System Principles, Standards and Key Questions for Assessment of State Systems of Care for CYSHCN DOMAIN: ELIGIBLITY AND ENROLLMENT 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. Outreach activities to enroll children into public and private insurance coverage include strategies designed and proven to be effective in reaching CYSHCN and their families, and are coordinated with relevant family organizations at the state and community level. 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:
Continuity of care is ensured during periods of enrollment and transition such as changes in or temporary loss of insurance coverage (public and private). 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: Written policies and procedures are in place for transitioning CYSHCN between non-network and network providers and communication with the medical home and family to ensure continuity of care. 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:
Written policies and procedures are in place allowing CYSHCN who are newly enrolled or have recently changed health plans to continue seeing providers, for up to six months after enrollment. 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: A comprehensive member services program with specialized staff and linkages to relevant family organizations at the state and local level is available to provide information and assistance to CYSHCN and their families in areas including: family resource needs, insurance coverage options, eligibility and enrollment questions, covered and non-covered services, navigating the medical and community system of care available for CYSHCN, enrollee status, complaints and grievances, and selection of a primary care provider or other such medical home with experience in serving 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:
Written and oral information that is provided for purposes of determining insurance eligibility and enrolling a child into public or private insurance coverage is culturally appropriate and provided in a manner and format appropriate for a child or their caregiver, including for those families who have limited English proficiency or sensory impairments. 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: SUMMARY: ELLIGEBILITY AND ENROLLMENT Effectiveness Indicator: Organizational Influence Indicator: Additional Notes: ENDNOTES: