporting.

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In some instances, the metric specifications for a given metric may have changed
substantially relative to the last time the state reported the metric. Examples of
substantial changes may include the state adding state-specific codes to reflect newly
covered services,4 CMS modifying a CMS-constructed metric to include additional
codes to ensure all relevant services are captured, or a national measure steward
updating the measure rate calculation for a metric that is an established quality
measure. If a metric changed substantially, the state should describe how the
specification change affected the metrics data relative to the previous monitoring
report, as well as any anticipated effect on trends over time.
Please note that milestone 3 does not have CMS-provided metrics; however, a state
may have identified metrics associated with this milestone within its monitoring
protocol.
If the state did not identify any trends in the data, it should put an X in the column
“State has no trends/update to report,” and should not enter any text in the column
“State response.”
− Subsection 2. Implementation update. The state should describe concisely but
precisely any changes made in the current reporting period regarding the
demonstration design and operational details since submitting its original
implementation plan, including any changes due to the COVID-19 pandemic. The
state should include within its description the name of the monitoring report in which
the update was first reported (DY#Q#). If a state has not made any changes since the
last monitoring report, and does not plan to make any changes, or if the
implementation prompt does not apply to the state’s demonstration, it should put an X
in the column “State has no trends/update to report,” and should not enter any text in
the column “State response.”
Grey cells indicate cells that do not need to be filled out for that row because they are not
applicable.
•

Section 4. Narrative information on other reporting topics. The state should report
narrative information in the table on five other reporting topics: financial/budget
neutrality, demonstration operations and policy, demonstration evaluation update, other
demonstration reporting, and notable state achievements and/or innovations. Any
narrative/summary text provided in the monitoring report should be brief and not exceed
250 words (2-3 paragraphs). If the state has no update to report on the requested prompt,
it should put an X in the column “State has no update to report,” and should not enter
any text in the column “State response.” A narrative update for certain reporting topics
(e.g. Budget neutrality, SUD-related demonstration operations and policy, etc.) is

4

If the state plans to make modifications or changes to monitoring metrics, the state should discuss the proposed
changes with the state’s CMS demonstration team. After discussion with CMS, the state should document these
changes in its monitoring protocol and resubmit using PMDA.

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required per 42 Code of Federal Regulations (CFR) 431.428(a) for annual monitoring
reports. For quarterly monitoring reports where the state is not expected to report for
these reporting topics, the state should put an X in the column “State has no update to
report.”
− Reporting topic 10. Budget neutrality. The state should provide a detailed
narrative on the current status of financial/budget neutrality and provide an analysis
of the budget neutrality to date.
− Reporting topic 11. SUD-related demonstration operations and policy. The state
should highlight significant SUD (or if a broader demonstration, then SUD-related)
demonstration operations or policy considerations that could positively or negatively
affect beneficiary enrollment, access to services, timely provision of services, budget
neutrality, or any other provision that has potential for beneficiary effects. The state
should also note any activity that may accelerate or create delays or impediments in
achieving the SUD demonstration’s approved goals or objectives, if not already
reported elsewhere in this document. Such considerations could include the
following, either real or anticipated:
▪

Any changes to SUD populations served, benefits, access, delivery systems, or
eligibility

▪

Legislative activities and state policy changes

▪

Fiscal changes that would result in changes in access, benefits, populations,
enrollment, etc.

▪

Related audit or investigation activity, including findings

▪

Litigation activity

▪

Status and/or timely milestones for health plan contracts

▪

Market changes that may impact Medicaid operations

▪

Any delays or variance with provisions outlined in STCs

▪

Systems issues or challenges that might impact the demonstration (e.g., eligibility
and enrollment [E&E], Medicaid management information systems [MMIS])

▪

Changes in key state personnel or organizational structure

▪

Procurement items that will impact demonstration (e.g., enrollment broker, etc.)

▪

Significant changes in payment rates to providers which will impact
demonstration or significant losses for Medicaid care organizations (MCOs)
under the demonstration

▪

Emergency Situation/Disaster

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▪

Other

− Reporting topic 12. SUD Demonstration evaluation update. The state should
include updates on evaluation work and timeline. This might include updates on
progress with:
▪

Evaluation design

▪

Evaluation procurement

▪

Execution of evaluation

▪

Evaluation deliverables

▪

Data collection, including any issues collecting, procuring, managing, or using
data for the state’s evaluation or federal evaluation

Annual monitoring reports should include available preliminary evaluation results
related to areas of focus in the approved evaluation design as outlined by 42 CFR
431.428(a)10.
The state should also provide status updates on deliverables related to the
demonstration evaluation and indicate whether the expected timelines are being met
and/or if there are any real or anticipated barriers in achieving the goals and
timeframes agreed to in the STCs. In addition to any status updates on the
demonstration evaluation, the state should list anticipated evaluation -related
deliverables related to this demonstration and their due dates.
− Reporting topic 13. Other SUD demonstration reporting. The state should
provide a detailed narrative on general reporting requirements not captured under
other reporting topics including any post-award public forums. For annual
monitoring reports, the state should, at a minimum:
▪

Include updates on the results of beneficiary satisfaction surveys, if conducted
during the reporting year, including grievances and appeals from beneficiaries,
per 42 CFR 431.428(a)5; and

▪

Provide an update on the annual post-award public forum, including all public
comments received regarding the progress of the demonstration project, per 42
CFR 431.428(a)11.

− Reporting topic 14. Notable state achievements and/or innovations. The state
should provide a detailed narrative on notable state achievements and/or innovations.

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2c) Complete Part C: Budget Neutrality Workbook
The budget neutrality reporting topic incorporates a Budget Neutrality Workbook for the
demonstration. This Budget Neutrality Workbook should be submitted as a sep arate
deliverable as part of each monitoring report.
3. Submit Parts A, B, and C according to the instructions below
3a) Name the files
The state should name the files according to the following convention:
StateAbbreviation_SUD-DY#Q#_Report_PartofReport_DateofSubmission, where:
•

State abbreviation is the two-letter abbreviation for the state name

•

DY#Q# is written with the number of the DY and quarter of the reporting period, no
spaces

•

Part of report refers to Part A, B or C, written as “Part-[A,B, or, C]”

•

Date of submission is the date the monitoring report is submitted using PMDA in
YYYYMMDD format

For example, a monitoring report submitted by a state with a standalone section 1115 SUD
demonstration on May 29, 2020 for SUD DY1Q1 would be comprised of three files named:
XX_SUD-DY1Q1_Report_Part-A_20200529, XX_SUD-DY1Q1_Report_Part-B_20200529,
and XX_SUD-DY1Q1_ Report_Part-C_20200529 where XX stands for the state’s 2-letter
abbreviation.
If the state’s section 1115 SUD demonstration is part of a broader demonstration, the state
should use the DY and Q of the broader demonstration and replace “SUD” with “1115” (i.e.,
XX_1115-DY1Q1_Report_Part-A_20200529, XX_1115-DY1Q1_Report_Part-B_20200529,
and XX_1115-DY1Q1_ Report_Part-C_20200529).
If a file is named with a Q4 it is understood to be the state’s annual monitoring report.
If a state needs to resubmit Parts A, B, or C, after making changes or revisions, the state
should use the same file naming convention instructions but insert “Revised” in front of the
file name. For example, if a state resubmits Part A for its SUD DY1Q1 monitoring report on
June 2, 2020, the file name would be: Revised_XX_SUD-DY1Q1_Report_PartA_20200602.
3b) Upload the files using PMDA
After naming the files using the naming convention above, the state should upload Parts A,
B, and C using PMDA for CMS to review through its state demonstration dashboard.

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This dashboard will list all section 1115 demonstrations associated with the state. The state
can upload Parts A, B, and C by navigating to the appropriate demonstration name (name of
the state’s stand-alone SUD demonstration or broader demonstration with a SUD
component). In the “Actions” column, select “Deliverables” from the drop-down menu and
click “Go,” which takes the state to its “Deliverables” page. A list of deliverables including
names, types, due dates, and other information will be displayed on this page. The state
should go to the appropriate deliverable (i.e., Quarterly Monitoring Report or Annual
Monitoring Report), click “Upload/View Docs” in the drop-down menu under the “Actions”
column, and finally click “Go.” This will take the state to the “Deliverable Details” page. In
the “Add a New State File” section, the state can upload its monitoring report (Part A, Part B,
and Part C) and provide any additional documents/comments to CMS. Any file named with
a Q4 should be submitted to the “Annual Monitoring Report” deliverable. The state should
make sure to mark the “Ready for CMS Review” button in the “Submission Confirmation”
section of the “Deliverable Details” page and click the “Update Status” button to complete
its submission. The deliverable status will be displayed as "Submitted" if the state's
submission is successful. The state should submit revised monitoring reports to the same
deliverable as the original submission.
If the state does not see the relevant deliverable on its “Deliverables” page, the state should
contact the PMDA help desk using phone number (443) 775-3226 between 6:00 am -12:00
am Eastern time (ET), or by email at [email protected].
For further instructions on monitoring report submission, the state should review the PMDA
state user manual (see Section A.1 for instructions on how to access the PMDA state user
manual).
B. Instructions for completing a retrospective monitoring report
If the monitoring protocol is approved after one or more of a state’s quarterly monitoring report
submission due date(s), the state will need to report metrics data to CMS retrospectively for any
prior quarters of section 1115 SUD demonstration implementation that precede the monitoring
protocol approval date. 5 Please note that the state is expected to include retrospective metrics
data with the second monitoring report submitted after monitoring protocol approval.
The state should compile and submit a separate monitoring report (Parts A and B only) for
retrospective data following the steps below.
5

While a state does not need to submit metrics data until after its monitoring protocol is approved by CMS, the state
should submit quarterly and annual monitoring reports according to the requirements in its STCs with narrative
updates on implementation progress, and other information that may be applicable. The state is encouraged to use
Part B to fulfill this reporting requirement until its monitoring protocol is approved. Please note that if a state
chooses to submit metrics data before its monitoring protocol is approved, it may need to resubmit these data after
monitoring protocol approval.

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1. Review customized Parts A and B
CMS will provide the state with customized templates for Parts A and B for its retrospective
reporting. The state should review these customized templates for accuracy prior to entering
data into Parts A and B.
2. Complete Parts A and B for the retrospective monitoring report
2a) Complete Part A: Monitoring Report Workbook
Using the instructions in Section A, the state should complete the “SUD metrics” tab for each
quarter of retrospective data. Each workbook will also include an “Instructions” tab with
state-specific instructions. The customized Part A will include one tab per retrospective
quarter named “DY#Q#,” where DY#Q# is written with the number of the SUD DY and
quarter of the retrospective reporting period. Retrospective Part A will also include one
“SUD reporting issues” tab for the entire retrospective reporting period which the state
should complete.
2b) Complete Part B: Monitoring Report Template
Please note that Section 1 (Title page) of the retrospective Part B will already be populated
with customized information for the states. Please review Section 1 for accuracy before
completing the remaining sections in the retrospective Part B.
Using the instructions in Section A, the state should complete:
•

Section 2. Executive summary. The state should provide a brief, targeted executive
summary to communicate key achievements, highlights, issues, and/or risks identified
during the entire retrospective reporting period. Please note that the executive summary
should provide a broad overview of the entire retrospective reporting period, rather than a
quarter by quarter summary.

•

Section 3. Narrative information on implementation, by milestone and reporting
topic. The state should report a general summary of metric trends by milestone and
reporting topic for the entire retrospective reporting period. In these general summaries,
the state should discuss any relevant trends that the data show related to each milestone
or reporting topic, including trends in state-specific metrics.
Please note that the state does not need to report on implementation updates in Section 3,
or complete Section 4 (Narrative information on other reporting topics) for retrospective
monitoring reports.

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Medicaid Section 1115 SUD Demonstrations
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3. Submit Parts A and B using PMDA
3a) Name the retrospective monitoring reports
The file name of the customized template provided to the state will accurately reflect
reporting periods included in the file. The state should only need to update the file name
with the date of submission. The full naming convention of the retrospective monitoring
reports is: StateAbbreviation_SUD-RetroDY#Q#_PartofReport_DateofSubmission, where:
•

State abbreviation is the two-letter abbreviation for the state name

•

RetroDY#Q# refers to the quarter(s) being reported on retrospectively. If a state is
reporting more than one quarter of retrospective data, it should include the range in the
file name by adding a dash (-) between the quarters (see below for an example).

•

Part of report refers to Part A or B, written as “Part-[A or B]”

•

Date of submission is the date the monitoring report is submitted using PMDA in
YYYYMMDD format

For example, a retrospective monitoring report submitted by a state on May 29, 2020 for
retrospective quarters DY1Q1 – DY1Q3 would be comprised of two files named: XX_SUDRetroDY1Q1-Q3_Part-A_20200529, XX_ SUD-RetroDY1Q1-Q3_Part-B_20200529, where
XX stands for a state’s 2-letter abbreviation.
If a state needs to resubmit Parts A or B for its retrospective monitoring report, after making
changes or revisions, the state should use the same file naming convention instructions, but
insert “Revised” in front of the file name. For example, if a state resubmits its Part A for
retrospective data spanning from DY1Q1-Q3 on June 2, 2020, the file name would be:
Revised_XX_SUD-RetroDY1Q1-Q3_Part-A_20200602.
3b) Navigate to the deliverables page
The state should use the instructions in Section A.3. to navigate to the “Deliverables” page in
PMDA.
The state should submit its retrospective monitoring report (Part A and Part B) to the
“Retrospective Report” deliverable for CMS to review.
If the state does not see the relevant deliverable on its “Deliverables” page, the state should
contact the PMDA help desk using phone number (443) 775-3226 between 6:00 am -12:00
am ET, or by email at [email protected].

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Medicaid Section 1115 SUD Demonstrations
Monitoring Report Instructions Version 4.0

Table 1. SUD monitoring reporting overview, by milestone or reporting topic
Part A.
Monitoring Report
Workbook

Reporting
topic #
Milestone or reporting topic

Part C.
Budget
Neutrality
Workbook

Part B.
Monitoring Report
Template a

0.

Title page

--

Section 1

--

0.

Executive summary

--

Section 2

--

1.

Assessment of need and
qualification for SUD
treatment services

•

SUD metrics tab

--

•

SUD reporting
issues tab

Section 3:
• Metrics trends
• Implementation
update

2.

Access to Critical Levels of
•
Care for OUD and other SUDs •
(Milestone 1)

SUD metrics tab
SUD reporting
issues tab

Section 3:
• Metrics trends
• Implementation
update

--

3.

Use of Evidence-based, SUD- •
specific Patient Placement
•
Criteria (Milestone 2)

SUD metrics tab

Section 3:
• Metrics trends
• Implementation
update

--

4.

Use of Nationally Recognized •
SUD-specific Program
•
Standards to Set Provider
Qualifications for Residential
Treatment Facilities
(Milestone 3)

SUD metrics tabb
SUD reporting
issues tab b

Section 3:
• Metrics trendsb
• Implementation
update

--

5.

