[Federal Register Volume 77, Number 196 (Wednesday, October 10, 2012)]
[Notices]
[Pages 61615-61620]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-24862]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Agency Information Collection Activities: Submission for OMB
Review; Comment Request
Periodically, the Substance Abuse and Mental Health Services
Administration (SAMHSA) will publish a summary of information
collection requests under OMB review, in compliance with the Paperwork
Reduction Act (44 U.S.C. Chapter 35). To request a copy of these
documents, call the SAMHSA Reports Clearance Officer on (240) 276-1243.
Project: Uniform Application for the Mental Health Block Grant and
Substance Abuse Block Grant FY 2014-2015 Application Guidance and
Instructions (OMB No. 0930-0168)--Revision
The Substance Abuse and Mental Health Services Administration
(SAMHSA) is requesting approval from the Office of Management and
Budget (OMB) for a revision of the 2014 and 2015 Community Mental
Health Services Block Grant (MHBG) and Substance Abuse Prevention and
Treatment Block Grant (SABG) Guidance and Instructions into a uniform
block grant application.
Currently, the SABG and the MHBG differ on a number of their
practices (e.g., data collection at individual or aggregate levels) and
statutory authorities (e.g., method of calculating MOE, stakeholder
input requirements for planning, set asides for specific populations or
programs, etc.). Historically, the Centers within SAMHSA that
administer these block grants have had different approaches to
application requirements and reporting. To compound this variation,
states have had different structures for accepting, planning, and
accounting for the block grants and the prevention set aside within the
SABG. As a result, how these dollars are spent and what is known about
the services and clients that receive these funds varies by block grant
and by state.
In addition, between 2014 and 2015, 32 million individuals who are
uninsured will have the opportunity to enroll in Medicaid or private
health insurance. This expansion of health insurance coverage will have
a significant impact on how State Mental Health Authorities (SMHAs) and
State Substance Abuse Authorities (SSAs) use their limited resources.
Many individuals served by these authorities are funded through federal
block grant funds. SAMHSA proposes that block grant funds be directed
toward four purposes: 1) to fund priority treatment and support
services for individuals without insurance or who cycle in and out of
health insurance coverage; 2) to fund those priority treatment and
support services not covered by Medicaid, Medicare or private insurance
offered through the exchanges and that demonstrate success in improving
outcomes and/or supporting recovery; 3) to fund universal, selective
and targeted prevention activities and services; and 4) to collect
performance and outcome data to determine the ongoing effectiveness of
behavioral health prevention, treatment and recovery
[[Page 61616]]
support services and to plan the implementation of new services on a
nationwide basis.
States should begin planning now for FY 2014 when more individuals
will have additional opportunities to be insured. To ensure sufficient
and comprehensive preparation, SAMHSA will use FY 2013 to continue to
work with states to plan for and transition the Block Grants to these
four purposes. This transition includes fully exercising SAMHSA's
existing authority regarding states' and jurisdictions' (subsequently
referred to as ``states'') use of block grant funds, and a shift in
SAMHSA staff functions to support and provide technical assistance for
states receiving block grant funds as they move through these changes.
The proposed MHBG and SABG build on ongoing efforts to reform
health care, ensure parity and provide states with new tools, new
flexibility, and state/territory-specific plans for available resources
to provide their residents the health care benefits they need. The
planning section of the block grant application provides a process for
states to identify priorities for individuals who need behavioral
health services in their jurisdictions, develop strategies to address
these needs, and decide how to expend block grant funds. In addition,
the planning section of the block grant requests additional information
from states that could be used to assist them in their reform efforts.
The plan submitted by each state will provide information for SAMHSA
and other federal partners to use in working with states to improve
their behavioral health systems over the next two years as health care
and economic conditions evolve.
The FY 2014-2015 block grant application provides states the
flexibility to submit one rather than two separate block grant
applications if they choose. It also allows states to develop and
submit a bi-annual rather than an annual plan, recognizing that the
demographics and epidemiology do not often change on an annual basis.
These options may decrease the number of applications submitted from
four in two years to one.
Over the next several months, SAMHSA will assist states
(individually and in smaller groups) as they develop their block grant
applications. While there are some specific statutory requirements that
SAMHSA will look for in each submitted application, SAMHSA intends to
approach this process with the goal of assisting states in setting a
clear direction for system improvements over time, rather than as a
simple effort to seek compliance with minimal requirements.
Consistent with previous applications, the FY 2014-2015 application
has sections that are required and other sections where additional
information is requested, but not required. The FY 2014-2015
application requires states to submit a face sheet, a table of
contents, a behavioral health assessment and plan, reports of
expenditures and persons served, executive summary, and funding
agreements, assurances, and certifications. In addition, SAMHSA is
requesting information on key areas that are critical to the state's
success in addressing health reform and parity. States will continue to
receive their annual grant funding if they only chose to submit the
required section of their state plans or choose to submit separate
plans for the MHBG or SABG. Therefore, as part of this block grant
planning process, SAMHSA is asking states to identify their technical
assistance needs to implement the strategies they identify in their
plans for FY 2014 and 2015.
To facilitate an efficient application process for states in FY
2014-2015, SAMHSA convened an internal workgroup to develop the block
grant planning section. In addition, SAMHSA consulted with
representatives from the State Mental Health and State Substance Abuse
Authorities to receive input regarding proposed changes to the block
grant. Comments were requested from federal partners including the
Department of Health and Human Services (HHS), the Office of Management
and Budget (OMB), the Office of National Drug Control Policy (ONDCP),
and the Assistant Secretary for Financial Resources (ASFR). Other
stakeholder groups consulted with included NASADAD and NASMHPD. Based
on these discussions with states, federal partners, and stakeholder
groups, SAMHSA is proposing the following revisions to the block grant
application.
Changes to Assessment and Planning Activities
SAMHSA has not made major revisions to the FY 2014-2015
application. The proposed revisions are based primarily on previous
instructions provided in the FY 2012-2013 application guidance. In
building on the FY 2012-2013 guidance, SAMHSA proposed revisions to
expand the areas of focus (environmental factors) for states to
describe their comprehensive plans to provide treatment, services, and
supports for individuals with behavioral health needs. These revisions
will enable SAMHSA to assess the extent to which states plan for and
implement provisions of the Affordable Care Act and determine whether
block grants funds are being directed toward the four purposes of the
grant.
The proposed revisions reflect changes within the planning section
of the application. The most significant of these changes relate to
prevention, particularly primary prevention; data and quality;
enrollment of individuals and providers; and descriptions of good and
modern behavioral health services. States are encouraged to address
each of the focus areas. SAMHSA has provided a set of guiding questions
to stimulate and direct the dialogue that states may engage in to
determine the various approaches used to develop their responses to
each of the focus areas.
The proposed revisions are described below:
Areas of Focus/Environmental Factors
Coverage for M/SUD Services--Beginning in 2014, block grant
dollars should be used to pay for (1) people who are uninsured, (2)
services that are not covered by insurance and Medicaid, (3)
prevention, and (4) the collection of performance and outcome data.
Presumably, there will be similar concerns at the state level that
state dollars are being used for people and/or services not otherwise
covered. States (or the federal exchange) are currently making plans to
implement the benchmark plan chosen for Qualified Health Plans (QHPs)
and their expanded Medicaid program. States should begin to develop
strategies that will monitor the implementation of the Act in their
states. States should begin to identify whether people have better
access to mental health and substance use disorder services. In
particular, states will need to determine if QHPs and Medicaid are
offering services for mental and substance abuse disorders and whether
services are offered consistent with provisions of MHPAEA.
Affordable Insurance Exchanges--Affordable Insurance
Exchanges (Exchanges) will be responsible for performing a variety of
critical functions to ensure access to much needed behavioral health
services. Outreach and education regarding enrollment in QHPs or
expanded Medicaid will be critical. SMHAs and SSAs should understand
their state's new eligibility determination and enrollment system. They
should also understand how insurers (commercial, Medicaid and Medicare
plans) will be making decisions regarding their provider networks.
States should consider
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developing benchmarks regarding the expected number of individuals in
their publicly funded behavioral health system that should be insured
by the end of FY 2015. In addition, states should set targets or
recommendations for the number of providers who will be participating
in insurers' networks that are currently not billing third party
insurance.
Program Integrity --The Act directs the Secretary of HHS to
define EHBs. Non-grandfathered plans in the individual and small group
markets both inside and outside the Exchanges, Medicaid benchmark and
benchmark equivalent plans, and basic health programs must cover these
EHBs. The selected benchmark plan would serve as a reference plan,
reflecting both the scope of services and limits offered by a ``typical
employer plan'' in a state as required by the Act.
At this point in time, many states will know which mental health
and substance abuse services are covered in their benchmark plans
offered by QHPs and Medicaid programs. SMHAs and SSAs should be focused
on two main areas related to EHBs: monitoring what is covered and
aligning block grants and state funds for what is not covered. These
include: 1) ensuring that QHPs and Medicaid programs are including EHBs
as per the state benchmark plan; 2) ensuring that individuals are aware
of the covered mental health and substance abuse benefits; 3) ensuring
that people will utilize the benefits despite concerns that employers
will learn of mental health and substance abuse diagnosis of their
employees; and 4) monitoring utilization of mental health and substance
abuse benefits in light of utilization review, medical necessity, etc.
SAMHSA expects states to implement policies and procedures that are
designed to ensure that block grant funds are used in accordance with
the four priority categories identified above. Consequently, states may
have to reevaluate their current management and oversight strategies to
accommodate the new priorities. They may also need to become more
proactive in ensuring that state-funded providers are enrolled in the
Medicaid program and have the ability to determine if clients are
enrolled or eligible to enroll in Medicaid. Additionally, compliance
review and audit protocols may need to be revised to provide for
increased tests of client eligibility and enrollment.
Use of Evidence in Purchasing Decisions--SAMHSA is
interested in whether or how states are using evidence in their
purchasing decisions, educating policymakers or supporting providers to
offer high quality services. In addition, SAMHSA is interested in
additional information that is needed by SMHAs and SSAs in their
efforts to continue to shape their and other purchasers decisions
regarding mental health and substance abuse services.
Quality--Up to 25 data elements, including those in the
table below will be available through the Behavioral Health Barometer
which SAMHSA will prepare at least bi-annually to share with states for
purposes of informing the planning process. Using this information,
states will select specific priority areas. States will receive
feedback on an annual basis in terms of national, regional and state
performance and will be expected to provide information on the
additional measures they have identified outside of the core measures
and state barometer. Reports on progress will serve to highlight the
impact of the block grant funded services and thus allow SAMHSA to
collaborate with the states and other HHS Operating Divisions in
providing technical assistance to improve behavioral health and related
outcomes.
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Substance abuse
Prevention treatment Mental health services
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Health............................... Youth and Adult Heavy Reduction/No Change In Level of Functioning.
Alcohol Use--Past 30 substance use past 30
Day. days.
Home................................. Parental Disapproval Of Stability in Housing... Stability in Housing.
Drug Use.
Community............................ Environmental Risk/ Involvement in Self- Improvement/Increase in
Exposure to Prevention Help. quality/number of
Messages And/or supportive
Friends Disapproval. relationships among
SMI population.
Purpose.............................. Pro-Social Connections- Percent in TX employed, Clients w/SMI or SED
Community Connections. in school, etc.--TEDS. who are employed, or
in school.
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Trauma--In order to better meet the needs of those they
serve, states should take an active approach to addressing trauma.
Trauma screening matched with trauma-specific therapies such as
exposure therapy or trauma-focused cognitive behavioral approaches
should be adopted to ensure that treatments meet the needs of those
being served. States should also consider adopting a trauma informed
care approach consistent with SAMHSA's trauma informed care definition
and principles. This means providing care based on an understanding of
the vulnerabilities or triggers of trauma survivors that traditional
service delivery approaches may exacerbate, so that these services and
programs can be more supportive and avoid re-traumatization.
Justice--The SABG and MHBG may be especially valuable in
supporting care coordination to promote pre-arrest, pre-adjudication
and pre-sentencing diversion, providing care during gaps in enrollment
after incarceration, and supporting other efforts related to
enrollment. Communities across the United States have instituted
problem-solving courts, including those for defendants with mental and
substance use disorders. These courts seek to prevent incarceration and
facilitate community-based treatment for offenders, while at the same
time protecting public safety. There are two types of problem-solving
courts related to behavioral health: Drug courts and mental health
courts. However, there are a number of different types of problem-
solving courts. In addition to drug courts and mental health courts,
some jurisdictions, for example, operate courts for DWI/DUI, veterans,
family, teen, reentry, as well as courts such as gambling, domestic
violence, truancy, etc. States are also encouraged to work with
municipalities to determine whether municipal mental health or drug
courts might be viable. Specialized courts provide a forum in which the
adversarial process can be relaxed and problem solving and treatment
processes can be emphasized. States should place emphasis on screening,
assessment, and services provided prior to arrest, adjudication and/or
sentencing to divert persons with mental and/or substance use disorders
from correctional settings. Secondarily, states should examine specific
barriers such as lack of identification needed for enrollment, loss of
eligibility resulting from incarceration, and care coordination for
individuals with chronic health conditions, housing
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instability, and employment challenges. Secure custody rates decline
when community agencies are present to advocate for alternatives for
detention.
Parity Education--SAMHSA encourages states to take
proactive steps to improve consumer knowledge about parity. As one plan
of action, states can develop communication plans to provide and
address key issues. SAMHSA is in a unique position to provide content
expertise to assist states, and is asking for input from states to
address this position.
Primary and Behavioral Health Care Integration
Activities--Numerous provisions in the Affordable Health Care Act and
elsewhere improve the coordination of care for patients through the
creation of health homes, where teams of health professionals will be
rewarded to coordinate care for patients with chronic conditions.
States that had approved Medicaid State Plan Amendments (SPAs) received
90 percent Federal Medicaid Assistance Percentage (FMAP) for health
home services for eight quarters. At this critical point in time, some
states are ending their two years of enhanced FMAP and rolling back to
their regular state FMAP for health home services. In addition, many
states may be a year into the implementation of their dual eligible
demonstration projects. States should indicate how these changes and
opportunities affect their application.
Health Disparities--In the block grant application, states
are asked to define the populations they intend to serve. Within these
populations of focus are subpopulations that may have disparate access
to, use of, or outcomes from provided services. These disparities may
be the result of differences in insurance coverage, language, beliefs,
norms, values, and/or socioeconomic factors specific to that
subpopulation. For instance, Latino adults with SMI may be at
heightened risk for metabolic disorder due to lack of appropriate in-
language primary care services; American Indian/Alaska Native youth may
have an increased incidence of underage binge drinking due to coping
patterns related to historical trauma within the American Indian/Alaska
Native community; and African American women may be at greater risk for
contracting HIV/AIDS due lack of access to education on risky sexual
behaviors in urban low-income communities, etc. While these factors
might not be pervasive among the general population served by the block
grant, they may be predominant among subpopulations or groups
vulnerable to disparities. To address and ultimately reduce
disparities, it is important for states to have a detailed
understanding of who is being served and not being served within their
communities, including in what languages services are provided, in
order to implement appropriate outreach and engagement strategies for
diverse populations. The types of services provided, retention in
services and outcomes are critical measures of quality and outcomes of
care for diverse groups. In order to address the potentially disparate
impact for their block grant funded efforts, states will be asked to
address access, use and outcomes for subpopulations, which can be
defined by the following factors: race, ethnicity, language, gender
(including transgender), tribal connection and sexual orientation
(i.e., lesbian, gay, bisexual).
Recovery--SAMHSA encourages states to take proactive steps
to implement recovery support services. SAMHSA is in a unique position
to provide content expertise to assist states, and is asking for input
from states to address this position. SAMHSA has launched Bringing
Recovery Supports to Scale Technical Assistance Center Strategy (BRSS
TACS). BRSS TACS assists states and others to promote adoption of
recovery-oriented supports, services, and systems for people in
recovery from mental or substance use disorders.
Children and Adolescents Behavioral Health Services--Since
1993, SAMHSA has funded the Children's Mental Health Initiative (CMHI)
to build the System of Care approach in states and communities around
the country. This has been an ongoing program with over 160 grants
awarded to states and communities. Every state has received at least
one CMHI grant. In 2007, SAMHSA awarded State Substance Abuse
Coordinator grants to 16 states to build a state infrastructure for
substance use disorders. This work has continued with a focus on
financing and workforce development to support a recovery-oriented
system of care that incorporates established evidenced-based treatment
for youth with substance use disorders.
SAMHSA expects that states will build on this well-documented,
effective system of care approach to serving children and youth with
behavioral health needs. Given the multi-system involvement of these
children and youth, the system of care approach provides the
infrastructure to improve care coordination and outcomes, manage costs
and better invest resources. The array of services and supports in the
system of care approach includes non-residential (e.g., wraparound
service planning, intensive care management, outpatient therapy,
intensive home-based services, substance use disorder intensive out
patient services, continuing care, mobile crisis response, etc.),
supportive services (e.g., peer youth support, family peer support,
respite services, mental health consultation, supported education and
employment, etc.), and residential services (e.g., therapeutic foster
care, crisis stabilization services, inpatient medical detoxification,
etc.).
Although the statutory dates for submitting the block grant
application, plan and annual report remain unchanged, SAMHSA requests
that the MHBG and SABG applications be submitted on the same date. In
addition, the dates for submitting the plans have changed to better
comport with most states fiscal and planning years (July 1st through
June 30th of the following year).
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Application
Application(s) for FY due Plan due Planning period Reports due
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2014................................. 4/1/13 Yes.................... 7/1/13-6/30/15 12/1/13
2015................................. 4/1/14 No..................... ................ 12/1/14
2016................................. 4/1/15 Yes.................... 7/1/15-6/30/17 12/1/15
2017................................. 4/01/16 No..................... ................ 12/1/16
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Summary of Changes as a Result of the 60-Day Federal Register Notice
SAMHSA received 232 comments from 36 individuals or organizations.
The comments expressed general support for the option to submit a
combined plan for mental and substance use disorders (M/SUD) for both
block grants, the movement to the behavioral health barometer, the
expressed four priorities for the block grants, the two-year planning
cycle, and tribal consultation. Many comments were duplicative and
include requests that SAMHSA eliminate any reference to
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initiatives in the President's budget proposal and include a discussion
of only those initiatives that are authorized; ask only for what is
required information and not include any areas that are requested;
clarify that SABG dollars cannot be used for mental health promotion;
provide clear operational definitions for each outcome measure;
simplify the data collected; reduce or clarify the expanded area of
focus; change the acronym for the substance abuse block grant back to
SAPTBG; address a concern from some states that the April 1 deadline
will be difficult given other priority activities in the states;
emphasize older adults and veterans; require substance abuse
representation on the planning council for those states submitting a
combined application; and, address a concern that the use of block
grant funds are becoming more prescriptive instead of giving states
maximum flexibility.
SAMHSA received some comments about the ``Behavioral Health
Advisory Council Composition by Member Type'' table indicating that the
reference to members from diverse racial and LGBTQ populations is
potentially confusing and creates a dilemma as to which category
members should be ascribed, the term `leading state experts' is also
confusing and somewhat arbitrary, and the membership categorization for
``Federally Recognized Tribe Representatives'' could be confused with
council members who happen to be tribal members. SAMHSA agrees with the
recommendations that the request for a number of individuals and
providers from diverse racial, ethnic, and LGBTQ backgrounds in the
table will skew the calculation of the percentage of consumers/state
members. SAMHSA has moved this information request, as well as the
request to identify any member who is an individual in recovery from
SUD or advocating for SUD services to the bottom of the table and
removed it from the calculation. ``Leading state expert'' is deleted.
Federally Recognized Tribal Representatives are individuals who are
officially designated by the tribe to sit on the Council.
SAMHSA added clarifying language within the prevention section,
that clarifies that states will be allowed to use some of their current
Mental Health Block Grant to support mental health promotion and mental
illness prevention activities related to adults with serious mental
illnesses and children with serious emotional disturbances and their
families. In addition, the 20% set aside funds of the Substance Abuse
Block Grant must be used for substance abuse primary prevention
activities by the state. Many evidenced-based substance abuse programs
have a positive impact on the prevention of substance use and abuse as
well as other health and social outcomes such as education, juvenile
justice involvement, violence prevention and mental health.
SAMHSA reduced the number of questions in the prevention planning
section, in the Primary and Behavioral Health Care Integration
Activities section, and in the Technical Assistance needs section..
SAMHSA has renumbered and, in some instances, renamed tables
throughout the document to eliminate the redundancy in the table
numbers between the planning and reporting sections and improve user
navigation. SAMHSA also revised the table entitled `Behavioral Health
Advisory Council Composition by Member Type.' In addition, SAMHSA
enhanced the tables of contents in the reporting sections to facilitate
user navigation.
Estimates of Annualized Hour Burden
The estimated annualized burden for a uniform application is 37,429
hours. Burden estimates are broken out in the following tables showing
burden separately for Year 1 and Year 2. Year 1 includes the estimates
of burden for the uniform application and annual reporting. Year 2
includes the estimates of burden for the application update and annual
reporting. The reporting burden remains constant for both years.
Table 1--Estimates of Application and Reporting Burden for Year 1
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Burden/
Application element Number respondents Responses/ response Total burden
respondents (hours)
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Application Burden
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Yr One Plan (separate submissions).... 30 (CMHS)............... 1 282 16,920
30 (SAPT)...............
Yr One Plan (combined submission)..... 30...................... 1 282 8,460
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Application Sub-total............. 60...................... .............. .............. 25,380
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Reporting Burden
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MHBG Report........................... 59...................... 1 186 10,974
URS Tables............................ 59...................... 1 35 2,065
SABG Report........................... \1\60................... 1 186 11,160
Table 5............................... \2\15................... 1 4 60
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Reporting Subtotal................ 60...................... .............. .............. 24,259
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Total............................. 119..................... .............. .............. 49,639
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\1\ Redlake Band of the Chippewa Indians from MN receives a grant.
\2\ Only 15 States have a management information system to complete Table 5.
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Table 2--Estimates of Application and Reporting Burden for Year 2
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Burden/
Application element Number respondents Responses/ response Total burden
respondents (hours)
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Application Burden
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Yr Two Plan........................... 24...................... 1 40 960
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Application Sub-total................. 24...................... .............. .............. 960
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Reporting Burden
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MHBG Report........................... 59...................... 1 186 10,974
URS Tables............................ 59...................... 1 35 2,065
SABG Report........................... 60...................... 1 186 11,160
Table 5............................... 15...................... 1 4 60
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Reporting Subtotal.................... 60...................... .............. .............. 24,259
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Total............................. 119..................... .............. .............. 25,219
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The total annualized burden for the application and reporting is
37,429 hours (49,639 + 25,219 = 74,858/2 years = 37,429).
Link for the application: www.samhsa.gov/grants/blockgrant.
Written comments and recommendations concerning the proposed
information collection should be sent by November 9, 2012 to the SAMHSA
Desk Officer at the Office of Information and Regulatory Affairs,
Office of Management and Budget (OMB). To ensure timely receipt of
comments, and to avoid potential delays in OMB's receipt and processing
of mail sent through the U.S. Postal Service, commenters are encouraged
to submit their comments to OMB via email to: [email protected]. Although commenters are encouraged to send
their comments via email, commenters may also fax their comments to:
202-395-7285. Commenters may also mail them to: Office of Management
and Budget, Office of Information and Regulatory Affairs, New Executive
Office Building, Room 10102, Washington, DC 20503.
Summer King,
Statistician.
[FR Doc. 2012-24862 Filed 10-9-12; 8:45 am]
BILLING CODE 4162-20-P