CMS-10398 #64 MCO Protocol with Instructions

Attachment 3.g. MCO Protocol with Instructions
MANAGED CARE ORGANIZATION LEADER’S INTERVIEW PROTOCOL
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1148 (CMS-10398 # 64). The time required to complete this information
collection is estimated to average 90 minutes to participate in this interview. 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.”
Your decision to participate in this aspect of the study is voluntary. Under the Privacy Act of 1974 any
personally identifying information obtained will be kept private to the extent of the law. If you do not
wish to participate in this interview or answer specific questions, please let us know. We believe there
are minimal risks to you from participation, and every effort will be made to protect your confidentiality.
In reports to CMS, we will refer to you anonymously as a “managed care informants.”
Your insights on the section 1115 SUD demonstrations are important and will be used by federal and
state policymakers as well as other Medicaid programs in improving Medicaid SUD services and
developing resources and supports for MCOs, behavioral health organizations, and providers
implementing SUD demonstrations.
Finally, we would like to record our conversation, to ensure our notes from today are complete. Do I
have your permission to audio record our conversation today? Do you have any questions before we
begin?
INTRODUCTIONS
Good [MORNING/AFTERNOON], my name is [LEAD INTERVIWER] from RTI International. I will be leading
the interview today. Also on the call are [SUPPORTING ANALYSTS] who will be taking notes.
As a reminder, this interview will last 60 minutes. As you may know, [STATE] began participating in
the section 1115 SUD demonstration on [STATE-SPECIFIC EFFECTIVE DATE]. The interview will discuss
changes your organization made for Medicaid beneficiaries in support of the section 1115 SUD
demonstration. In [STATE], changes were made that related to: [SELECT AS APPROPRIATE: PATIENT
PLACEMENT/MEDICAID COVERAGE OF SUD SERVICES AND MEDICATION/CARE COORDINATION
REQUIREMENTS/REQUIRING RESIDENTIAL FACILITIES TO ENSURE ACCESS TO MEDICATION-ASSISTED
TREATMENT ON- AND OFFSITE/OTHER (SPECIFY)].
We would like to know how those state-level changes affected your organization. For each topic, we will
ask what your organization was doing prior to changes for the demonstration, what changes you
implemented in response to these changes, the challenges you encountered, and any observed impact
on providers and Medicaid members.
Would you like to introduce yourselves and your role in the organization?
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[ONLY ASK QUESTION X IF CONFIRMATION IS NEEDED]
X. Before we get started, we would like to confirm a few facts with you.
a) Could you confirm that your current contract with Medicaid became effective on
[DATE]?
b) Could you confirm that [STATE] [carved in/carved out] [SPECIFIC SUD SERVICE(S)] after
the demonstration was implemented, effective [DATE]?
c) [IF NOT KNOWN] Finally, in what regions of the state are you contracted with Medicaid
to operate?
OVERALL PERSPECTIVES ON THE SECTION 1115 SUD DEMONSTRATION
1. We’d like to hear your overall perspective on the demonstration, briefly. Considering all of the
changes made as part of the demonstration in [STATE], what effect do you think the
demonstration has had on the overall delivery of Medicaid-covered SUD services and what
changes, if any, have you observed?
2. From your vantage point, what would you describe as the most positive impact of the Medicaid
program’s section 1115 SUD demonstration? How so?
a) Has the demonstration increased the number of Medicaid-enrolled providers offering
SUD services?
i. [IF YES] Where have you seen this increase (e.g., outpatient, inpatient or
residential, which levels of care)?
b) Has the demonstration increased the number of your Medicaid members receiving SUD
treatment?
i. [IF YES] Where have you seen this?
3. Have there been any unintended effects from the state’s Medicaid section 1115 SUD
demonstration that you have observed?
a) [IF YES] What have you observed?
4. Finally, how has the COVID-19 pandemic affected implementation by your organization or your
providers? Which aspects of implementation have been affected and how?
a) Are there specific aspects of implementation that were hardest hit?
5. Did COVID-19 increase or decrease the number of your Medicaid members receiving SUD
treatment?” ?
a) What have you observed (e.g., more demand by new or existing enrollees)?
PATIENT PLACEMENT AND UTILIZATION MANAGEMENT
We would like to understand what role your organization played before the demonstration and after
changes were made, in support of patient placement, medical necessity determinations, any process
that informed the appropriate level of care (e.g., monitoring provider compliance with patient
placement criteria, documentation review, supports to providers for patient assessment or intake, prior
authorization, post-admission retrospective authorization), and utilization management.
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As part of the demonstration, your state made changes to Medicaid managed care contracts that
required MCOs to [DESCRIBE REQUIREMENT] effective [DATE]. The Medicaid program also required that
[PROVIDER TYPES] [DESCRIBE REQUIREMENT] and [DESCRIBE REQUIREMENT] effective [EFFECTIVE
DATE].
6. Prior to the changes made in support of the demonstration, what policies and practices did you
have in place? (e.g., coordination with Interim Management Entity, previous assessment
instruments, conducting medical necessity determinations or utilization review for SUD services)
MCO Impacts
7. After the changes [STATE] made via the 1115 demonstration regarding patient placement
criteria and utilization management, what did your organization implement in response (e.g., to
document, monitor, or support provider compliance with requirements, support medical
necessity determinations, new utilization management processes, payment approval processes,
etc.)? What were the operational, administrative, or contractual changes?
PROBE FOR:
a) Challenges and how they were addressed (Sample question: What challenges did you
face implementing these changes? How did you address these challenges [e.g., new
provider supports, coordinate with the state])?
i. Impact of COVID (Sample question: How did the COVID-19 pandemic impact
implementation of these changes?)
b) Facilitators (Sample question: What factors supported your changes [e.g., state
resources, state provider outreach]?)
Provider Impacts
8. How have these changes affected SUD providers [in your network]?
PROBE FOR:
a) Challenges and how they were addressed (Sample question: What challenges did your
providers face because of new requirements on use of standardized patient placement
criteria and other requirements? How did you work with providers to address these
challenges?)
i. Concerns among providers about medication assisted treatment
ii. Impact of COVID
b) Facilitators
c) Impacts on intermediate outcomes (Sample question: Have changes made by providers
resulted in increased use of [e.g., widely accepted patient criteria; capacity of all levels of
care; increased identification, initiation, and patient engagement])?

Member Impacts

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9. Considering all the changes in state requirements and changes by your own organization related
to the processes we just discussed, what has been the impact of these changes on Medicaid
members?
PROBE FOR:
a) Challenges and how they were addressed (e.g., stigma among patients against using
medication for their treatment)
b) Impacts on intermediate outcomes (Sample question: What impact have these changes
had on members’ access to appropriate care, engagement in care, or retention in care)?
c) Health equity (Sample question: What impact at the Medicaid member-level have
changes had that could impact disparities in access and treatment or provider supply for
priority populations, such as different racial/ethnic groups, pregnant women, youth,
justice-involved)?
ADDITION OF SUD SERVICES/LEVELS OF CARE
Our next set of questions relate to SUD services [STATE MEDICAID PROGRAM NAME] added to further
the objectives of the demonstration. To support the demonstration, [STATE MEDICAID PROGRAM
NAME] added or expanded coverage of the following SUD services:
[READ EACH SERVICE/LEVEL OF CARE AND ITS EFFECTIVE DATE]
[RESIDENTIAL SERVICES IN IMDs] on [EFFECTIVE DATE]
[ADDITION/EXPANSION] of [SERVICE/LEVEL OF CARE] on [EFFECTIVE DATE]
[METHADONE] on [EFFECTIVE DATE]
[IF NEEDED] Could you confirm, are/is [any of these services/SERVICE] CARVED OUT of
your state contract?
[IF APPLICABLE]: In addition, [STATE] [CARVED IN/CARVED OUT] [SERVICE TYPES] on [EFFECTIVE DATE].
MCO impacts
10. With respect to service changes by Medicaid, what changes did you make to your operations or
procedures, such as provider enrollment processes, provider contracts, and provider training,
reimbursement or billing changes?
PROBE: Were these changes specific to one service, all services added, [OR ALL SERVICES
CARVED [IN/OUT] of your contract?
a) [ONLY ASK IF STATE AUTHORIZED MCO USE OF IN-LIEU-OF PROVISION PRE-DEMO]: How
about services your state previously authorized access to through the in-lieu-of-provision:
[IMDs/[FACILITY TYPE/for LEVEL OF CARE]. What changes did you make after the
demonstration?
b) [ONLY ASK IF STATE CARVED-OUT/IN SERVICES]: How about services that were [CARVEDIN/CARVED-OUT]. What changes did you make to manage these services?
c) How about reimbursement or billing? Did you make any changes for SUD services?

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PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
ii.
Difficulty recruiting providers into network
iii.
Reimbursement/billing
b) Facilitators
i. Reimbursement/billing changes
11. What were your processes like before these changes (e.g., provider enrollment processes,
provider contracts, and provider training)? How much of a change was this from what you were
doing before?
a) [ONLY ASK IF STATE AUTHORIZED SERVICES WITH IN-LIEU-OF PROVISION]: How about
services your state authorized access to through the in-lieu-of-provision: [IMDs/[FACILITY
TYPE/for LEVEL OF CARE].
b) [ONLY ASK IF STATE CARVED-OUT/IN SERVICES]: How about services that were carvedin/carved-out. What did your processes look like before the demonstration?
Provider Impacts
12. How have the changes [STATE] or your organization made affected providers [in your
network]?PROBE FOR:
a) Challenges (e.g., impact on provider willingness to enroll in the network) and how they were
addressed (e.g., provision of provider trainings or technical assistance)
i.
Impact of COVID
b) Facilitators
Member impacts
13. Prior to the addition of SUD services to Medicaid through section 1115 mentioned a moment
ago, how did your Medicaid members access these services through other funding sources or inlieu-of provisions?
a) Did your operations include supporting access to these services not covered in the Medicaid
state plan for your members? How so?
b) Prior to these changes, which services were the most difficult for members to access? How
so?
c) [ONLY ASK IF STATE AUTHORIZED SERVICES WITH IN-LIEU-OF PROVISION] How about services
your state authorized access to through the in-lieu-of-provision: [IMDs/[FACILITY TYPE/for
LEVEL OF CARE]?
d) [ONLY ASK IF STATE CARVED-OUT/IN SERVICES] How did your operations support Medicaid
members’ access to these services if carved-out from your contract?
14. How have the changes in Medicaid coverage of [IMD/RESIDENTIAL LEVELS OF CARE] affected
access to these services for your Medicaid members?

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a) Overall, would you consider these changes to have negative impacts, positive impacts, or no
impacts on members?
How would you describe the overall magnitude of impacts for Medicaid members: would
you say the impact has been minor, moderate, or major?
PROBE FOR:
a) Challenges and how they were addressed
b) Facilitators
c) Impacts on intermediate outcomes
d) Health equity (Sample question: What impact have changes had on equitable access and
treatment or provider supply for priority populations, such as different racial/ethnic groups,
pregnant women, youth, justice-involved)?
e) Impact of services formerly accessed through in-lieu-of provision
f) Impact of services formerly carved-in or carved-out
15. [IF APPLICABLE TO STATE] How have the changes in [WITHDRAWAL MANAGEMENT/INTENSIVE
OUTPATIENT/METHADONE] coverage/reimbursement affected your Medicaid members?
PROBE FOR:
a) Impacts on intermediate outcomes
b) Health equity
CARE COORDINATION AND TRANSITION PLANNING
Next, let’s discuss care coordination and transition planning before and after the state made changes as
part of the demonstration. As part of the demonstration, [STATE] made the following changes:
[READ DESCRIPTION OF STATE-SPECIFIC CARE COORDINATION/TRANSITION IN CARE CHANGES]
[CARE COORDINATION CHANGE] in [EFFECTIVE DATE].
[TRANSITION PLANNING CHANGE] in [EFFECTIVE DATE].
MCO impacts
15. Prior to [STATE] making these changes, what was your organization’s approach to supporting
care coordination?
16. After the [STATE] made changes, what changes did your organization make to support care
coordination? (e.g., transportation, new staff such as peer support counselors, new referral or
contractual requirements/relationships etc.)?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators

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17. Prior to [STATE] making changes related to transition planning, what was your organization’s
approach to supporting transitions between levels of care?
18. After the [STATE] made changes, what was your approach to supporting transitions between
levels of care? (e.g., transportation, new staff such as peer support counselors, new referral or
contractual requirements/relationships etc.)
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
Provider Impacts
19. How did the changes in [CARE COORDINATION/TRANSITION PLANNING] organization affect
providers or your provider network?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
Member Impacts
20. What impact did changes in [CARE COORDINATION/TRANSITION PLANNING] have on your
members, if any?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Impacts on intermediate outcomes
c) Health equity

RECOVERY SUPPORT SERVICES
Next we’ll talk about recovery support services. As part of the demonstration, [STATE] implemented:
[READ LIST OF CHANGES TO RECOVERY SUPPORT SERVICES]
[PEER SPECIALIST SUPPORT CHANGE] in [EFFECTIVE DATE]
[SUPPORTIVE HOUSING CHANGE] in [EFFECTIVE DATE]
[SUPPORTIVE EMPLOYMENT CHANGE] in [EFFECTIVE DATE]
[TRANSPORTATION/OTHER RSS CHANGE] in [EFFECTIVE DATE]
MCO Impacts

