Families receive information Yes Title V 0 None about the services and 1 Weak (IF YES) How effective are those State Medicaid supports that they will policies and procedures? CHIP 2 Moderate receive in a method chosen 1 Not effective Health Plan/Insurer 3 Strong by the family (e.g., written, 2 Somewhat effective Provider (please specify) verbal, language of choice). 3 Very effective Family/Consumer Other (please specify) OPTIONAL: Why? No for score, above ) (Select “0” Not applicable to my organization Enter Score: Enter Score: All written materials provided to Yes Title V 0 None are (IF YES) How effective are those State Medicaid 1 Weak CYSHCN and their families culturally appropriate, policies and procedures? CHIP 2 Moderate 1 Not effective Health Plan/Insurer 3 Strong provided in the primary 2 Somewhat effective Provider (please specify) language of the CYSHCN 3 Very effective Family/Consumer and their family, and Other (please specify) provided in a manner and format appropriate for OPTIONAL: children and their parents Why? or caregivers who have No for score, above ) (Select “0” limited English Not applicable to my organization proficiency or sensory impairments. Enter Score: Enter Score:
Families receive information about the services and supports that they will receive in a method chosen by the family (e.g., written, verbal, language of choice). 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: All written materials provided to CYSHCN and their families are culturally appropriate, provided in the primary language of the CYSHCN and their family, and provided in a manner and format appropriate for children and their parents or caregivers 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: