Attachment 5a Monitoring Report Template

Medicaid Section 1115 SMI/SED Demonstrations Monitoring Report – Part B Version 3.0

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

Medicaid Section 1115 Serious Mental Illness and Serious
Emotional Disturbance Demonstrations

Monitoring Report Template

Note: PRA Disclosure Statement to be added here

1. Title page for the state’s serious mental illness and serious emotional disturbance (SMI/SED) demonstration or the SMI/SED 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).
SMI/SED demonstration start datea		Automatically populated with the start date for the section 1115 SMI/SED demonstration or SMI/SED component if part of a broader demonstration (MM/DD/YYYY).
Implementation date of SMI/SED demonstration, if different from SMI/SED demonstration start dateb		Automatically populated with the SMI/SED demonstration implementation date (MM/DD/YYYY).
SMI/SED (or if broader demonstration, then SMI/SED-related) demonstration goals and objectives		Automatically populated with the summary of the SMI/SED (or if broader demonstration, then SMI/SED-related) demonstration goals and objectives.
SMI/SED demonstration year and quarter		Enter the SMI/SED demonstration year and quarter associated with this report (e.g., SMI/SED DY1Q3 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 SMI/SED 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 SMI/SED demonstration approval. For example, if the state’s STCs at the time of SMI/SED demonstration approval note that the SMI/SED demonstration is effective January 1, 2020 – December 31, 2025, the state should consider January 1, 2020 to be the start date of the SMI/SED demonstration. Note that the effective date is considered to be the first day the state may begin its SMI/SED 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 SMI/SED 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. Ensuring Quality of Care in Psychiatric Hospitals and Residential Settings (Milestone 1)
1.1 Metric trends
1.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 1.		*EXAMPLE: #20: Beneficiaries with SMI/SED treated in an IMD for mental health	*EXAMPLE: The number of beneficiaries with SMI/SED who were treated for mental health in an IMD decreased by 5% due to an increase in crisis stabilization services 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 licensure or accreditation processes for participating hospitals and residential settings
1.2.1.b The oversight process (including unannounced visits) to ensure participating hospital and residential settings meet state’s licensing or certification and accreditation requirements			*EXAMPLE: The state increased the frequency of unannounced visits from twice a year to three times a year in January 2020 (first reported in DY1Q4 report).
1.2.1.c The utilization review process to ensure beneficiaries have access to the appropriate levels and types of care and to provide oversight on lengths of stay
1.2.1.d The program integrity requirements and compliance assurance process
1.2.1.e The state requirement that psychiatric hospitals and residential settings screen beneficiaries for co-morbid physical health conditions, SUDs, and suicidal ideation, and facilitate access to treatment for those conditions
1.2.1.f Other state requirements/policies to ensure good quality of care in inpatient and residential treatment settings
1.2.2 The state expects to make other program changes that may affect metrics related to Milestone 1
2. Improving Care Coordination and Transitions to Community-Based Care (Milestone 2)
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 2
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 Actions to ensure that psychiatric hospitals and residential treatment settings carry out intensive pre-discharge planning, and include community-based providers in care transitions
2.2.1.b Actions to ensure psychiatric hospitals and residential settings assess beneficiaries’ housing situations and coordinate with housing services providers
2.2.1.c State requirement to ensure psychiatric hospitals and residential settings contact beneficiaries and community-based providers within 72 hours post discharge
2.2.1.d Strategies to prevent or decrease the lengths of stay in EDs among beneficiaries with SMI or SED (e.g., through the use of peers and psychiatric consultants in EDs to help with discharge and referral to treatment providers)
2.2.1.e Other state requirements/policies to improve care coordination and connections to community-based care)
2.2.2 The state expects to make other program changes that may affect metrics related to Milestone 2
3. Access to Continuum of Care, Including Crisis Stabilization (Milestone 3)
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 3
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 State requirement that providers use an evidenced-based, publicly available patient assessment tool to determine appropriate level of care and length of stay
3.2.1.b Other state requirements/policies to improve access to a full continuum of care including crisis stabilization
3.2.2 The state expects to make other program changes that may affect metrics related to Milestone 3
4. Earlier Identification and Engagement in Treatment, Including Through Increased Integration (Milestone 4)
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 4
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 Strategies for identifying and engaging beneficiaries in treatment sooner (e.g., with supported education and employment)
4.2.1.b Plan for increasing integration of behavioral health care in non-specialty settings to improve early identification of SED/SMI and linkages to treatment
4.2.1.c Establishment of specialized settings and services, including crisis stabilization services, focused on the needs of young people experiencing SMI or SED
4.2.1.d Other state strategies to increase earlier identification/engagement, integration, and specialized programs for young people
4.2.2 The state expects to make other program changes that may affect metrics related to Milestone 4
5. SMI/SED health information technology (health IT)
5.1 Metric trends
5.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to its health IT metrics
5.2 Implementation update
5.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 5.2.1.a The three statements of assurance made in the state’s health IT plan
5.2.1.b Closed loop referrals and e-referrals from physician/mental health provider to physician/mental health provider and/or physician/mental health provider to community-based supports
5.2.1.c Electronic care plans and medical records
5.2.1.d Individual consent being electronically captured and made accessible to patients and all members of the care team
5.2.1.e Intake, assessment and screening tools being part of a structured data capture process so that this information is interoperable with the rest of the health IT ecosystem
5.2.1.f Telehealth technologies supporting collaborative care by facilitating broader availability of integrated mental health care and primary care
5.2.1.g Alerting/analytics
5.2.1.h Identity management
5.2.2 The state expects to make other program changes that may affect metrics related to health IT
6. Other SMI/SED-related metrics
6.1 Metric trends
6.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to other SMI/SED-related metrics
6.2 Implementation update
6.2.1 The state expects to make the following program changes that may affect other SMI/SED-related metrics

4. Narrative information on other reporting topics

Prompts	State has no update to report (place an X)	State response
7. Annual Assessment of Availability of Mental Health Services (Annual Availability Assessment)
7.1 Description of changes to baseline conditions and practices
7.1.1 Describe and explain any changes in the mental health service needs (for example, prevalence and distribution of SMI/SED) of Medicaid beneficiaries with SMI/SED compared to those described in the Initial Assessment of the Availability of Mental Health Services. Recommended word count is 500 words or less
7.1.2 Describe and explain any changes to the organization of the state’s Medicaid behavioral health service delivery system compared to those described in the Initial Assessment of the Availability of Mental Health Services. Recommended word count is 500 words or less
7.1.3 Describe and explain any changes in the availability of mental health services for Medicaid beneficiaries with SMI/SED in the state compared to those described in the Initial Assessment of the Availability of Mental Health Services. At minimum, explain any changes across the state in the availability of the following services: inpatient mental health services; outpatient and community-based services; crisis behavioral health services; and care coordination and care transition planning. Recommended word count is 500 words or less
7.1.4 Describe and explain any changes in gaps the state identified in the availability of mental health services or service capacity while completing the Annual Availability Assessment compared to those described in the Initial Assessment of the Availability of Mental Health Services. Recommended word count is 500 words or less
7.1.5 Describe and explain whether any changes in the availability of mental health services have impacted the state’s maintenance of effort (MOE) on funding outpatient community-based mental health services. Recommended word count is 500 words or less
7.2 Implementation update
7.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 7.2.1.a The state’s strategy to conduct annual assessments of the availability of mental health services across the state and updates on steps taken to increase availability
7.2.1.b Strategies to improve state tracking of availability of inpatient and crisis stabilization beds
8. Maintenance of effort (MOE) on funding outpatient community-based mental health services
8.1 MOE dollar amount
8.1.1 Provide as a dollar amount the level of state appropriations and local funding for outpatient community-based mental health services for the most recently completed state fiscal year
8.2 Narrative information
8.2.1 Describe and explain any reductions in the MOE dollar amount below the amount provided in the state’s application materials. The state should confirm that it did not move resources to increase access to treatment in inpatient or residential settings at the expense of community-based services
9. SMI/SED financing plan
9.1 Implementation update
9.1.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: 9.1.1.a Increase availability of non-hospital, non-residential crisis stabilization services, including services made available through crisis call centers, mobile crisis units, and observation/assessment centers, with a coordinated community crisis response that involves law enforcement and other first responders
9.1.1.b Increase availability of on-going community-based services, e.g., outpatient, community mental health centers, partial hospitalization/day treatment, assertive community treatment, and services in integrated care settings such as the Certified Community Behavioral Health Clinic model
10. Budget neutrality
10.1 Current status and analysis
10.1.1 Describe the current status of budget neutrality and an analysis of the budget neutrality to date. If the SMI/SED component is part of a broader demonstration, the state should provide an analysis of the SMI/SED-related budget neutrality and an analysis of budget neutrality as a whole
10.2 Implementation update
10.2.1 The state expects to make other program changes that may affect budget neutrality
11. SMI/SED-related demonstration operations and policy
11.1 Considerations
11.1.1 The state should highlight significant SMI/SED (or if broader demonstration, then SMI/SED-related) demonstration operations or policy considerations that could positively or negatively impact 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 SMI/SED 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 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
11.2.2 The state is working on other initiatives related to SMI/SED
11.2.3 The initiatives described above are related to the SMI/SED demonstration as described (The state should note similarities and differences from the SMI/SED demonstration)
11.2.4 Compared to the demonstration design and operational details, the state expects to make the following changes to: 11.2.4.a How the delivery system operates under the demonstration (e.g., through the managed care system or fee for service)
11.2.4.b Delivery models affecting demonstration participants (e.g. Accountable Care Organizations, Patient Centered Medical Homes)
11.2.4.c Partners involved in service delivery
11.2.4.d The state Medicaid agency’s Memorandum of Understanding (MOU) or other agreement with its mental health services agency
12. SMI/SED demonstration evaluation update
12.1 Narrative information
12.1.1 Provide updates on SMI/SED 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 SMI/SED 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 SMI/SED (or if broader demonstration, then SMI/SED 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:

The MPT, FUH-CH, FUH-AD, FUA-AD, FUM-AD, AAP, and APM measures (#13, 14, 15, 16, 17, 18, 7, 8, 9, 10, 26, 29) 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.”

2