2011-15070. 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 obtain a copy of these documents, see the following link: http://www.samhsa.gov/​grants/​blockgrant/​.

Project: Uniform Application for the Community Mental Health Services Block Grant and Substance Abuse and Prevention Treatment Block Grant FY 2012-2013 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 2012 and 2013 Community Mental Health Services Block Grant (MHSBG) and Substance Abuse Prevention and Treatment Block Grant (SAPTBG) Guidance and Instructions into a uniform block grant application. To minimize the burden, the two separate clearances for the block grant applications will be merged into one.

Currently, the SAPTBG and the MHSBG 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 different structures for accepting, planning, and accounting for the Block Grants and the Prevention Set Aside within the SAPTBG. 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 2012 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 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 are insured. To ensure sufficient and comprehensive preparation, SAMHSA will use FY 2012 and 2013 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 Mental Health Block Grant and the Substance Abuse Prevention and Treatment Block Grant build on ongoing efforts to reform health care, ensure parity and provide States and Territories with new tools, new flexibility, and state/territory-specific plans for available resources to provide their residents the health care benefits they need. The revised planning section of the Block Grant application provides a process for States and Territories 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 and Territory will provide information for SAMHSA and other Federal partners to use in working with States and Territories to improve their behavioral health systems over the next two years as health care and economic conditions evolve.

Currently, States and Territories are asked to provide strategies for seventeen areas that were developed almost twenty years ago. This new Block Grant application guides and prompts States and Territories to consider multiple populations and program areas that are likely to be priorities for States and Territories today, and to consider how changes in other funding streams that were not as relevant in prior years might fit with Block Grant funds today and in the future.

In addition, the new Block Grant application provides States and Territories the flexibility to submit one rather than two separate Block Grant applications if they choose. It also allows States and Territories 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 and Territories (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 and Territories 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 2012-2013 application has sections that are required and other sections where additional information is requested, but not required. The FY 2012-2013 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 and certifications. In addition, SAMHSA is requesting information on key areas that are critical to their success to address 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 SAPTBG. Therefore, as part of this Block Grant planning process, SAMHSA is asking States and Territories to identify their technical assistance needs to implement the strategies they identify in their plans for FY 2012 and 2013.

To facilitate an efficient application process for States in FY 2012-2013, SAMHSA convened an internal workgroup to develop the application for 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. Based on these discussions with States, SAMHSA is proposing several changes to the Block Grant programs, discussed in greater detail below.

Changes to Assessment and Planning Activities

Under the previous SAPTBG, States were requested to address seventeen national goals. Some of these seventeen goals were population specific (pregnant women), while others were service specific (substance abuse prevention strategies). The MHSBG required States to address a set of criterion for children with serious emotional disturbances and adults with serious mental illness. While both Block Grants required States to do an assessment and plan, they did not always allow the State or SAMHSA to obtain an overall picture of the State's behavioral health needs and to incorporate consistent priorities and planning activities, especially for individuals with a co-occurring mental and substance use disorder. States will be asked to follow a four-step planning process which consists of: (1) Assessing the strengths and needs of the service system; (2) identifying the unmet service needs and critical gaps within the current system; (3) prioritize the State planning activities, and; (4) develop goals, strategies and performance indicators.

The revised Block Grant application requires States to identify and analyze the strengths, needs, and priorities of their behavioral health systems. One important change is that States will be requested to take into account the priorities for the specific populations that are the current focus of the Block Grants in the context of the changing health care environment and SAMHSA's strategic initiatives. The focus of SAMHSA's Block Grant programs has not changed significantly over the past 20 years. While many of these populations originally targeted for the Block Grants are still a priority, additional populations have evolving needs that should be addressed. These include military families, youth who need substance use disorder services, individuals who experience trauma, increased numbers of individuals released from correctional facilities, and lesbian, gay, bi-sexual, transgender and questioning (LGBTQ) individuals. The uniform plan required in the Block Grant application must address the statutory populations (as appropriate for each Block Grant) and should address these other populations.

One population of particular note in 2014 will be the newly-insured. States should begin planning now for individuals with low-incomes who are currently uninsured but will gain health coverage in 2014 when additional coverage options are available. Many of these individuals will be covered by Medicaid or private insurance in FY 2014, and this will present new opportunities for behavioral health systems to expand access and capacity. In addition, States should identify who will not be covered after FY 2014, as well as whose coverage is insufficient and how Federal funds will be used to support these individuals who may need treatment and supports.

SAMHSA is also encouraging SMHAs and SSAs to develop and submit a combined plan to address a number of other common areas, including bi-directional integration of behavioral health and primary care services, provision of recovery support services and a combined plan for the provision of services for individuals with co-occurring mental and substance use disorders. These combined plans should be included in a State's application (for those states submitting one Block Grant application). For States that submit separate Block Grant applications, these combined plans for these activities should be included in both the State MHSBG and SAPTBG applications.

The new Block Grant application requires States to follow the following planning steps:

• Step One: Assess the strengths and needs of the service system to address the specific populations. This will include a description of the organization of the current public system, the roles of the state, county, and localities in the provision of service and the ability of the system to address diverse needs.
• Step Two: Identify the unmet service needs and critical gaps within the current system. Included in this step is the identification of data sources used to determine the needs and gaps for the populations identified as a priority.
• Step Three: Prioritize State planning activities. Given the information in Step 2, the States will prioritize the target populations as appropriate for each Block Grant as well as other priority populations as determined by the State.
• Step Four: Develop goals, strategies and performance indicators. For each of the priorities identified in Step 3, the state will identify at least one goal, strategies to reach that goal, and the performance indicators to be examined over the next two years.

In addition to the planning steps, States are requested to provide the following information:

• Information on the Use of Block Grant Dollars for Block Grant Activities—States should project how Block Grant funds will be used to provide services for the target populations or areas identified in their plans for States that have a combined MHSBG and SAPTBG application. SAMHSA encourages States to use MHSBG and SAPTBG funds to support their or other agencies' efforts to develop reimbursement strategies that support innovation. For example, States could use Block Grant funds to support various demonstration projects through other Federal programs (Medicaid, HUD, Veterans Affairs). The new Block Grant application asks States to describe their overall reimbursement approach for services purchased with MHSBG and SAPTBG funds. States must identify the reimbursement methodology proposed for each service, prevention and emotional health development strategy, and system improvement. States are requested to project their expenditures under the MHSBG and the SAPTBG for treatment and support services.
• Information on Activities that Support Individuals in Directing the Services—In the new Block Grant application, States are asked to provide information regarding policies and programs that allow individuals with mental illness and/or substance use disorder to direct their own care.
• Information on Data and Information Technology—SAMHSA is requesting States to provide unique client-level encounter data for specific services that are purchased with Block Grant funds. States will be requested to complete the service utilization table in the Reporting Section of the Application. States should provide information on the number of unduplicated individuals by each service purchased with Block Grant Funds. If the State is currently unable to provide unique client level data for any part of its behavioral health system, the State is requested to describe in the Block Grant application their plan, process, resources needed and timeline for developing such capacity.
• Description of State's Quality Improvement Reporting—States have been reporting the program performance monitoring activities to include the use of independent peer review to improve the quality and appropriateness of treatment services delivered by providers receiving funds from the block grant (See 42 U.S.C. 300x-53(a) and 45 CFR 96.136), States are asked to attach their current quality improvement plan to their Block Grant application.
• Description of State's Consultation with Tribes—SAMHSA is required by the 2009 Memorandum on Tribal Consultation to submit plans on how it is to engage in regular and meaningful consultation and collaboration with tribal officials in the development of Federal policies that have Tribal implications. SAMHSA is requesting that States provide a description of how they consulted with Tribes in their State. This description should indicate how concerns of the Tribes were addressed in the State Block Grant plan(s). States shall not require any Tribe to waive its sovereign immunity in order to receive funds or in order for services to be provided for Tribal members on Tribal lands.
• Description of State's Service Management Strategies—SAMHSA, similar to other public and private payers of behavioral health services, seeks to ensure that services purchased under the Block Grant are provided to individuals in the right scope, amount and duration. The Block Grant application asks States to describe the processes that they will employ over the next planning period to identify trends in over/underutilization of SAPTBG or MHSBG funded services. They must also describe the strategies that they will deploy to address these utilization issues. SAMHSA is also requesting the States to describe the resources needed to implement utilization management strategies and the timeframes for implementing these strategies.
• Development of State Dashboards—An important change to the administration of the MHSBG and SAPTBG is the creation of State dashboards on key performance indicators. National dashboard indicators will be based on outcome and performance measures that will be developed by SAMHSA in FY 2011. For FY 2012, States will be requested to identify a set of state-specific performance measures for this incentive program. In addition, SAMHSA will identify several national indicators to supplement the state-specific measures for the incentive program. The State, in consultation with SAMHSA, will establish a baseline in the first year of the planning cycle and identify the thresholds for performance in the subsequent year. The State will also propose the instrument used to measure the change in performance for the subsequent year. The State dashboards will be used to determine if States receive an incentive based on performance. SAMHSA is considering a variety of incentive options for this dashboard program and will solicit input from the States on the options.
• Information of State's Suicide Prevention Plan—As an attachment to the Block Grant application(s), States are requested to provide the most recent copy of their suicide prevention plan. While this is not a required plan, SAMHSA is interested in knowing the strategies that State's are proposing to address suicide prevention. If a State does not have a suicide prevention plan or if it has not been updated in the past three years States are requested to describe when they will create or update their plan.
• Identification of Technical Assistance Needs—States are requested to describe the data and technical assistance needs identified by the State during the process of developing this plan that will be needed or helpful to implement the proposed plan.
• Process for Comment on State Plan—Current statute requires that, as a condition of the funding agreement for the grant, States will provide opportunity for the public to comment on the State plan. In the application, States are asked to describe their efforts and procedures to obtain public comment on the State plan.
• Description of Processes to Involve Individuals and Families—In the Block Grant application States are requested to describe their efforts to actively engage individuals and families in developing, implementing and monitoring the State mental health and substance abuse systems.
• Description of the Use of Technology—Interactive Communication Technologies (ICTs) are more frequently being used to deliver various health care services. In the Block Grant application, States are requested to provide information on their use or planned use of ICTs.
• Process for Obtaining Support of State Partners—The success of a State's MHSBG and SAPTBG will rely heavily on the strategic partnership that SMHAs and SSAs have or will develop with other health, social services, education and other State and local governmental entities. States are requested to identify these partners in their Block Grant application and describe the roles they will play in assisting the State to implement the priorities identified in the plan. SAMHSA is requesting States to provide a letter of support indicating agreement with the description of their role and collaboration with the SSA and/or SMHA and other State agencies (e.g. State education authorities, the State Medicaid agency, etc.)
• Description of State Behavioral Health Advisory Council—Each State is required to establish and maintain a State advisory council for services for individuals with a mental disorder. SAMHSA strongly encourages States to expand and use the same council to advise and consult regarding issues and services for persons with or at risk of substance abuse and substance use disorders as well.

Other Changes

States will be allowed to submit a joint application for the Mental Health Services Block Grant and the Substance Abuse and Prevention and Treatment Block Grant.

States will no longer be required to submit an annual plan. The new application allows States to submit a two-year plan for FY 2012 and 2014.

Although the statutory dates for submitting the Block Grant application, plan and annual report remain unchanged, SAMHSA requests that the MHSBG and SAPTBG applications be submitted on the same date. In addition, the dates for submitting the plans have been changed to better comport with most States fiscal and planning years (July 1st through June 30th of the following year). More information can be found in the application overview.

Also, the dates States are requested to submit the annual reports have been changed for the SAPTBG. These annual reports will be due on the same date as the reports for the MHSBG, December 1st. Opting not to submit the Block grant application, plan and annual report on the same date for the SAPTBG as the MHSBG will not affect State funding in any way (amount or timeliness of payment).

Various reporting requirements for narrative descriptions have been deleted and included as an assurance to confirm compliance.

Summary of Changes as a Result of the Federal Register Notice

On April 11, 2011 a Federal Register Notice was posted to obtain comments on the proposed collection of information sought through the revised application for the SAPTBG and the MHSBG. In total, 772 comments from 522 individuals or organizations were received. The comments were (1) Supportive of the changes proposed to the FY 2012-2013 Block Grant Application, (2) requested clarification regarding certain areas or (3) requested specific changes to the Block Grant Application.

The most frequent comments in support of the revised Block Grant application focused on the following areas:

• Allowing States to submit a bi-annual plan instead of an annual plan.
• Having a standard format for both the MHSBG and SAPTBG.
• SAMHSA's efforts to encourage States to use the revised Block Grant application process to be better prepared to respond to several major Federal initiatives.
• Focus on planning for populations that are uninsured and below 133% of the Federal poverty level that may become insured in FY 2014.
• Inclusion of family involvement, tribal consultation and a focus on the provision of recovery support services.
• Commending SAMHSA on including adolescents as a target group that States can include in their needs assessment and State Plan.

The most frequent comments seeking clarification in the revised Block Grant application focused on the following areas:

• Requesting clarification on the sections of the Block Grant application that were required versus requested.
• Requesting that SAMHSA provide States flexibility regarding the submission of Block Grant applications post the statutory submission given the compressed timeframes.
• Requesting assurances that SAMHSA will not disapprove a State Plan or payment that did not include the requested information in the block grant application.
• Clarification that SAMHSA is not consolidating the MHBG and SAPTBG funds.
• Requesting definitions and procedure codes for the services that are included in Table 5 of the State Plan document and the reporting sections.
• Additional clarification regarding the process to develop dashboard measures for States and the proposed incentive program.
• Additional clarification and technical assistance regarding strategies to perform formal Tribal consultation.
• Comments regarding SAMHSA's proposed FY 2012 budget and the creation of State Prevention Grants. The comments were not in support of the FY 2012 proposal. While these were important comments that were not relevant to the FRN regarding the changes in the Block grant application.

During the 60 day review period SAMHSA conducted fourteen teleconferences to review the changes to the MHSBG and SAPTBG with State Substance Abuse authorities, State Mental Health Authorities and other stakeholders. SAMHSA also did a significant public outreach effort to solicit comments on the revised block grant application through announcements in various periodicals, trade association materials and prominently displayed the FRN and the application on the SAMHSA Web site.

Based on the comments received through the Federal Register Notice, SAMHSA has made changes to the revised block grant application. These changes include:

• Clarifying which sections of the block grant application are required to be submitted as part of the State Plan and which sections SAMHSA is requesting, but not requiring States to submit. SAMHSA continues to strongly encourage States to submit this information. This will allow SAMHSA to understand the Applicant State's efforts and identify how it can assist the applicant State meet its goals in a changing environment. In addition, this information will identify States that are models and assist other States with areas of common concern.
• Clarify to States that not submitting this information will not change SAMHSA's approval of their Plan or payment, States are strongly encouraged to submit as much as they can so the nation as a whole will have a complete picture of needs of individuals with behavioral health conditions as well as the innovative approaches States are undertaking in these areas as well as the barriers they encounter to design and implement important policies and programs.
• Provided some additional clarity regarding specific sections of the plan in the following areas: Data and Information Technology, consultation with Tribes, Support of State Partners, and State behavioral Health Advisory Council.
• Provided additional clarification on specific sections of the reporting section for the MHBG and SABG.

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

Application element	Number respondents	Responses/ respondents	Burden/ response (hours)	Total burden
Application Burden:
Yr One Plan (separate submissions)	30 (CMHS) 30 (SAPT)	1	282	16,920
Yr One Plan (combined submission)	30	1	282	8,460
Application Sub-total	60			25,380
Reporting Burden:
MHBG Report	59	1	186	10,974
URS Tables	59	1	35	2,065
SAPTBG Report	60 1	1	186	11,160
Table 5	15 2	1	4	60
Reporting Subtotal	60			24,259
Total	119			49,639
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.

Table 2—Estimates of Application and Reporting Burden for Year 2

Application element	Number respondents	Responses/ respondents	Burden/ response (hours)	Total burden
Application Burden:
Yr Two Plan	24	1	40	960
Application Sub-total	24			960
Reporting Burden:
MHBG Report	59	1	186	10,974
URS Tables	59	1	35	2,065
SAPTBG Report	60	1	186	11,160
Table 5	15	1	4	60
Reporting Subtotal	60			24,259
Total	119			25,219

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: http://www.samhsa.gov/​grants/​blockgrant/​.

Written comments and recommendations concerning the proposed information collection should be sent by July 18, 2011 to: SAMHSA Desk Officer, Human Resources and Housing Branch, Office of Management and Budget, New Executive Office Building, Room 10235, Washington, DC 20503; due to potential delays in OMB's receipt and processing of mail sent through the U.S. Postal Service, respondents are encouraged to submit comments by fax to: 202-395-7285.

Dated: June 13, 2011.

Elaine Parry,

Director, Office of Management, Technology and Operations.