[Federal Register Volume 77, Number 135 (Friday, July 13, 2012)]
[Notices]
[Pages 41432-41436]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-17084]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration


Agency Information Collection Activities: Proposed Collection; 
Comment Request

    In compliance with Section 3506(c)(2)(A) of the Paperwork Reduction 
Act of 1995 concerning opportunity for public comment on proposed 
collections of information, the Substance Abuse and Mental Health 
Services Administration (SAMHSA) will publish periodic summaries of 
proposed projects. To request more information on the proposed projects 
or to obtain a copy of the information collection plans, call the 
SAMHSA Reports Clearance Officer on (240) 276-1243.
    Comments are invited on: (a) Whether the proposed collections of 
information are necessary for the proper performance of the functions 
of the agency, including whether the information shall have practical 
utility; (b) the accuracy of the agency's estimate of the burden of the 
proposed collection of information; (c) ways to enhance the quality, 
utility, and clarity of the information to be collected; and (d) ways 
to minimize the burden of the collection of information on respondents, 
including through the use of automated collection techniques or other 
forms of information technology.

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 Mental Health Block 
Grant (MHBG) and Substance Abuse 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 2013 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 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 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 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.
    The 2014-2015 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 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

[[Page 41433]]

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 SABG. 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 2014 and 2015.
    To facilitate an efficient application process for states in FY 
2014-2015, 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. Comments were requested from federal partners 
including HHS, OMB, ONDCP, and 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 2014-2015 application. 
The proposed revisions are based primarily on previous instructions 
provided in the 2012-2013 application guidance. In building on the 
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, 
and (2) services that are not covered by insurance and Medicaid. 
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 expended 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 mental and substance abuse services 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 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 benchmarks 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. SMHA 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 bench mark; (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 behavioral health 
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 be required 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 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

[[Page 41434]]

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 Day.  substance use past 30
                                                               days.
Home.............................  Parental Disapproval Of    Stability in Housing....  Stability in Housing.
                                    Drug Use.
Community........................  Environmental Risk/        Involvement in Self-Help  Improvement/Increase in
                                    Exposure to Prevention                               quality/number of
                                    Messages And/or Friends.                             supportive
                                   Disapproval..............                             relationships among SMI
                                                                                         population.
Purpose..........................  Pro-Social Connections--   Percent in TX employed,   Clients w/SMI or SED who
                                    Community Connections.     in school, etc.--TEDS.    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-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, reentry, as well as courts such as gambling, domestic violence, 
truancy, etc. 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 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 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 Afordable 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.
     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; Native American youth may have an 
increased incidence of underage binge drinking due to coping patterns 
related to historical trauma within the Native American 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

[[Page 41435]]

people in recovery from substance use and/or mental health 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
----------------------------------------------------------------------------------------------------------------
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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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 of respondents       Responses/       response      Total burden
                                                                    respondents       (hours)
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Application Burden:
    Yr One Plan (separate            30 (CMHS) 30 (SAPT)                       1             282          16,920
     submissions).
    Yr One Plan (combined            30.........................               1             282           8,460
     submission.
                                    ----------------------------------------------------------------------------
        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
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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.


                        Table 2--Estimates of Application and Reporting Burden for Year 2
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                                                                                      Burden/
               Application element                   Number of      Responses/       response      Total burden
                                                    respondents     respondents       (hours)
----------------------------------------------------------------------------------------------------------------
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

[[Page 41436]]

 
    Table 5.....................................              15               1               4              60
                                                 ---------------------------------------------------------------
        Reporting Subtotal......................              60  ..............  ..............          24,259
                                                 ---------------------------------------------------------------
            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.
    Send written comments to Summer King, SAMHSA Reports Clearance 
Officer, Room 2-1057, One Choke Cherry Road, Rockville, MD 20857 OR 
email a copy to [email protected]. All written comments should 
be received within 60 days of the published date of this notice.

Cathy Friedman,
Public Health Analyst.
[FR Doc. 2012-17084 Filed 7-12-12; 8:45 am]
BILLING CODE 4162-20-P