CMS-10398 #57 Monitoring Report Template

Medicaid Section 1115 SUD Demonstrations Monitoring Report – Part B Version 4.0

[State name – automatically populated] [Demonstration name – automatically populated]

Medicaid Section 1115 Substance Use Disorder Demonstrations
Monitoring Report Template

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.

1. Title page for the state’s substance use disorder (SUD) demonstration or the SUD component of the broader demonstration

The title page is a brief form that the state completed as part of its monitoring protocol. The title page will be populated with the information from the state’s approved monitoring protocol. The state should complete the remaining two rows. Definitions for certain rows are below the table.

State		Automatically populated with the state name.
Demonstration name		Automatically populated with the demonstration name.
Approval period for section 1115 demonstration		Automatically populated with the current approval period for the section 1115 demonstration as listed in the current special terms and conditions (STC), including the start date and end date (MM/DD/YYYY – MM/DD/YYYY).
SUD demonstration start datea		Automatically populated with the start date for the section 1115 SUD demonstration or SUD component if part of a broader demonstration (MM/DD/YYYY).
Implementation date of SUD demonstration, if different from SUD demonstration start dateb		Automatically populated with the SUD demonstration implementation date (MM/DD/YYYY).
SUD (or if broader demonstration, then SUD -related) demonstration goals and objectives		Automatically populated with the summary of the SUD (or if broader demonstration, then SUD- related) demonstration goals and objectives.
SUD demonstration year and quarter		Enter the SUD demonstration year and quarter associated with this monitoring report (e.g., SUD DY1Q3 monitoring report). This should align with the reporting schedule in the state’s approved monitoring protocol.
Reporting period		Enter calendar dates for the current reporting period (i.e., for the quarter or year) (MM/DD/YYYY – MM/DD/YYYY). This should align with the reporting schedule in the state’s approved monitoring protocol.

^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 SUD demonstration is effective January 1, 2020 – December 31, 2025, the state should consider January 1, 2020 to be the start date of the SUD demonstration. Note 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.

^b Implementation date of SUD demonstration: The date the state began claiming or will begin claiming federal financial participation for services provided to individuals in institutions for mental disease.

2. Executive summary

The executive summary should be reported in the fillable box below. It is intended for summary-level information only. The recommended word count is 500 words or less.

Enter the executive summary text here.

3. Narrative information on implementation, by milestone and reporting topic

Prompt	State has no trends/update to report (place an X)	Related metric(s) (if any)	State response
1. Assessment of need and qualification for SUD services
1.1 Metric trends
1.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to assessment of need and qualification for SUD services		*EXAMPLE: #5: Medicaid Beneficiaries Treated in an IMD for SUD	*EXAMPLE: The number of beneficiaries with a SUD diagnosis treated in an IMD in the last year decreased by #% due to the closure of one IMD in the state.
1.2 Implementation update
1.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 1.2.1.a The target population(s) of the demonstration			*EXAMPLE: The state is expanding the clinical criteria to include # diagnoses
1.2.1.b The clinical criteria (e.g., SUD diagnoses) that qualify a beneficiary for the demonstration			*EXAMPLE: The state projects an #% increase in beneficiaries with a SUD diagnosis due to an increase in the FPL limits which will be effective on MM/DD/YYYY.
1.2.2 The state expects to make other program changes that may affect metrics related to assessment of need and qualification for SUD services
2. Access to Critical Levels of Care for OUD and other SUDs (Milestone 1)
2.1 Metric trends
2.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 1
2.2 Implementation update
2.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 2.2.1.a Planned activities to improve access to SUD treatment services across the continuum of care for Medicaid beneficiaries (e.g., outpatient services, intensive outpatient services, medication-assisted treatment, services in intensive residential and inpatient settings, medically supervised withdrawal management)
2.2.1.b SUD benefit coverage under the Medicaid state plan or the Expenditure Authority, particularly for residential treatment, medically supervised withdrawal management, and medication-assisted treatment services provided to individual IMDs
2.2.2 The state expects to make other program changes that may affect metrics related to Milestone 1
3. Use of Evidence-based, SUD-specific Patient Placement Criteria (Milestone 2)
3.1 Metric trends
3.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 2
3.2. Implementation update
3.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 3.2.1.a Planned activities to improve providers’ use of evidence-based, SUD-specific placement criteria
3.2.1.b Implementation of a utilization management approach to ensure (a) beneficiaries have access to SUD services at the appropriate level of care, (b) interventions are appropriate for the diagnosis and level of care, or (c) use of independent process for reviewing placement in residential treatment settings
3.2.2 The state expects to make other program changes that may affect metrics related to Milestone 2
4. Use of Nationally Recognized SUD-specific Program Standards to Set Provider Qualifications for Residential Treatment Facilities (Milestone 3)
4.1 Metric trends
4.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 3 Note: There are no CMS-provided metrics related to Milestone 3. If the state did not identify any metrics for reporting this milestone, the state should indicate it has no update to report.
4.2 Implementation update
4.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 4.2.1.a Implementation of residential treatment provider qualifications that meet the ASAM Criteria or other nationally recognized, SUD-specific program standards
4.2.1.b Review process for residential treatment providers’ compliance with qualifications
4.2.1.c Availability of medication-assisted treatment at residential treatment facilities, either on-site or through facilitated access to services off site
4.2.2 The state expects to make other program changes that may affect metrics related to Milestone 3
5. Sufficient Provider Capacity at Critical Levels of Care including for Medication Assisted Treatment for OUD (Milestone 4)
5.1 Metric trends
5.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 4
5.2 Implementation update
5.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: Planned activities to assess the availability of providers enrolled in Medicaid and accepting new patients in across the continuum of SUD care
5.2.2 The state expects to make other program changes that may affect metrics related to Milestone 4
6. Implementation of Comprehensive Treatment and Prevention Strategies to Address Opioid Abuse and OUD (Milestone 5)
6.1 Metric trends
6.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 5
6.2 Implementation update
6.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 6.2.1.a Implementation of opioid prescribing guidelines and other interventions related to prevention of OUD
6.2.1.b Expansion of coverage for and access to naloxone
6.2.2 The state expects to make other program changes that may affect metrics related to Milestone 5
7. Improved Care Coordination and Transitions between Levels of Care (Milestone 6)
7.1 Metric trends
7.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 6
7.2 Implementation update
7.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: Implementation of policies supporting beneficiaries’ transition from residential and inpatient facilities to community-based services and supports
7.2.2 The state expects to make other program changes that may affect metrics related to Milestone 6
8. SUD health information technology (health IT)
8.1 Metric trends
8.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to its health IT metrics
8.2 Implementation update
8.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 8.2.1.a How health IT is being used to slow down the rate of growth of individuals identified with SUD
8.2.1.b How health IT is being used to treat effectively individuals identified with SUD
8.2.1.c How health IT is being used to effectively monitor “recovery” supports and services for individuals identified with SUD
8.2.1.d Other aspects of the state’s plan to develop the health IT infrastructure/capabilities at the state, delivery system, health plan/MCO, and individual provider levels
8.2.1.e Other aspects of the state’s health IT implementation milestones
8.2.1.f The timeline for achieving health IT implementation milestones
8.2.1.g Planned activities to increase use and functionality of the state’s prescription drug monitoring program
8.2.2 The state expects to make other program changes that may affect metrics related to health IT
9. Other SUD-related metrics
9.1 Metric trends
9.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to other SUD-related metrics
9.2 Implementation update
9.2.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to other SUD-related metrics

4. Narrative information on other reporting topics

Prompts	State has no update to report (place an X)	State response
10. Budget neutrality
10.1 Current status and analysis
10.1.1 If the SUD component is part of a broader demonstration, the state should provide an analysis of the SUD-related budget neutrality and an analysis of budget neutrality as a whole. Describe the current status of budget neutrality and an analysis of the budget neutrality to date.
10.2 Implementation update
10.2.1 The state expects to make other program changes that may affect budget neutrality
11. SUD-related demonstration operations and policy
11.1 Considerations
11.1.1 The state should highlight significant SUD (or if 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 impacts. 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. See Monitoring Report Instructions for more detail.
11.2 Implementation update
11.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 11.2.1.a How the delivery system operates under the demonstration (e.g., through the managed care system or fee for service)
11.2.1.b Delivery models affecting demonstration participants (e.g., Accountable Care Organizations, Patient Centered Medical Homes)
11.2.1.c Partners involved in service delivery
11.2.2 The state experienced challenges in partnering with entities contracted to help implement the demonstration (e.g., health plans, credentialing vendors, private sector providers) and/or noted any performance issues with contracted entities
11.2.3 The state is working on other initiatives related to SUD or OUD
11.2.4 The initiatives described above are related to the SUD or OUD demonstration (The state should note similarities and differences from the SUD demonstration)
12. SUD demonstration evaluation update
12.1 Narrative information
12.1.1 Provide updates on SUD evaluation work and timeline. The appropriate content will depend on when this monitoring report is due to CMS and the timing for the demonstration. There are specific requirements per 42 Code of Federal Regulations (CFR) § 431.428a(10) for annual [monitoring] reports. See Monitoring Report Instructions for more details.
12.1.2 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
12.1.3 List anticipated evaluation-related deliverables related to this demonstration and their due dates
13. Other SUD demonstration reporting
13.1 General reporting requirements
13.1.1 The state reports changes in its implementation of the demonstration that might necessitate a change to approved STCs, implementation plan, or monitoring protocol
13.1.2 The state anticipates the need to make future changes to the STCs, implementation plan, or monitoring protocol, based on expected or upcoming implementation changes
13.1.3 Compared to the demonstration design and operational details, the state expects to make the following changes to: 13.1.3.a The schedule for completing and submitting monitoring reports
13.1.3.b The content or completeness of submitted monitoring reports and/or future monitoring reports
13.1.4 The state identified real or anticipated issues submitting timely post-approval demonstration deliverables, including a plan for remediation
13.1.5 Provide updates on the results of beneficiary satisfaction surveys, if conducted during the reporting year, including updates on grievances and appeals from beneficiaries, per 42 CFR § 431.428(a)5
13.2 Post-award public forum
13.2.2 If applicable within the timing of the demonstration, provide a summary of the annual post-award public forum held pursuant to 42 CFR § 431.420(c) indicating any resulting action items or issues. A summary of the post-award public forum must be included here for the period during which the forum was held and in the annual monitoring report.
14. Notable state achievements and/or innovations
14.1 Narrative information
14.1.1 Provide any relevant summary of achievements and/or innovations in demonstration enrollment, benefits, operations, and policies pursuant to the hypotheses of the SUD (or if broader demonstration, then SUD related) demonstration or that served to provide better care for individuals, better health for populations, and/or reduce per capita cost. Achievements should focus on significant impacts to beneficiary outcomes. Whenever possible, the summary should describe the achievement or innovation in quantifiable terms, e.g., number of impacted beneficiaries.

*The state should remove all example text from the table prior to submission.

Note: Licensee and states must prominently display the following notice on any display of Measure rates:
Measures IET-AD, FUA-AD, FUM-AD, and AAP [Metrics #15, 17(1), 17(2), and 32] are Healthcare Effectiveness Data and Information Set (HEDIS®) measures that are owned and copyrighted by the National Committee for Quality Assurance (NCQA). HEDIS measures and specifications are not clinical guidelines, do not establish a standard of medical care and have not been tested for all potential applications. The measures and specifications are provided “as is” without warranty of any kind. NCQA makes no representations, warranties or endorsements about the quality of any product, test or protocol identified as numerator compliant or otherwise identified as meeting the requirements of a HEDIS measure or specification. NCQA makes no representations, warranties, or endorsement about the quality of any organization or clinician who uses or reports performance measures and NCQA has no liability to anyone who relies on HEDIS measures or specifications or data reflective of performance under such measures and specifications.
The measure specification methodology used by CMS is different from NCQA’s methodology. NCQA has not validated the adjusted measure specifications but has granted CMS permission to adjust. A calculated measure result (a “rate”) from a HEDIS measure that has not been certified via NCQA’s Measure Certification Program, and is based on adjusted HEDIS specifications, may not be called a “HEDIS rate” until it is audited and designated reportable by an NCQA-Certified HEDIS Compliance Auditor. Until such time, such measure rates shall be designated or referred to as “Adjusted, Uncertified, Unaudited HEDIS rates.”

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