Sufficient Provider Capacity at •
Critical Levels of Care
•
including for Medication
Assisted Treatment for OUD
(Milestone 4)

SUD metrics tab
SUD reporting
issues tab

Section 3:
• Metrics trends

--

Implementation of
•
Comprehensive Treatment and •
Prevention Strategies to
Address Opioid Abuse and
OUD (Milestone 5)

SUD metrics tab

Section 3:
• Metrics trends
• Implementation
update

--

6.

SUD reporting
issues tab

SUD reporting
issues tab

•

Implementation
update

7.

Improved Care Coordination
and Transitions between
Levels of Care (Milestone 6)

•
•

SUD metrics tab
SUD reporting
issues tab

Section 3:
• Metrics trends
• Implementation
update

--

8.

SUD health information
technology (health IT)

•
•

SUD metrics tabc
SUD reporting
issues tab c

Section 3:
• Metrics trends
• Implementation
update

--

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Medicaid Section 1115 SUD Demonstrations
Monitoring Report Instructions Version 4.0

Part A.
Monitoring Report
Workbook

Reporting
topic #
Milestone or reporting topic
9.

Other SUD-related metrics

•

SUD metrics tab

•

SUD reporting
issues tab

Part C.
Budget
Neutrality
Workbook

Part B.
Monitoring Report
Template a
Section 3:
• Metrics trends
• Implementation
update

--

10.

Budget neutrality

--

Section 4:
• Current status and
analysis
• Implementation
update

Submit
completed
workbook

11.

SUD-related demonstration
operations and policy

--

Section 4:
• SUD-related
demonstration
operations and
policy
• Implementation
update

--

12.

SUD demonstration evaluation -update

Section 4:
-• SUD demonstration
evaluation update

13.

Other demonstration reporting --

Section 4:
-• Other demonstration
reporting

14.

Notable state achievements
and/or innovations

Section 4:
-• Notable state
achievements and/or
innovations

--

a

See detailed instructions (Section A.2.b) for instructions on narrative reporting, which varies by reporting topic.
There are no CMS-provided metrics for Milestone 3. However, if the state identifies metrics for reporting on this
topic, it should be reported as shown.
b

c

There are no CMS-provided metrics for the health IT topic; the state must identify relevant health IT metrics
according to the instructions provided in the Monitoring Protocol Instructions.

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Medicaid Section 1115 SUD Demonstration
Monitoring Report Instructions Version 4.0

APPENDIX A
GUIDELINES FOR INCLUDING MEDICAID SECTION 1115 SUD
DEMONSTRATIONS MONITORING METRICS AND NARRATIVE INFORMATION
IN MONITORING REPORTS

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Medicaid Section 1115 SUD Demonstrations
Monitoring Protocol Instructions Version 4.0

This appendix provides reporting instructions applicable to the section 1115 SUD demonstration
monitoring metrics and other monitoring information. See Chapter 1 Section B of the technical
specifications manual for additional instructions.
The state should report data to CMS in accordance with the schedule and format agreed upon in
the approved monitoring protocol. Given the dynamic nature of Medicaid data, metrics should
be produced at the same time in each measurement period throughout the SUD demonstration.
This applies even if data are not shared with CMS until a later date. For example, if a state
submits data quarterly, the submission should contain three monthly values for each monthly
metric, each produced at the same time relative to its measurement period.
Guidelines for including metrics and narrative information in monitoring reports are as follows:
•

Each quarterly monitoring report should contain (1) narrative information on implementation
for the most recent demonstration quarter, (2) grievances and appeals metrics for the most
recent demonstration quarter, and (3) all other monthly and quarterly metrics for the prior
quarter (which allows at least 90 days for claims run-out and other considerations for data
completeness).

•

To allow for adequate time to implement annual specification updates from measure
stewards, annual metrics that are established quality measures should be reported as follows:
− For a state with SUD demonstration years that end July 31 through November 30: in the
annual monitoring report
− For a state with SUD demonstration years that end May 31 or June 30: in the first
quarterly monitoring report of the next SUD demonstration year
− For a state with SUD demonstration years that end February 28 through April 30: in the
second quarterly monitoring report of the next SUD demonstration year
− For a state with SUD demonstration years that end December 31 or January 31: in the
third quarterly monitoring report of the next SUD demonstration year

•

All other annual metrics should be reported in the first quarterly monitoring report of the next
SUD demonstration year, rather than in the annual monitoring report. This allows at least 90
days for claims run-out and other considerations for data completeness.

Table A.1 illustrates these guidelines.

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Medicaid Section 1115 SUD Demonstrations
Monitoring Protocol Instructions Version 4.0

Table A.1. Reporting in quarterly and annual section 1115 SUD monitoring reports

Monitoring report name

Monitoring report due date:

DY1Q1
report

DY1Q2
report

DY1Q3
report

DY1Q4
(annual) DY2Q1
reportb report

DY2Q2
report

DY2Q3
report

Due 60 Due 60 Due 60
Due 90 Due 60 Due 60
Due 60
days after days after days after days after days after days after days after
quarter quarter quarter quarter quarter quarter quarter
ends
ends
ends
ends
ends
ends
ends

Measurement periods, by reporting category
Narrative information on
implementation

DY1Q1

DY1Q2

DY1Q3

DY1Q4

DY2Q1

DY2Q2

DY2Q3

Grievances and appeals

DY1Q1

DY1Q2

DY1Q3

DY1Q4

DY2Q1

DY2Q2

DY2Q3

Other monthly and quarterly metrics

n.a.

DY1Q1

DY1Q2

DY1Q3

DY1Q4

DY2Q1

DY2Q2

Annual metrics that are established
quality measuresa

n.a.

n.a.

n.a.

Other annual metrics

n.a.

n.a.

n.a.

Note:

A state A state A state A state
with a
with a
with a
with a
DY
DY
DY
DY
ending
ending
ending ending on
07/31 – on 05/31 on 2/28 – 12/31 or
11/30: or 06/30: 4/30:
1/31:
CY1
CY1
CY1
CY1
n.a.

DY1

n.a.

n.a.

The state is expected to submit retrospective metrics data in the second monitoring report submission after
monitoring protocol approval.

a

Metrics that are established quality measures should be calculated for the calendar year. Note that one established
quality measure (Metric #22) should be calculated over a 2-year period (starting with the calendar year in which the
demonstration began and the calendar year prior). All other metrics should be calculated for the SUD demonstration
year.
Per the STCs, the state’s Q4 information that would ordinarily be provided in a separate fourth quarterly
monitoring report should be reported as distinct information within the annual monitoring report. If the state’s SUD
demonstration is part of a broader section 1115 demonstration, the state should consider its broader section 1115
demonstration Q4 monitoring report to be the state’s annual monitoring report.
b

CY = calendar year; CY1 = the calendar year in which the demonstration began; DY = Demonstration year; Q =
quarter; n.a. = not applicable (information not expected to be included in report)

Technical assistance. CMS offers technical assistance to help the state collect, report, and use
these metrics. For technical assistance, contact the section 1115 demonstration monitoring and
evaluation mailbox ([email protected]), copying the state’s CMS
demonstration team on the message.

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Medicaid Section 1115 SUD Demonstrations
Monitoring Protocol Instructions Version 4.0

APPENDIX B
CALCULATING PERCENT CHANGE FOR MEDICAID SECTION 1115 SUD
DEMONSTRATIONS MONITORING METRICS

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Medicaid Section 1115 SUD Demonstrations
Monitoring Protocol Instructions Version 4.0

The Monitoring Report Instructions direct the state to report on metric trends in Part B of its
monitoring reports, including all changes (+ or -) greater than 2%, within each milestone and
reporting topic. Tables B.1 and B.2 below provide examples of how to calculate the percent
change based on the data reported in the “SUD metrics” tab of Part A for three metrics. These
instructions also apply to state-specific metrics.
For monthly metrics, including state-specific metrics, the state should first calculate an average
monthly value for the current quarter and an average monthly value for the prior quarter. To
determine the “percent change,” calculate the difference between the metric’s current quarter
average value and the prior quarter average value. Table B.1 illustrates the percentage
calculation for a monthly measure, using Metric #3 (Medicaid Beneficiaries with SUD
Diagnosis) as an example. The row below the monthly counts in this table is the average count
for the quarter ((A+B+C)/3). The difference between the average count for quarter 1 (column D)
and quarter 2 (column E) is reported in column F, “Count change” (E - D). Column G, “Percent
change,” shows as the difference between the value in the “Count change” and the average count
for quarter 1 (F/D) as a percentage.
Table B.1. Example calculation of percent change for monthly metric

Metric

Quarter 1
Numerator
or count
Denominator
(D)

Quarter 2
Rate
/%

Numerator
or count
Denominator
(E)

#3: Medicaid Beneficiaries with SUD Diagnosis (monthly)
Month
1=A
**
7,000 **
**
Month
2=B
**
7,035 **
**
Month
3=C
**
7,120 **
**
Average

7,052

*

*

Rate
/%

7,120

**

7,155

**

7,175

**

7,150

*

Count
change
(F)

%
change
(G)

*

*

*

*

*

*

*

*
98

1.4%

% = Percentage.
*Light grey shaded cells represent how to calculate count and percentage changes.
**Dark grey shaded cells represent cells that are greyed out within Part A.

For quarterly and annual metrics, including state-specific metrics, “percent change” refers to the
percent difference in the metric value between the current and prior quarters or years,
respectively. Table B.2 provides three examples of annual metrics, which are expressed as
counts, percentages, or rates. In this table, column G reports the difference between metric
counts for year 1 and 2 (E - B), or the difference between the metric rates for year 1 and 2 (F C). Column H, “Percent change” reports the difference between the value in the column “Count
change” divided by the values for year 1 (G/B for counts and G/C for rates).

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Medicaid Section 1115 SUD Demonstration
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Table B.2. Example calculation of percent change for annual measure
Year 1

Year 2
Rate/
Rate/
Numerator
%
Numerator
%
Denominator
or count
(C=B/ Denominator
or count
(F=E/
Metric
(A)
(B)
A)
(D)
(E)
D)
#5: Medicaid Beneficiaries Treated in an IMD for SUD (count)
**
**
**
**
Year
20,100
21,270
#15: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (percentage)
Year
7,052
2,600 36.9%
#36: Average Length of Stay in IMDs (rate)

7,150

Year

2,200

2,000

20,000

10.0

3,000

Count
change
(G)
*
1,170
*

42.0%

13.6

5.8%
*

5.1%
*

30,000

%
change
(H)
*

13.8%
*

3.6

36.4%

% = Percentage.
* Light grey shaded cells represent how to calculate count and percentage changes.
**Dark grey shaded cells represent cells that are greyed out within Part A.

The state can also follow these instructions on calculating percent change values to assess its
progress toward the annual goals it selected for each metric in Part A of its monitoring protocol.
For example, the state can assess progress toward its annual goals in its first DY by calculating
for each metric the percent change between its value in DY1 and its value at baseline. 6 If the
percent change value is positive, this would align with an annual goal of “increase” while if the
percent change is negative, this would align with an annual goal of “decrease.” Please note that
while the monitoring reports do require updates on metric trends calculated using the instructions
provided above, the monitoring reports do not require that the state provide an assessment of its
progress toward annual goals; the additional instructions in this paragraph are provided in case
the state would like to assess this progress for its own purposes.

6

As the demonstration proceeds, the state can assess progress toward its annual goals by calculating for each metric
the percent change between its value in the current demonstration year versus the previous demonstration year.

24