Daily Rules, Proposed Rules, and Notices of the Federal Government
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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
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.
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:
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.
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).
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
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.
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.
Link for the application:
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: