Substance Use Disorder Section 1115 Demonstration Opportunity

Description of the Demonstration Opportunity

As part of the U.S. Department of Health and Human Services’ effort to combat the ongoing opioid crisis, the Centers for Medicare & Medicaid Services (CMS) created an opportunity under the authority of section 1115(a) of the Social Security Act (Act) for states to demonstrate and test flexibilities to improve the continuum of care for beneficiaries with substance use disorders (SUDs) including Opioid Use Disorder.  This demonstration opportunity aims to give states flexibility to design demonstrations that improve access to high quality, clinically appropriate treatment for opioid use disorder (OUD) and other substance use disorders (SUDs) while incorporating metrics for demonstrating that outcomes for Medicaid beneficiaries are in fact improving under these demonstrations.  Further, through this initiative, CMS offers states the opportunity to demonstrate how to implement best practices for improving OUD and other SUD treatment in ways that take into account the particular challenges raised by the opioid epidemic in each state.

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 SUD 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: This implementation plan template provides a framework for the state to document its approach to implementing SUD policies. It also helps to determine appropriate information for the state to report to CMS in the quarterly and annual monitoring reports.
• Monitoring Protocol Template: The monitoring protocol template and instructions provide the state the ability to document what and how it plans to report to CMS on the quarterly and annual monitoring metrics and implementation updates.
• Monitoring Report Template: The monitoring report template and instructions provide the state with a framework for how to report information to CMS quarterly and annually. In addition to the template and instructions, the tools include a list of quantitative 1115 SUD 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 SUD 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 SMI/SED 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 SUD section 1115 demonstration. The evaluation design guidance contains two documents:
  1. A master narrative
  2. An appendix specific to SUD
  3. An appendix for estimating the costs of the demonstration

Federal monitoring and evaluation: CMS conducts federal monitoring and evaluation of section 1115 SUD Demonstrations. Federal monitoring includes periodic Cross State Analyses which summarize trends over time from state demonstration monitoring reports.

Additionally, in September 2018, CMS also contracted with Research Triangle Institute (RTI) to design and conduct federal evaluations through a meta-analysis.  The design for the federal meta evaluation of SUD demonstrations 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.

The Rapid Cycle Reports include:

Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: An In-Depth Look Into Pre demonstration Measures of SUD Need, Treatment Use, Availability, and Outcomes Across States (February 2023) 

Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Features of State Approaches to Improve Medicaid SUD Treatment Delivery Systems (February 2023) 

Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: State Experiences Expanding Availability of Medication Assisted Treatment for Patients in Residential Settings (February 2023) 

Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Implementation Challenges Across States (February 2023)

Learning Collaboration and Other Resource Documents

• SUD State Engagement Webinar (video, slides)
• Data Sharing to Support Medicaid Section 1115 Demonstrations (video)