CMS-10398 $64 Behavioral Health Stakeholder Interview Protocol with In

Attachment 3.h. Behavioral Health Stakeholder Interview Protocol with Instructions
(Residential Providers)
RESIDENTIAL BEHAVIORAL HEALTH LEADER 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 “provider 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 patients.
Would you like to introduce yourselves and share your role in the organization?
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1. Could you please tell us a little about your organization (e.g., services and levels of care offered,
patients served, number of providers, etc.)?
2. When did your organization start accepting Medicaid patients?
PATIENT PLACEMENT CRITERIA
We want to start out by discussing how your organization and your Medicaid patients were affected
by required state changes in the use of patient placement criteria. Your organization was required by
[STATE] as part of the section 1115 demonstration to use standardized [INSERT NAME] patient
placement criteria beginning [EFFECTIVE DATE OF NEW CRITERIA]. In addition, [STATE] also [LIST ANY
OTHER CHANGES OR INITIATIVES UNDER MILESTONE 2 (e.g., provider trainings, provider manual
revisions, additional or updated requirements enforced within the providers’ MCO network)].
Provider Impacts
3. How did the assessment process change as a result of the state-level changes (e.g., processes used
to assess patients and determine the most appropriate level of care, intake assessments, payment
approval processes)? What was your process like before the state-level changes?
PROBE FOR:
a) Challenges and how they were addressed (Sample question: What challenges did your
organization face implementing these changes? How were those challenges addressed [e.g.,
provider understanding and staff response to new processes, financial impact])?
i.
Impact of COVID (Sample question: How did the COVID-19 pandemic impact changes
related to patient placement criteria?)
b) Facilitators (Sample question: What factors supported changes within your organization [e.g.,
partners, funding, resources, provider trainings]?)
c) Health equity (Sample question: To what extent did you tailor implementation towards
vulnerable or marginalized populations?)
4. Could you describe other operational or administrative changes your organization made in
response to changes in patient placement criteria? (e.g., updated electronic health record or
billing system, hiring of new staff, new workflows, additional or updated requirements enforced
within the providers’ MCO network, new credentialing, accreditation, or licensing for Medicaid
approval, reimbursement, or prior authorization)?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators (e.g., provider trainings, provider manual revisions, MCO support)
5. Did your organization participate in provider trainings? If so, which ones? Were they helpful? Why
or why not?
PROBE FOR:

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a) Did your organization offer trainings to providers? Could you tell me about what those
covered?
Patient impacts
6. Turning to your patients, how have the changes in the assessment process affected your patients
with Medicaid (e.g., availability of each level of care meeting patient needs)?
PROBE FOR:
a) Challenges and how they were addressed (e.g., stigma towards patients using medication for
treatment)
i.
Impact of COVID
b) Facilitators (e.g., more appropriate placement in a level of care or setting)
c) Impact on intermediate outcomes (Sample question: What impact has that had on patient
access to care? Engagement in care? Retention in care? Etc.? [e.g., patient use of certain levels
or care more or less than others, changes in types of treatment recommended to patients,
patient ability to get the level of care they need])
d) Health equity (Sample question: How has implementation affected access to care for
vulnerable, specific, or marginalized populations [e.g., urban vs. rural, persons with
disabilities, pregnant women, racial/ethnic, language barriers]? How was that assessed?)

MEDICAID COVERAGE, BILLING, AND REIMBURSEMENT
Shifting topics, we next want to discuss how changes in Medicaid coverage of certain services has
affected your organization and your patients with Medicaid. As part of the demonstration, [STATE
ADDED/EXPANDED BLANK COVERAGE (e.g., Methadone, intensive outpatient/partial hospitalization
services, residential/IMDs, or withdrawal management services)] on [EFFECTIVE DATE].
Provider Impacts
7. How has the [ADDED/EXPANDED] Medicaid coverage of [RESIDENTIAL LOCS] affected your
organization? How has the added Medicaid coverage for services provided in IMDs affected your
organization? (e.g., operational and administrative changes in staffing, electronic systems, new state
licensure, or MCO contracts; added beds or buildings; added or removed programs with more than
16 beds) What is different as a result of the change? Interviewer: repeat question and probes if
multiple residential LOCs apply.
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators (e.g., partners, resources, funding, technical assistance)
8. What has been your organization’s experience in billing Medicaid for [INSERT SERVICE]? Interviewer:
repeat question and probes if multiple residential LOCs apply. What was your experience billing
Medicaid for these services before the change?
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PROBE FOR:
a) Challenges and how they were addressed (e.g., extent that Medicaid reimbursement reflects
costs of providing [SERVICE] to Medicaid beneficiaries, billing for services like room and board
not covered by Medicaid, experience with Medicaid certification/enrollment, staff response, staff
retention, changes in willingness to accept Medicaid patients)
i.
Impact of COVID
b) Facilitators (e.g., partners, resources, funding, technical assistance, trainings, provider manual
updates)
9. [IF APPLICABLE TO STATE] How has the [ADDED/EXPANDED] Medicaid coverage of [WITHDRAWAL
MANAGEMENT/INTENSIVE OUTPATIENT/METHADONE] affected your organization?
PROBE FOR:
a) Challenges and how they were addressed (e.g., extent that Medicaid reimbursement reflects
costs of providing [SERVICE] to Medicaid beneficiaries, billing for services like room and board
not covered by Medicaid, experience with Medicaid certification/enrollment, staff response)
i.
Impact of COVID
b) Facilitators (e.g., partners, resources, funding, technical assistance, trainings, provider manual
updates)
Patient impacts
10. Turning to your patients, how have the changes in [IMD/RESIDENTIAL LOCS]
coverage/reimbursement affected your ability to provide appropriate care for Medicaid patients?
Interviewer: repeat question and probes if multiple residential LOCs (apply.
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
c) Impact on intermediate outcomes
d) Health equity
11. [IF APPLICABLE TO STATE] How have the changes in [WITHDRAWAL MANAGEMENT/INTENSIVE
OUTPATIENT/METHADONE] coverage/reimbursement affected your ability to provide withdrawal
management for Medicaid patients?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
c) Impact on intermediate outcomes
d) Health equity
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CARE COORDINATION AND TRANSITIONS IN CARE
Moving onto our last topic, we want to finish with a discussion on how changes in Medicaid-required
care coordination and transition policies have affected your organization and care for your patients with
Medicaid. As part of the demonstration, [STATE] implemented [LIST CARE COORDINATION CHANGES
HERE] in [DATE/YEAR].
Care Coordination
Provider Impacts
12. With the implementation of the demonstration, what changes did your organization make to meet
the state requirements around care coordination? (e.g., adding transportation or new types of staff
like peer counselors, new referral or contractual relationships) What was your organization doing
before these changes were made?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
Patient Impacts
13. Turning to your patients, how have the changes in care coordination affected your patients with
Medicaid?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
c) Impact on intermediate outcomes
d) Health equity
Transitions in Care
Provider Impacts
14. With the implementation of the demonstration, how have required changes in transition planning
affected your organization? (e.g., revised protocols and communication with other facilities)
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
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Patient Impacts
15. Turning to your patients, how have the changes in transition planning affected your patients with
Medicaid?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
c) Impact on intermediate outcomes
d) Health equity

RECOVERY SUPPORT SERVICES
As part of the demonstration, [STATE] implemented [LIST CHANGES TO RECOVERY SUPPORT SERVICES
(RSS) (e.g., peer support, supportive housing, employment) HERE] in [DATE/YEAR].
Provider Impacts
16. Could you please describe the types of recovery support services offered by your organization
arising from the state-level changes? What did you offer before?
Interviewer: repeat question and probes for each RSS.
PROBE FOR:
a) Challenges and how they were addressed (e.g., gaps in services, staffing, funding)
i.
Impact of COVID
b) Facilitators (e.g., collaboration or coordination with other organizations)
c) Impact on intermediate outcomes
d) Health equity
17. What other factors impacted the delivery of [RSS IMPLEMENTED AS A RESULT OF THE
DEMONSTRATION] at your organization?
18. Which organizations do you collaborate with to provide [RSS IMPLEMENTED AS A RESULT OF THE
DEMONSTRATION]? What services do they provide?
i.
PROBE: How did you collaborate with other organizations to provide [RSS]?
ii.
PROBE: What challenges have you encountered? How were they addressed?
iii.
PROBE: What facilitates those partnerships?
19. How do you coordinate [RSS IMPLEMENTED AS A RESULT OF THE DEMONSTRATION] with SUD
treatment at your organization?
20. What would you change about the provision of RSS? Why?

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Patient Impacts
21. Turning to your patients, how have the changes in recovery support services affected your patients
with Medicaid?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
c) Impact on intermediate outcomes
d) Health equity
22. How has Medicaid coverage of RSS affected access to other clinical services (e.g., other behavioral or
physical health services)?
23. What else could be done to improve provision of RSS (e.g., other services added, changes in
reimbursement, better training for peer specialists)?
i.
PROBE: What types of services (e.g., intensive outpatient, withdrawal management)
would benefit most from improvements to your current set of RSS?
ii.
PROBE: How would such improvements affect patients’ access to care? Engagement in
care? Retention in care?
24. What other types recovery support services are still needed to meet patients’ needs?
i.
PROBE: How would adding those services affect patients’ access to care? Engagement in
care? Retention in care?
ii.
PROBE: Do you have plans for expanding RSS in the future under the demonstration? [IF
YES] Could you describe those plans?

RESIDENTIAL MAT
As part of the demonstration, [STATE] required residential facilities to dispense MAT onsite or facilitate
access to MAT offsite [and LIST ANY OTHER MAT-RELATED CHANGES SPECIFIC TO THE STATE].
Provider Impact
25. Were you providing residential MAT before the state made changes? Was it on- or off-site?
26. What changes did your organization make to align with the state-level requirements? (e.g.,
infrastructure to safely store medication, contractual or referral relationships, transportation to OTPs
or OBOT appointments) What did you have in place before the requirements went into effect?
Interviewer: Repeat question and probes for each change.
PROBE FOR:
a) Challenges and how they were addressed
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i.
ii.

Impact of COVID
Provider stigma towards MAT (sample question(s): Did you experience concerns from
providers about prescribing MAT? What type of stigma (e.g., resistance among providers
to accept a treatment model for SUD that includes MAT, providers prescribing one drug
over another, community-based stigma, etc.) did you observe?)
iii.
Provider capacity
iv.
Challenges in provision of different types of MAT
b) Facilitators (e.g., collaboration or coordination with other organizations, provider trainings, state
enforcement activities, measures within organization to enforce compliance to MAT
requirement)
27. How did staff in your organization respond to changes? Did the impact of changes vary among
clinical versus non-clinical providers? How so?
28. How does your organization collaborate with outpatient facilities to provide MAT?
29. How is the state monitoring and enforcing the MAT requirement? What measures do you take at
your organization to monitor compliance with the MAT requirement?
Patient Impacts
30. Turning to your patients, how have the changes in residential MAT requirements affected your
capacity to provide appropriate care for your patients with Medicaid?
PROBE FOR:
a) Challenges and how they were addressed
i.
Impact of COVID
b) Facilitators
c) Impact on intermediate outcomes (e.g., are more/less patients using MAT, patient ability to
adhere to medication)
d) Health equity

WRAP UP
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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