Attachment 5b Monitoring Report Workbook

[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

Attachment 5b. The Medicaid Section 1115 SMISED Monitoring WorkbookPlanned Metrics_Clean.xlsx

GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations

OMB: 0938-1148

Document [xlsx]
Download: xlsx | pdf

Overview

PRA disclosure statement
SMI - SED planned metrics
SMI - SED definitions
SMI - SED planned subpops
SMI - SED reporting schedule

Sheet 1: PRA disclosure statement
Substance Use Disorder (SUD)
Note: PRA Disclosure Statement to be added here
blank row
Serious Mental Illness and Serious Emotional Disturbance (SMI/SED)
Note: PRA Disclosure Statement to be added here
end of worksheet
end of worksheet

Sheet 2: SMI - SED planned metrics
Medicaid Section 1115 SMI/SED Demonstrations Monitoring Protocol (Part A) - Planned metrics (Version 3.0)























































State [State Name - automatically populated]






















































Demonstration Name [Demonstration Name - automatically populated]






















































blank row























































Table: Serious Mental Illness and Serious Emotional Disturbance Planned Metrics























































Standard information on CMS-provided metrics Baseline, annual goals, and demonstration target Alignment with CMS-provided technical specifications manual Phased-in metrics reporting





































Standard information on CMS-provided metrics
#		 Standard information on CMS-provided metrics
Metric name		 Standard information on CMS-provided metrics
Metric description		 Standard information on CMS-provided metrics
Milestone or reporting topic		 Standard information on CMS-provided metrics
Metric type		 Standard information on CMS-provided metrics
Reporting category		 Standard information on CMS-provided metrics
Data source		 Standard information on CMS-provided metrics
Measurement period		 Standard information on CMS-provided metrics
Reporting frequency		 Standard information on CMS-provided metrics
Reporting priority		 Standard information on CMS-provided metrics
State will report (Y/N)		 Baseline, annual goals, and demonstration target
Baseline reporting period (MM/DD/YYYY--MM/DD/YYYY)		 Baseline, annual goals, and demonstration target
Annual goal		 Baseline, annual goals, and demonstration target
Overall demonstration target		 Alignment with CMS-provided technical specifications manual
Attest that planned reporting matches the CMS-provided technical specifications manual (Y/N)		 Alignment with CMS-provided technical specifications manual
Explanation of any deviations from the CMS-provided technical specifications manual (different data source, definition, codes, target population, etc.)a,b		 Phased-in metrics reporting
State plans to phase in reporting (Y/N)		 Phased-in metrics reporting
SMI/SED monitoring report in which metric will be phased in (Format DY#Q#; e.g. DY1Q3)		 Phased-in metrics reporting
Explanation of any plans to phase in reporting over time





































EXAMPLE:
20
(Do not delete or edit this row)		 EXAMPLE:
Beneficiaries With SMI/SED Treated in an IMD for Mental Health 		EXAMPLE:
Number of beneficiaries in the demonstration population who have a claim for inpatient or residential treatment for mental health in an IMD during the reporting year		 EXAMPLE:
Milestone 3		 EXAMPLE:
CMS-constructed		 EXAMPLE:
Other annual metrics		 EXAMPLE:
Claims		 EXAMPLE:
Year		 EXAMPLE:
Annually		 EXAMPLE:
Required		 EXAMPLE:
Y		 EXAMPLE:
01/01/2020-12/31/2020		 EXAMPLE:
Increase		 EXAMPLE:
Consistent		 EXAMPLE:
N		 EXAMPLE:
The Department will use state-defined procedure codes (list specific codes) to calculate this metric.		 EXAMPLE:
Y		 EXAMPLE:
DY3Q1		 EXAMPLE:
The demonstration site will be updating its EHR during the start of the demonstration. We plan to phase in reporting after the system update has been completed by mid to late 2021 (DY2).





































1 SUD Screening of Beneficiaries Admitted to Psychiatric Hospitals or Residential Treatment Settings Two rates will be reported for this measure:
1. SUB-2: Patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay
2. SUB-2a: Patients who received the brief intervention during the hospital stay		 Milestone 1 Established quality measure Annual metrics that are an established quality measure Medical record review or claims Year Annually Recommended














































2 Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH) Percentage of children and adolescents ages 1 to 17 who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment Milestone 1 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































4 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient Psychiatric Facility (IPF) The rate of unplanned, 30-day, readmission for demonstration beneficiaries with a primary discharge diagnosis of a psychiatric disorder or dementia/Alzheimer’s disease. The measurement period used to identify cases in the measure population is 12 months from January 1 through December 31. Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































6 Medication Continuation Following Inpatient Psychiatric Discharge This measure assesses whether psychiatric patients admitted to an inpatient psychiatric facility (IPF) for major depressive disorder (MDD), schizophrenia, or bipolar disorder filled a prescription for evidence-based medication within 2 days prior to discharge and 30 days post-discharge. Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































7 Follow-up After Hospitalization for Mental Illness: Ages 6 to 17 (FUH-CH) Percentage of discharges for children ages 6 to 17 who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider. Two rates are reported:
• Percentage of discharges for which the child received follow-up within 30 days after discharge
• Percentage of discharges for which the child received follow-up within 7 days after discharge		 Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































8 Follow-up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD) Percentage of discharges for beneficiaries age 18 and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider. Two rates are reported:
• Percentage of discharges for which the beneficiary received follow-up within 30 days after discharge
• Percentage of discharges for which the beneficiary received follow-up within 7 days after discharge		 Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































9 Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA-AD) Percentage of emergency department (ED) visits for beneficiaries age 18 and older with a primary diagnosis of alcohol or other drug (AOD) abuse dependence who had a follow-up visit for AOD abuse or dependence. Two rates are reported:
• Percentage of ED visits for AOD abuse or dependence for which the beneficiary received follow-up within 30 days of the ED visit
• Percentage of ED visits for AOD abuse or dependence for which the beneficiary received follow-up within 7 days of the ED visit		 Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































10 Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD) Percentage of emergency department (ED) visits for beneficiaries age 18 and older with a primary diagnosis of mental illness or intentional self-harm and who had a follow-up visit for mental illness. Two rates are reported:
• Percentage of ED visits for mental illness for which the beneficiary received follow-up within 30 days of the ED visit
• Percentage of ED visits for mental illness for which the beneficiary received follow-up within 7 days of the ED visit		 Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































11 Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count) Number of suicide or overdose deaths among Medicaid beneficiaries with SMI or SED within 7 and 30 days of discharge from an inpatient facility or residential stay for mental health Milestone 2 CMS-constructed Other annual metrics State data on cause of death Year Annually Recommended














































12 Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate) Rate of suicide or overdose deaths among Medicaid beneficiaries with SMI or SED within 7 and 30 days of discharge from an inpatient facility or residential stay for mental health Milestone 2 CMS-constructed Other annual metrics State data on cause of death Year Annually Recommended














































13 Mental Health Services Utilization - Inpatient Number of beneficiaries in the demonstration population who use inpatient services related to mental health during the measurement period Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required














































14 Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization Number of beneficiaries in the demonstration population who used intensive outpatient and/or partial hospitalization services related to mental health during the measurement period Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required














































15 Mental Health Services Utilization - Outpatient Number of beneficiaries in the demonstration population who used outpatient services related to mental health during the measurement period Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required














































16 Mental Health Services Utilization - ED Number of beneficiaries in the demonstration population who use emergency department services for mental health during the measurement period Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required














































17 Mental Health Services Utilization - Telehealth Number of beneficiaries in the demonstration population who used telehealth services related to mental health during the measurement period Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required














































18 Mental Health Services Utilization - Any Services Number of beneficiaries in the demonstration population who used any services related to mental health during the measurement period Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required














































19a Average Length of Stay in IMDs Average length of stay (ALOS) for beneficiaries with SMI discharged from an inpatient or residential stay in an IMD. Three rates are reported:
• ALOS for all IMDs and populations
• ALOS among short-term stays (less than or equal to 60 days)
• ALOS among long-term stays (greater than 60 days)		 Milestone 3 CMS-constructed Other annual metrics Claims
State-specific IMD database		 Year Annually Required














































19b Average Length of Stay in IMDs (IMDs receiving FFP only) Average length of stay (ALOS) for beneficiaries with SMI discharged from an inpatient or residential stay in an IMD receiving federal financial participation (FFP). Three rates are reported:
• ALOS for all IMDs and populations
• ALOS among short-term stays (less than or equal to 60 days)
• ALOS among long-term stays (greater than 60 days)		 Milestone 3 CMS-constructed Other annual metrics Claims
State-specific IMD database		 Year Annually Required














































20 Beneficiaries With SMI/SED Treated in an IMD for Mental Health Number of beneficiaries in the demonstration population who have a claim for inpatient or residential treatment for mental health in an IMD during the reporting year Milestone 3 CMS-constructed Other annual metrics Claims Year Annually Required














































21 Count of Beneficiaries With SMI/SED (monthly) Number of beneficiaries in the demonstration population during the measurement period and/or in the 11 months before the measurement period Milestone 4 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required














































22 Count of Beneficiaries With SMI/SED (annually) Number of beneficiaries in the demonstration population during the measurement period and/or in the 12 months before the measurement period Milestone 4 CMS-constructed Other annual metrics Claims Year Annually Required














































23 Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (HPCMI-AD) Percentage of beneficiaries ages 18 to 75 with a serious mental illness and diabetes (type 1 and type 2) who had hemoglobin A1c (HbA1c) in poor control (> 9.0%) Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims
Medical records		 Year Annually Required














































24 Screening for Depression and Follow-up Plan: Age 18 and Older (CDF-AD) Percentage of beneficiaries age 18 and older screened for depression on the date of the encounter or 14 days prior to the date of the encounter using an age appropriate standardized depression screening tool, and if positive, a follow-up plan is documented on the date of the eligible encounter Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims
Medical records		 Year Annually Recommended














































25 Screening for Depression and Follow-up Plan: Ages 12 to 17 (CDF-CH) Percentage of beneficiaries ages 12 to 17 screened for depression on the date of the encounter or 14 days prior to the date of the encounter using an age appropriate standardized depression screening tool, and if positive, a follow-up plan is documented on the date of the eligible encounter Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims
Electronic medical records		 Year Annually Recommended














































26 Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With SMI The percentage of Medicaid beneficiaries age 18 years or older with SMI who had an ambulatory or preventive care visit during the measurement period Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































29 Metabolic Monitoring for Children and Adolescents on Antipsychotics Percentage of children and adolescents ages 1 to 17 who had two or more antipsychotic prescriptions and had metabolic testing. Three rates are reported:
•Percentage of children and adolescents on antipsychotics who received blood glucose testing
•Percentage of children and adolescents on antipsychotics who received cholesterol testing
•Percentage of children and adolescents on antipsychotics who received blood glucose and cholesterol testing		 Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































30 Follow-Up Care for Adult Medicaid Beneficiaries Who are Newly Prescribed an Antipsychotic Medication Percentage of new antipsychotic prescriptions for Medicaid beneficiaries who meet the following criteria:
•age 18 years and older, and
•completed a follow-up visit with a provider with prescribing authority within four weeks (28 days) of prescription of an antipsychotic medication		 Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required














































32 Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not Inpatient or Residential The sum of all Medicaid spending for mental health services not in inpatient or residential settings during the measurement period Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required














































33 Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient or Residential The sum of all Medicaid costs for mental health services in inpatient or residential settings during the measurement period Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required














































34 Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not Inpatient or Residential Per capita costs for non-inpatient, non-residential services for mental health, among beneficiaries in the demonstration population during the measurement period Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required














































35 Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient or Residential Per capita costs for inpatient or residential services for mental health among beneficiaries in the demonstration population during the measurement period Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required














































36 Grievances Related to Services for SMI/SED Number of grievances filed during the measurement period that are related to services for SMI/SED Other SMI/SED metrics CMS-constructed Grievances and appeals Administrative records Quarter Quarterly Required














































37 Appeals Related to Services for SMI/SED Number of appeals filed during the measurement period that are related to services for SMI/SED Other SMI/SED metrics CMS-constructed Grievances and appeals Administrative records Quarter Quarterly Required














































38 Critical Incidents Related to Services for SMI/SED Number of critical incidents filed during the measurement period that are related to services for SMI/SED Other SMI/SED metrics CMS-constructed Grievances and appeals Administrative records Quarter Quarterly Required














































39 Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries With SMI/SED Total Medicaid costs for beneficiaries in the demonstration population who had claims for inpatient or residential treatment for mental health in an IMD during the reporting year Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required














































40 Per Capita Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries With SMI/SED Per capita Medicaid costs for beneficiaries in the demonstration population who had claims for inpatient or residential treatment for mental health in an IMD during the reporting year Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required














































Q1 [Insert selected metric(s) for health IT question 1]
Health IT State-specific



Required














































Q2 [Insert selected metric(s) for health IT question 2]
Health IT State-specific



Required














































Q3 [Insert selected metric(s) for health IT question 3]
Health IT State-specific



Required














































State-specific metrics blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank blank





































[Insert row(s) for any additional state-specific metrics by right-clicking on row 50 and selecting "Insert"]












n.a. n.a.








































blank row























































a If the state is not reporting a required metric (i.e., column K = “N”), enter explanation in corresponding row in column P.























































b The state should use column P to outline calculation methods for specific metrics as explained in Version 3.0 of the Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations Monitoring Protocol Instructions.























































End of worksheet























































Sheet 3: SMI - SED definitions
Medicaid Section 1115 SMI/SED Demonstrations Monitoring Protocol (Part A) - SMI/SED Definitions (Version 3.0)

State [State Name - automatically populated]
Demonstration Name [Demonstration Name - automatically populated]
blank row

Table: Serious Mental Illness and Serious Emotional Disturbance Definitions

Narrative description of the SMI/SED demonstration population
EXAMPLEa
Adults age 18 or older with serious mental illness or children under the age of 18 with a serious emotional disturbance living within the state.

. Serious Mental Illness (SMI) Serious Emotional Disturbance (SED)
Narrative description of how the state defines the population for purposes of monitoring (including age range, diagnosis groups, and associated service use requirements) EXAMPLEa
*At least one acute inpatient claim/encounter with any diagnosis of schizophrenia, bipolar I disorder, or major depression, OR
*At least two visits in an outpatient, intensive outpatient (IOP), partial hospitalization (PH), emergency department (ED), or nonacute inpatient setting, on different dates of service, with any diagnosis of schizophrenia, OR
*At least two visits in an outpatient, IOP, PH, ED, or nonacute inpatient setting on different dates of service with a diagnosis of bipolar I disorder. 		See SMI example for format and required information
Codes used to identify populationb

States may use ICD-10 diagnosis codes or state-specific treatment, diagnosis, or other types of codes to identify the population. When applicable, states should supplement ICD-10 codes with state-specific codes.		 EXAMPLEa
*Schizophrenia: F20.0-F20.5, F20.81, F20.89
*Major depression: F32.0 - F32.4, F33.0 - F33.3
*Bipolar I disorder: F30.10-F30.13, F30.2 - F30.9		 See SMI example for format and required information
Procedure (e.g., CPT, HCPCS) or revenue codes used to identify/define service requirementsb

If the state is not using procedure or revenue codes, the state should include the data source(s) (e.g., state-specific codes) used to identify/define service requirements.		 EXAMPLEa
*Outpatient: 98960-98962, 99211-99215, G0155, G0176, G0177, G0409, 0510, 0513, 0515-0517		 See SMI example for format and required information
aThe examples are based on a definition of SMI from the National Committee for Quality Assurance (NCQA). The examples provided are intended to be illustrative only. The example codes provided are not comprehensive.
bStates may choose to include codes as separate tabs in this workbook.

End of worksheet

  

Sheet 4: SMI - SED planned subpops
Medicaid Section 1115 SMI/SED Demonstrations Monitoring Protocol (Part A) - Planned subpopulations (Version 3.0)








State [State Name - automatically populated]







Demonstration Name [Demonstration Name - automatically populated]







blank row








Table: Serious Mental Illness and Serious Emotional Disturbance Planned Subpopulations








Planned subpopulation reporting Alignment with CMS-provided technical specifications manual
blank Subpopulations Relevant metrics
Planned subpopulation reporting
Subpopulation category		 Planned subpopulation reporting
Subpopulations		 Planned subpopulation reporting
Reporting priority		 Planned subpopulation reporting
Relevant metrics		 Planned subpopulation reporting
Subpopulation type		 Planned subpopulation reporting
State will report (Y/N)		 Alignment with CMS-provided technical specifications manual
Subpopulations
Attest that planned subpopulation reporting within each category matches the description in the CMS-provided technical specifications manual (Y/N)		 Alignment with CMS-provided technical specifications manual
Subpopulations
If the planned reporting of subpopulations does not match (i.e., column G = “N”), list the subpopulations state plans to report (Format comma separated)a,b,c		 Alignment with CMS-provided technical specifications manual
Relevant Metrics
Attest that metrics reporting for subpopulation category matches CMS-provided technical specifications manual (Y/N)		 Relevant Metrics
If the planned reporting of relevant metrics does not match (i.e., column I = “N”), list the metrics for which state plans to report for each subpopulation category (Format: metric number, comma separated)
EXAMPLE:
Age group
(Do not delete or edit this row)		 EXAMPLE:
Children (Age<16), Transition-age youth (Age 16-24), Adults (Age 25–64), Older adults (Age 65+)		 EXAMPLE:
Required		 EXAMPLE:
Metrics #11, 12, 13, 14, 15, 16, 17, 18, 21, 22		 EXAMPLE:
CMS-provided		 EXAMPLE:
Y		 EXAMPLE:
N		 EXAMPLE:
Children/Young adults (ages 12-20), Adults (ages 21-65)		 EXAMPLE:
N		 EXAMPLE:
11, 12, 13, 14
Standardized definition of SMI Individuals who meet the standardized definition of SMI Required Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




State-specific definition of SMI Individuals who meet the state-specific definition of SMI Required Metrics #13, 14, 15, 16, 17, 18, 21, 22 State-specific




Age group Children (Age<16), Transition-age youth (Age 16-24), Adults (Age 25–64), Older adults (Age 65+) Required Metrics #11, 12, 13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Dual–eligible status Dual-eligible (Medicare-Medicaid eligible), Medicaid only Required Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Disability Eligible for Medicaid on the basis of disability, Not eligible for Medicaid on the basis of disability Recommended Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Criminal justice status Criminally involved, Not criminally involved Recommended Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Co-occurring SUD Individuals with co-occurring SUD Recommended Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Co-occurring physical health conditions Individuals with co-occurring physical health conditions Recommended Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




State-specific subpopulations blank blank blank blank blank blank blank blank blank
[Insert row(s) for any state-specific subpopulation(s)]




n.a. n.a. n.a. n.a.
blank row








a If the state is not reporting a required subpopulation category (i.e., column F = “N”), enter explanation in corresponding row in column H.








b If the state is reporting on the Dual-eligible status subpopulation category, the state should use column H to outline its subpopulation identification approach as explained in Version 3.0 of the Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations Monitoring Protocol Instructions.





c If the state is planning to phase in the reporting of any of the subpopulation categories, the state should (1) select N in column G and (2) provide an explanation and the report (SMI/SED DY and Q) in which it will begin reporting the subpopulation category in column H.





End of worksheet








Sheet 5: SMI - SED reporting schedule
Medicaid Section 1115 SMI/SED Demonstrations Monitoring Protocol (Part A) - Reporting schedule (Version 3.0)



























State [State Name - automatically populated]


























Demonstration Name [Demonstration Name - automatically populated]


























blank row



























Instructions:
























(1) In the reporting periods input table (Table 1), use the prompt in column A to enter the requested information in the corresponding row of column B. All monitoring report names and reporting periods should use the format DY#Q# or CY# and all dates should use the format MM/DD/YYYY with no spaces in the cell. The information entered in these cells will auto-populate the SMI/SED demonstration reporting schedule in Table 2. All cells in the input table must be completed in entirety for the standard reporting schedule to be accurately auto-populated.






















(2) Review the state's reporting schedule in the SMI/SED demonstration reporting schedule table (Table 2). For each of the reporting categories listed in column F, select Y or N in column H, "Deviations from standard reporting schedule (Y/N)" to indicate whether the state plans to report according to the standard reporting schedule. If a state's planned reporting does not match the standard reporting schedule for any quarter and/or reporting category (i.e. column H= “Y”), the state should describe these deviations in column I, "Explanation for deviations (if column H="Y")" and use column J, “Proposed deviation in measurement period from standard reporting schedule in column G,” to indicate the SMI/SED measurement periods with which it wishes to overwrite the standard schedule (column G). All other columns are locked for editing and should not be altered by the state.






















blank row
























Table 1. Serious Mental Illness and Serious Emotional Disturbance Reporting Periods Input Table
























. Demonstration reporting periods/dates


























Dates of first SMI/SED demonstration year: blank


























Start date (MM/DD/YYYY)



























End date (MM/DD/YYYY)



























Dates of first quarter of the baseline reporting period for CMS-constructed metrics: blank


























Reporting period (SMI/SED DY and Q)
(Format DY#Q#; e.g., DY1Q1)



























Start date (MM/DD/YYYY)a



























End date (MM/DD/YYYY)


























Broader section 1115 demonstration reporting period corresponding with the first SMI/SED reporting quarter, if applicable. If there is no broader demonstration, fill in the first SMI/SED reporting period.
(Format DY#Q#; e.g., DY3Q1)



























First SMI/SED monitoring report due date (per STCs)
(MM/DD/YYYY)



























First SMI/SED monitoring report in which the state plans to report annual metrics that are established quality measures (EQMs): blank


























Baseline period for EQMs
(Format CY#; e.g., CY2019)



























SMI/SED DY and Q associated with monitoring report
(Format DY#Q#; e.g., DY1Q1)



























SMI/SED DY and Q start date (MM/DD/YYYY)



























SMI/SED DY and Q end date (MM/DD/YYYY)



























Dates of last SMI/SED reporting quarter: blank


























Start date (MM/DD/YYYY)



























End date (MM/DD/YYYY)



























End of table



























Table 2. Serious Mental Illness and Serious Emotional Disturbance Demonstration Reporting Schedule
























SMI/SED reporting quarter start date
(MM/DD/YYYY)		 SMI/SED reporting quarter end date
(MM/DD/YYYY)		 Monitoring report due
(per STCs)
(MM/DD/YYYY)		 Broader section 1115 reporting period, if applicable; else SMI/SED reporting period
(Format DY#Q#; e.g., DY1Q3)		 SMI/SED reporting period
(Format DY#Q#; e.g., DY1Q3)		 Reporting category For each reporting category, measurement period for which information is captured in monitoring report per standard reporting schedule (Format DY#Q#; e.g., DY1Q3)b
SMI/SED		 Deviation from standard reporting schedule
(Y/N)		 Explanation for deviations
(if column H="Y")		 Proposed deviation in measurement period from standard reporting schedule in column G
(Format DY#Q#; e.g., DY1Q3)























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures





















blank blank blank blank blank Other annual metrics


























Narrative information





















blank blank blank blank blank Grievances and appeals





















blank blank blank blank blank Other monthly and quarterly metrics





















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank blank Other annual metrics



























Narrative information






















blank blank blank blank blank Grievances and appeals






















blank blank blank blank blank Other monthly and quarterly metrics






















blank blank blank blank blank Annual availability assessment






















blank blank blank blank blank Annual metrics that are established quality measures






















blank blank blank blank
Other annual metrics






















[Add rows for all additional demonstration reporting quarters]
























































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 demonstration is effective January 1, 2020 – December 31, 2025, the state should consider January 1, 2020 to be the start date of the 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. To generate an accurate reporting schedule, the start date as listed in Table 1 of the “SMI/SED reporting schedule" tab should align with the first day of a month. If a state’s SMI/SED demonstration begins on any day other than the first day of the month, the state should list its start date as the first day of the month in which the effective date occurs. For example, if a state’s effective date is listed as January 15, 2020, the state should indicate "01/01/2020" as the start date in Table 1 of the “SMI-SED reporting schedule” tab. Please see Appendix A of the Monitoring Protocol Instructions for more information on determining demonstration quarter timing.



















b The auto-populated reporting schedule in Table 2 outlines the data the state is expected to report for each SMI/SED demonstration year and quarter. However, the state is not expected to begin reporting any metrics data until after protocol approval. The state should see Section B of the Monitoring Report Instructions for more information on retrospective reporting of data following protocol approval.

AA# refers to the Annual Assessment of the Availability of Mental Health Services (“Annual Availability Assessment”) and the SMI/SED DY in which the Annual Availability Assessment will be submitted (for example, “AA1” refers to the Annual Availability Assessment that will be submitted with the state’s annual monitoring report for SMI/SED DY1). Data in each Annual Availability Assessment should be reported as of the month and day indicated in the state’s approved monitoring protocol. If the state cannot submit its Annual Availability Assessments when it submits its annual monitoring reports, it should propose and describe a reporting deviation in Columns G and H.



















End of worksheet




































































































































































































































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