Serious Mental Illness Section 1115 Demonstration Opportunity

Description of the Demonstration Opportunity

CMS provides flexibility to test comprehensive approaches to care for beneficiaries with serious mental illness (SMI) or serious emotional disturbance (SED) through a section 1115 demonstration opportunity.  This SMI/SED demonstration opportunity will allow states, upon CMS approval of their demonstrations, to receive Federal Financial Participation (FFP) for services furnished to Medicaid beneficiaries during short term stays for acute care in psychiatric hospitals or residential treatment settings that qualify as IMDs if those states are also taking action, through these demonstrations, to ensure good quality of care in IMDs and to improve access to community-based services as described below.  Through these demonstrations, states will focus on demonstrating improved care for individuals with serious mental health conditions in inpatient or residential settings that qualify as IMDs as well as through improvements to community based mental health care.

Additionally, the Family First Prevention Services Act (FFPSA) of the Bipartisan Budget Act of 2018 amends Title IV-E of the Social Security Act to limit foster care maintenance payments (FCMPs) (payments for room, board, and certain other costs for children in foster care) to 14 days for children placed in childcare institutions (CCIs).  One exception to this limitation is for children placed in facilities designated as QRTPs.  As described below, a QRTP over 16 beds may meet the Medicaid definition of an IMD.  Federal Medicaid law prohibits states from receiving federal financial participation (FFP) (i.e., the federal government’s share of a state’s Medicaid expenditures) for services delivered to individuals residing in an IMD, except in very limited circumstances, such as the inpatient psychiatric services for individuals under 21 benefit (the “psych under 21 benefit”).  This is a requirement that precedes the FFPSA. As a result, states may be prohibited from claiming FFP for Medicaid services delivered to children while they reside in a QRTP that has more than 16 beds.  CMS addressed this issue in Technical Assistance Questions and Answers dated September 20, 2019.

Monitoring and Evaluation Materials

State monitoring and evaluation guidance materials: CMS developed resources to support state approaches to monitoring and evaluation of their section 1115 SMI/SED demonstration opportunity. These materials are listed below and align with CMS’ requirements for all section 1115 demonstrations. To learn more about these resources, please review the 1115 Demonstration State Monitoring & Evaluation Resources webpage.

• Implementation Plan Template: The implementation plan provides a framework for the state to document its approach to implementing SMI/SED policies. It also helps to determine appropriate information for the state to report to CMS in the quarterly and annual monitoring reports.
• Monitoring Report Template: The monitoring report template provides the state with a framework for how to report information to CMS quarterly and annually, including the mental health availability assessment. In addition to the template, the tools include a list of quantitative 1115 SMI/SED monitoring metrics on which states will be expected to report.
• Mid-Point Assessment Technical Assistance: The mid-point assessment technical assistance resource describes the requirements for such an assessment of the section 1115 SMI/SED demonstration to support the state with planning and executing the assessment. The resource illustrates how to use monitoring metrics data to inform tracking demonstration progress through the middle of its lifecycle, and outlines the report components, including example templates that the state may customize and use.  The resource also provides information specific to the SUD demonstrations.
• Evaluation Design Guidance: The evaluation design guidance highlights key hypotheses, evaluation questions, measures, and evaluation approaches, which will provide for a rigorous evaluation of a SMI/SED section 1115 demonstration.  The evaluation design guidance contains two documents:
  • A master narrative
  • An appendix specific to SMI/SED
  • An appendix for estimating the costs of the demonstration

Federal monitoring and evaluation:  CMS conducts federal monitoring and evaluation of section 1115 SUD Demonstrations.

In September 2018, CMS also contracted with Research Triangle Institute (RTI) to design and conduct federal evaluations through a meta-analysis. The meta-evaluation design for SMI can be found here.  A meta-analytic approach that draws on experiences across multiple states implementing the same type of demonstration will provide CMS and states with a deeper understanding of the variables that impact successful implementation and outcomes of demonstrations, and whether these initiatives should be replicated in other states.

In the meta-evaluation, state reported data is supplemented by other secondary and primary data sources, including Transformed Medicaid Statistical Information System (TMSIS) and national survey data.  Additionally, RTI conducts limited key informant interviews and case studies to help illuminate best practices and understand particularly challenging policies to implementation.

To identify innovative approaches to address high-priority challenges, RTI will draw from the assembled analyses to create rapid-cycle reports and a summative evaluation reports.

Rapid Cycle Reports will be posted as they become available.

Learning Collaboration and Other Resource Documents: Coming Soon!