Comprehensive habilitative Yes Title V 0 None services include therapies, (IF YES) How effective are those State Medicaid 1 Weak services and devices for a child, policies and procedures? CHIP 2 Moderate based upon their individual 1 Not effective Health Plan/Insurer 3 Strong needs, to prevent and avert 2 Somewhat effective Provider (please specify) deterioration of functioning or 3 Very effective Family/Consumer attain or maintain a skill or Other (please specify) function never learned or acquired due to a chronic or OPTIONAL: disabling condition, including Why? those early intervention services No (Select for score, above ) “0” specified in a child’s Not applicable to my organization Individualized Family Service Plan (IFSP as part of Early Intervention) and the services outlined in a school-age child’s Individualized Education Plan (IEP as part of Special Education) are available. Enter Score: Enter Score: Habilitative services are a Yes Title V 0 None covered benefit and offered in (IF YES) How effective are those Medicaid 1 Weak addition to rehabilitative policies and procedures? CHIP 2 Moderate services, and are of like type and 1 Not effective Health Plan/Insurer 3 Strong substantially equivalent in 2 Somewhat effective Provider (please specify) scope, amount and duration to 3 Very effective Family/Consumer rehabilitative services.,, Other (please specify) OPTIONAL: Why? No (Select for score, above ) “0” Not applicable to my organization Enter Score: Enter Score:
Comprehensive habilitative services include therapies, services and devices for a child, based upon their individual needs, to prevent and avert deterioration of functioning or attain or maintain a skill or function never learned or acquired due to a chronic or disabling condition, including those early intervention services specified in a child’s Individualized Family Service Plan (IFSP as part of Early Intervention) and the services outlined in a school-age child’s Individualized Education Plan (IEP as part of Special Education) are available. 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: Habilitative services are a covered benefit and offered in addition to rehabilitative services, and are of like type and substantially equivalent in scope, amount and duration to rehabilitative 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 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:
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