System Principles, Standards and Key Questions for Assessment of State Systems of Care for CYSHCN DOMAIN: ACCESS TO CARE State: ___________________________________ Date: _____________________ Type of Agency Completing this Tool: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify _________) Family/Consumer Other (please specify: _____________________________) When providing answers in this assessment tool, please do so from the perspective of the organization or system in which you work or are affiliated. Column A System Standards (Structure and Process) Column B Within my organization, there are policies and procedures in place for this standard: Column C What agencies/entities in your state have the authority to implement and/or ensure this standard? (Check all that apply.) Column D Please rate your organization’s authority to implement or improve policies and procedures that support this standard. The system has the capacity to ensure CYSHCN geographical and timely access to appropriate primary and specialty services, including in-network providers and timely referrals to physical, mental and dental care providers, pediatric primary care and pediatric subspecialists, children’s hospitals, pediatric regional centers where available, and ancillary providers. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score:
Pediatric specialists who have a demonstrated clinical relationship as the clinical coordinator of care for a CYSHCN, among other responsibilities, are able to serve as a primary care provider (PCP) for CYSHCN. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: Freedom of choice in selecting a primary care provider and written policies and procedures describing how enrollees choose and are assigned to a PCP, and how they may change their PCP is in place. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score:
Access to pediatric specialists (face-to-face or via telemedicine) specified in a child’s plan of care is provided without prior authorization from a child’s primary care provider or Contractor (e.g., health plan) whether or not such specialists participate in a Contractor’s provider network. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: Transportation assistance is provided to families with difficulties accessing needed medical services. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: