Attachment 11.a - g. SMI _SED Demonstration Implementation Docs

Attachment 1.a. SMI/SED Demonstration Implementation Interview Introductory Email
from CMS to State Medicaid Director and Director of the Single State Agency for Mental
Health
To:
Health
CC:
Subject:

Director State Medicaid Agency and Director of the Single State Agency for Mental
RTI SMI Team Lead, CMCS Demonstration Team
RTI International Evaluation of Section 1115 Serious Mental Illness/Serious
Emotional Disturbance Demonstrations

Dear [State Medicaid Director and Director of the Single State Agency for Mental Health],
Your state has received approval from the Centers for Medicare & Medicaid Services (CMS) to
implement a section 1115 serious mental illness/serious emotional disturbance (SMI/SED)
demonstration. States with section 1115 SMI/SED demonstrations are required to conduct
independent evaluations of their demonstrations and report monitoring data regularly. To
complement individual state evaluations and monitoring, the CMS has contracted with RTI
International to conduct a meta-evaluation of SMI/SED demonstrations. This evaluation
will look across states with SMI/SED demonstrations to understand the demonstrations’
effectiveness, and how variations in state demonstration features and the context in which
demonstrations are implemented lead to differences in effectiveness. CMS is requesting that you
participate in the activities described below to support the meta-evaluation.
RTI will conduct a telephone interview with the state Medicaid director (or designee). The
purpose of the interview is to clarify and confirm the accuracy of information already gathered
by RTI about your state’s pre-demonstration SMI/SED treatment coverage and service delivery
policies, and details regarding program features of your demonstration, implementation
experiences, challenges, and programmatic changes. We expect this interview will take no more
than 60 minutes.
RTI will ensure flexibility interview scheduling, allowing you to choose the date and time that
best fits your schedule.
RTI will follow up with you via email to schedule a time for the first telephone interview. The
calls will be conducted from [DATE RANGE]. We appreciate your participation in this
important evaluation. Please contact me at [INSERT CMS PHONE NUMBER] if you have
questions.
Thank you,
[NAME OF CMS PROJECT OFFICER]

Attachment 1.b. SMI/SED Demonstration Implementation Interview Email Invitation
To:
Health
CC:

Director State Medicaid Agency and Director of the Single State Agency for Mental
CMCS Demonstration Team, RTI SMI Team Lead

Subject:

RTI International Evaluation of Section 1115 Serious Mental Illness/Serious
Emotional Disturbance Demonstrations

Dear [Director State Medicaid Agency and Director of the Single State Agency for Mental
Health],
I am writing from RTI International as follow up to an email you received on
[DATE] from [STATE CMS PROJECT OFFICER NAME], your section 1115
serious mental illness/serious emotional disturbance (SMI/SED) demonstration
project officer, regarding the meta-evaluation we are undertaking on behalf of
CMS. As part of the evaluation, we are conducting telephone interviews with state
Medicaid directors and directors of the single state agencies for mental health in
states implementing SMI demonstrations.
Interviews are intended to improve our understanding of your state’s predemonstration SMI treatment, coverage, and service delivery and program
features of your demonstration. Information from these conversations will help
CMS understand the effectiveness of SMI demonstrations to increase access to
mental health treatment. Your participation is important to helping CMS support
policy and programmatic development for other demonstration states and future
demonstrations.
The telephone interview will take no more than 60 minutes. Below we provide
some potential times for calls. Would any of these times be amenable to you? If
not, could you provide a few alternative times? If there is another person at your
agency who would be more appropriate for this conversation, please provide us
with their contact information. Please provide the date and time that works best
for you, and we will ensure our staff is available.
•
•
•
•

Day of week m/dd - time
Day of week m/dd – time
Day of week m/dd – time
Day of week m/dd – time

•

We greatly appreciate your help in confirming our available information
and helping to answer our questions.