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21. Prior to the demonstration, which recovery support services could your Medicaid members
access through other funding sources or in-lieu-of provisions? (e.g., supportive housing, peer
specialists, employment)?
22. How did additions of recovery services in Medicaid impact access for your Medicaid members??
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
Provider Impacts
23. Did the changes [STATE] and your organization made impact providers or your provider
network?
PROBE FOR:
a) Challenges and how they were addressed (e.g., shortage of peer specialists, peer training)
i.
Impact of COVID
b) Facilitators
Member Impacts
24. What impact did changes to recovery support services have on your members, if any?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
c) Impacts on intermediate outcomes
d) Health equity
RESIDENTIAL MAT
As part of the demonstration, [STATE] required residential facilities to dispense MAT onsite or facilitate
access to MAT offsite [and OTHER MAT-RELATED CHANGES SPECIFIC TO THE STATE].
25. Prior to [STATE]’s approval of the SUD section 1115 demonstration, did you require residential
SUD providers within your network to offer MAT onsite or facilitate access to MAT offsite?
PROBE FOR:
a) Pre-demonstration MAT: [Sample question: To what extent did residential providers in your
regions facilitate access to MAT? Did any residential providers administer MAT onsite?]
b) Provider decisions [Sample question: What factors contributed to provider decisions NOT to
facilitate MAT, prior to the demonstration (e.g., stigma, lack of training, lack of MAT
providers in area)?]
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26. Prior to the new MAT requirements, did you offer support to providers to administer MAT onsite (e.g., training, educational outreach, financial incentives)?
a) Did you offer support for facilitating access to MAT off-site (e.g., scheduling transportation,
connecting facilities with in-network outpatient subscribers)?
27. Was MAT utilization by residential patients monitored in administrative data? How so?
MCO Impacts
28. After the state set new MAT requirements, did you add requirements for residential providers in
your network to assure their compliance with the state requirement
a) What did your provider contracts require, specifically?
b) What are providers required to do to increase access to MAT offsite?
c) How do providers demonstrate to you that they meet new requirements (i.e.,
documentation of cooperative agreements at the time of enrollment in your network)?
d) Did you require providers already in your network to submit more documentation or reapply for eligibility to join your network?
e) Does your organization monitor compliance after provider enrollment? If so, how?
PROBE FOR:
a) Challenges and how they were addressed Provider stigma towards MAT (sample
question(s): Did you experience concerns from providers about prescribing MAT? What did
you attribute that to?
i.
Impact of COVID
b) Facilitators

29. Now that the state has set new MAT requirements, does your organization offer new supports
to residential providers to help them expand access to MAT for their patients?
a) Could you describe these new supports (e.g., training, technical assistance, other)?
b) Do you assist with scheduling or providing transportation? How does that work?
c) Does your organization assist residential providers by linking them to outpatient subscribers
in their area who can provide MAT off-site for their patients? Could you describe the
assistance you provide?
d) Did your own staff receive any training from state-funded initiatives about MAT?
30. [IF RESIDENTIAL IS CARVED IN TO MCO CONTRACTS]: Are you paying residential facilities
differently to encourage providers to offer MAT onsite? [IF YES] How are incentives structured?
a) Does payment method facilitate the observance in encounter or claims data of MAT use by
RT clients onsite and offsite?
b) What advice or specifications can you share with our federal evaluation team to reliably
measure MAT use during residential stays for your members?
Provider Impacts
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31. Have residential providers [in your network] sought to add onsite administration of MAT in
response to the MAT requirement?
a) (IF SO): Would you say there has been an increase, decrease, or no change in the number of
providers offering MAT onsite?
b) How have you monitored that activity?
32. What challenges have providers faced implementing onsite MAT requirements?
PROBE FOR:
a) How challenges were addressed
i.
Impact of COVID
b) Facilitators
33. What has been your providers’ experiences with implementing offsite MAT requirements?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
34. How would you describe provider progress toward meeting offsite MAT requirements? (e.g.,
increased, decreased, no change).
35. [IF RESIDENTIAL IS CARVED IN TO MCO CONTRACTS] How do you monitor compliance with MAT
requirements by your residential providers? (i.e., on-site audits, analysis of administrative data)
a) Have you observed changes in providers’ administration of MAT on-site?
b) Have you observed changes in access to MAT off-site?
c) To what do you attribute these changes?
Member impacts
36. How have new MAT requirements impacted your Medicaid members’ ability to access MAT at
all levels of care?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
c) Impacts on intermediate outcomes
d) Health equity
WRAP UP

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Thank you very much for participating in this interview. Your insight is incredibly valuable to
understanding how states are implementing the section 1115 SUD demonstrations, the challenges they
are experiencing, and the impact they are having on states ability to meet the needs of those with SUD.
Before we wrap up this interview, we wanted to ask if there was anything we didn’t cover or discuss that
you feel is important for us as evaluators to know.

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