If you have questions, please do not hesitate to contact me via email [EMAIL
ADDRESS] or telephone [TELEPHONE NUMBER].
Thank you and we look forward to speaking with you.
[NAME OF RTI STAFF MEMBER]

Attachment 1.c. SMI/SED Demonstration Implementation Interview Confirmation Email
To:
Health

Director State Medicaid Agency and Director of the Single State Agency for Mental

CC:

CMCS Demonstration Team, RTI SMI/SED Team Lead

Subject:

Telephone Interview Confirmation for RTI International Evaluation of Section 1115
Serious Mental Illness/Serious Emotional Disturbance Demonstrations

Good [MORNING/AFTERNOON] [NAME],
This is a confirmation that your interview on the serious mental illness/serious emotional
disturbance (SMI/SED) section 1115 demonstration for your state is on:
Day and Date:
Time:

[EST/PT/CST]

To connect to the interview for audio only, use either the smartphone one-tap dial telephone
number or the landline telephone number, both listed below. RTI staff will participate using
Zoom teleconference technology. You can also join us by clicking on the link below at the start
time of your interview. Two days before the interview date, we will send you a reminder email
or an updated email invitation with the links included for ease of access.
Your interview will be conducted by [NAME OF RTI INTERVIEWER], copied on this email.
Thank you in advance for your time and insight, please let us know if you have any questions,
concerns, or comments. We are looking forward to speaking with you!
Thank you,
[NAME OF RTI STAFF MEMBER]
Zoom Call-In information:
To join using one tap dial (cell phone) tap hyperlink: [+555-555-5555,123456789]
To join using a computer, click https://rtiorg.zoom.us/j/123456789

Attachment 1.d. SMI/SED Demonstration Implementation Interview Outlook Invitation
To:
Director State Medicaid Agency and Director of the Single State Agency for
Mental Health
CC:

CMCS Demonstration Team, RTI SMI/SED Team Lead

Subject:

RTI International Evaluation of Section 1115 Serious Mental Illness/Serious
Emotional Disturbance Demonstrations

Good [MORNING/AFTERNOON] [NAME],
Thank you for agreeing to participate in an interview to support the Centers for Medicare &
Medicaid Services meta-evaluation of section 1115 serious mental illness/serious emotional
disturbance (SMI/SED) demonstrations.
This is an invitation for your interview on [DAY OF WEEK, MONTH, DATE, 2021] regarding
[YOUR STATE’s] section 1115 SMI/SED demonstration.
To connect to the interview for audio only, use either the smartphone one-tap dial telephone
number or the landline telephone number, both listed below. RTI staff will participate using
Zoom teleconference technology. You can also join us by clicking on the link below at the start
time of your interview. Two days before the interview date, we will send you a reminder email
or an updated email invitation with the links included for ease of access.
If you need to reschedule your interview or would like assistance using the Zoom platform,
please email or call [NAME OF RTI INTERVIEWER].
Thank you in advance for your time and insight, please let us know if you have any questions,
concerns, or comments.
Thank you,
[NAME OF RTI STAFF MEMBER]

Zoom Call-In information:
To join using one tap dial (cell phone) tap hyperlink: [+555-555-5555,123456789]
To join using a computer, click https://rtiorg.zoom.us/j/123456789

Attachment 1.e. SMI/SED Demonstration Implementation Interview Reminder Email
To:

Director State Medicaid Agency Director of the Single State Agency for Mental
Health

CC:

CMCS Demonstration Team, RTI SMI/SED Team Lead

Subject:

Telephone Interview for RTI International Evaluation of Section 1115 Serious
Mental Illness/Serious Emotional Disturbance Demonstrations

Good [MORNING/AFTERNOON] [STATE MEDICAID DIRECTOR NAME],
Thank you for agreeing to be interviewed to support the Centers for Medicare & Medicaid
Services meta-evaluation of section 1115 serious mental illness/serious emotional disturbance
(SMI/SED) demonstrations.
This is a reminder that your interview about the section 1115 SUD demonstration in your state is
on
Day and Date:
Time:

[EST/PT/CST]

To connect to the interview for audio only, use either the smartphone one-tap dial telephone
number or the landline telephone number, both listed below. RTI staff will participate using
Zoom teleconference technology. You can also join us by clicking on the link below at the start
time of your interview.
Your interview will be conducted by [NAME OF RTI INTERVIEWER], copied on this email.
Please feel free to invite them to the interview and forward the invitation to them.
Thank you in advance for your time and insight, please let us know if you have any questions,
concerns, or comments. We are looking forward to speaking with you.
Thank you,
[NAME OF RTI STAFF]

Attachment 1.f. SMI/SED Demonstration Implementation Interview Protocol with Instructions
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 # 59). The time required to complete this information
collection is estimated to average 60 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 “state officials”
Your insights on the section 1115 SMI/SED waivers (or demonstrations) are important and will be used
by federal and state policymakers as well as other Medicaid programs in improving Medicaid mental
health services and developing resources and supports for states implementing SMI/SED
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. The interview will be in-depth discussion of
implementation experience, challenges, and programmatic changes for Medicaid beneficiaries in
support of the section 1115 SMI/SED demonstration.
We would like to know how those state-level changes affected delivery of services for Medicaid
enrollees with SMI or SED. For each topic, we will ask what changes [STATE] implemented as part of the
demonstration, the challenges you encountered, and any observed impact on providers and Medicaid
enrollees.
Would you like to introduce yourselves and your role in the organization?
Overall Perspectives on the Section 1115 SMI/SED Demonstration
To get us started, I would like to start with some high-level questions about SMI/SED treatment services
in [State] and your SMI demonstration.
1. To start, we would like to confirm a few dates with you:

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a.

[STATE]’s SMI demonstration was approved [INSERT DEMONSTRATION
APPROVAL DATE]. Is this the date you began drawing federal financial
participation (FFP) for IMD stays? If not, when did you start drawing FFP? When
did you begin other demonstration-related activities?

2. From your perspective, what was the motivation for pursuing the SMI/SED section 1115
demonstration?
a.

PROBE: Where were the biggest gaps in service delivery or coverage prior to the
demonstration (e.g., gaps in community-based care or crisis care for Medicaid enrollees
with SMI/SED)?
Note to interviewer: only provide the examples if someone needs them.

3. From your perspective, what are the most important activities [STATE] is doing under the
demonstration?
4. Which demonstration activities do you think are most likely to have the greatest impact on
Medicaid enrollees with SMI or SED and why?
a.

b.

PROBES: Improved access to IMD services? Crisis services? Community-based services?
Integrated primary and behavioral health care? Integration with social services? Improved
access to mental health care for youth? Any state reported changes in provider
reimbursement for treatment?
PROBE: Have you already noticed an impact? How so?

5. Are there other changes the state is making outside the demonstration that you expect to have
significant impact on Medicaid enrollees with SMI or SED? What are they?
Insert prompts with state activities that we already know about and that may be relevant.
a.

PROBE: Were any of these activities funded with grants or state-only funds?

6. [For states that also have a section 1115 SUD demonstration] Your state also has a section 1115
substance use disorder (SUD) demonstration. Do you coordinate activities between the SMI and
the SUD demonstration? If yes, how so?
a.

PROBE: What challenges have you faced in coordinating efforts? How have you dealt with
the challenges?

Milestone 1: Ensuring Quality of Care in Psychiatric Hospitals and Residential Settings

7. Have any of your state’s regulations, licensing criteria, or utilization review policies for SMI
residential providers changed because of the demonstration? If so, how? For example, do you
have any new types of residential providers for the SMI or SED that you do not have for the SUD
population? Did you put new requirements in place for residential providers serving SMI/SED
patients that are not needed for residential providers serving SUD patients.

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a.
b.
c.

PROBE: Can you talk about provider feedback on the new standards?
PROBE: Did the COVID-19 public health emergency change anything you had put in place?
Do you plan to keep any of the COVID-19 related changes going forward?
PROBE: Are there any challenges have you faced changing regulations or policies? What
are they, and how are you dealing with them?

8. What was the patient assessment tool used to determined appropriate length of stay or level
care in a residential or inpatient setting prior to the demonstration? Did this change with the
implementation of the demonstration?
a.

PROBE: Are there any challenges have you faced concerning patient assessment tools?
What are they, and how are you dealing with them?

Milestone 2: Improving Care Coordination and Transitions to Community-Based Care
9. As part of the demonstration, did you make any changes:
(1) to help providers coordinate mental health care and physical health care for Medicaid
enrollees with SMI or SED? If yes, please describe those changes and current strategies to
improve coordination.
a. PROBE: [If the state has managed care and fee-for-service] If yes, did changes and
current strategies differ for individuals enrolled in fee-for-service Medicaid and
individuals enrolled in Medicaid managed care? How so?
b. PROBE: What has been the impact of these changes?
c. PROBE: Are there any challenges that you face implementing care coordination
activities through the demonstration? What are they, and how are you dealing with
them?
d. PROBE: Were there any facilitators that support coordination?
(2) to help providers coordinate with SUD services? If yes, please describe those changes and
current strategies to improve coordination.
a. PROBE: [If the state has managed care and fee-for-service] If yes, did changes and
current strategies differ for individuals enrolled in fee-for-service Medicaid and
individuals enrolled in Medicaid managed care? How so?
b. PROBE: What has been the impact of these changes?
c. PROBE: Are there any challenges that you face implementing care coordination
activities through the demonstration? What are they, and how are you dealing with
them?
d. PROBE: Were there any facilitators that support coordination?
(3) to help residential or inpatient providers coordinate with community-based mental health
treatment providers? If yes, please describe those changes and current strategies to
improve coordination.

3

a. PROBE: [If the state has managed care and fee-for-service] If yes, did changes and
current strategies differ for individuals enrolled in fee-for-service Medicaid and
individuals enrolled in Medicaid managed care? How so?
b. PROBE: What has been the impact of these changes?
c. PROBE: Are there any challenges that you face implementing care coordination
activities through the demonstration? What are they, and how are you dealing with
them?
d. PROBE: Were there any facilitators that support coordination?
10. As part of the demonstration, did you make any changes to help providers coordinate with
social service providers like housing agencies or organizations providing supportive employment
and education services? If yes, please describe those changes and current strategies to improve
coordination?
Insert prompts for state related activities that we already know about; e.g. housing
assessments and referrals, supportive employment pilot
a.

b.
c.

PROBE: [If the state has managed care and fee-for-service] If yes, did changes and current
strategies differ for individuals enrolled in fee-for-service Medicaid and individuals
enrolled in Medicaid managed care? How so?
PROBE: Are there any challenges that you face implementing care coordination activities
through the demonstration? What are they, and how are you dealing with them?
PROBE: Were there any facilitators that support coordination?

11. How has SMI/SED treatment and service availability changed with the demonstration?
a.

PROBE: Has there been any change in treatment availability for youth?
PROBE: Have you seen an increase in treatment among SMI/SED patients since the
implementation of the demonstration?

12. How is the state leveraging health IT to improve care coordination for Medicaid enrollees with
SMI or SED?
Insert prompts for state related activities that we already know about; e.g., electronic care
plans, and electronic transitions of care documents, advance care coordination, alert providers
to patients at risk for discontinuing engagement in mental health treatment
13. How has the COVID-19 pandemic impacted care coordination changes you made or had planned
to make?
14. Were there any other changes to your state’s approach to care coordination you would like to
discuss? If yes, can you describe those other changes?
Milestone 3: Increasing Access to Continuum of Care Including Crisis Stabilization Services
15. Are there any changes to crisis stabilization services for:

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(1) adults that are being implemented as part of the demonstration? If yes, please describe
those changes.
(2) children and adolescents that are being implemented as part of the demonstration? If yes,
please describe those changes.
(3) other vulnerable populations that are being implemented as part of the demonstration? If
yes, please describe those changes.
Insert prompts for crisis service activities that we already know about; e.g., pilots for youth or
justice-involved individuals
a.

b.
a.
b.

PROBE: [If the state has managed care and fee-for-service] If yes, did changes and current
strategies differ for individuals enrolled in fee-for-service Medicaid and individuals
enrolled in Medicaid managed care? How so?
PROBE: What has been the impact of these changes?
PROBE: Are there any challenges that you face implementing crisis services through the
demonstration? What are they, and how are you dealing with them?
PROBE: Were there any facilitators that support coordination?

16. How does [STATE] track available mental health inpatient and crisis stabilization beds?
a.
b.
c.

PROBE: Is this different from what you were doing before the demonstration? How so?
PROBE: Are there any challenges that you face monitoring bed availability? What are they,
and how are you dealing with them?
PROBE: Were there any facilitators that helped your efforts to monitor available beds?

17. Do you expect the number of Medicaid enrollees with SMI receiving crisis services to change
because of the demonstration? Why or why not? Do you expect the number of Medicaid
enrollees with SED receiving crisis services to change because of the demonstration? How so?
18. How has COVID-19 impacted availability of mental health services, including crisis services, for
[STATE’s] Medicaid enrollees with SMI or SED?
a.

PROBE: How has [State] utilized telehealth services for the SMI/SED population?

Milestone 4: Early Identification and Engagement in Treatment
19. What did early identification of SMI for SED for Medicaid enrollees look like prior to the
demonstration? What has changed with implementation of the demonstration?
a.
b.
c.

PROBE: Were the early identification strategies different for adults vs. children?
PROBE: Are there any challenges that you face trying to help providers identify mental
health conditions earlier? What are they, and how are you dealing with them?
PROBE: Were there any facilitators that support early identification?

20. How has COVID-19 impacted the early identification activities you made or had planned to
make?

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21. Longer-term patient engagement in treatment and loss to follow-up is a common issue. Are
there any changes [STATE] is making as part of the demonstration to support providers in
retaining patients with SMI or SED in treatment? If yes, please describe those changes.
a.
b.
c.

PROBE: Is the [STATE] focused on particular populations (e.g., children, other vulnerable
groups) when trying out strategies to support retention in treatment?
PROBE: Are there any challenges that you face trying to help providers engage and retain
patients? What are they, and how are you dealing with them?
PROBE: If no challenges, were there any facilitators that support early identification?

22. How has COVID-19 impacted patient engagement activities you made or had planned to make?
23. Have specialized behavioral health services particularly for children and adolescents changed
under the demonstration? What was offered before, and what is offered now?
Insert prompts for state activities related to children and adolescents with SED that we already
know about and that may be relevant
a.
b.

PROBE: Are there any challenges that you face trying to deliver services to children with
SED? What are they, and how are you dealing with them?
PROBE: If no challenges, were there any facilitators that support service delivery for
children?

Other Successes or Challenges
24. Are there other implementation challenges or successes under the section 1115 SMI/SED
demonstration that we have not yet discussed you would like to mention?

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Attachment 1.g. SMI/SED Demonstration Implementation Interview Thank You Email
Dear [NAME OF INTERVIEW PARTCIPANT(S)]:
Thank you again for taking the time to meet with us and share information about your state’s
SMI/SED demonstration. Information from these conversations will help CMS understand the
effectiveness of SMI/SED demonstrations to increase access to mental health treatment. Your
participation is important to helping CMS support policy and programmatic development for
other demonstration states and future demonstrations.
In the next few weeks, we may reach out with a few additional clarifying questions.
[INCLUDE THIS TEXT ONLY IF PARTICIPANTS OFFERED TO SEND RESOURCES:
During the interview you mentioned sending us [NAME RESOURCE(S)]. Could you send those
to us at your earliest convenience?]
Please do not hesitate to reach out if you have any follow-up questions or reflections. Thank you
again!
Sincerely,
[INTERVIEW LEAD]