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 Column B Column C Column D System Standards Within my organization, there are What agencies/entities in your Please rate your organization’s (Structure and Process) policies and procedures in place for state have the authority to authority to implement or improve this standard: implement and/or ensure this policies and procedures that support standard? (Check all that this standard. apply.) Outreach activities to enroll Yes Title V 0 None children into public and (IF YES) How effective are those State Medicaid 1 Weak private insurance coverage policies and procedures? CHIP 2 Moderate include strategies designed 1 Not effective 3 Strong Health Plan/Insurer and proven to be effective in 2 Somewhat effective Provider (please specify) reaching CYSHCN and their 3 Very effective Family/Consumer families, and are coordinated Other (please specify) with relevant family organizations at the state OPTIONAL: and community level. Why? No for score, above ) (Select “0” Not applicable to my organization Enter Score: Enter Score:
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:
2_Eligibility%20and%20Enrollment_In%20DepthFINAL.docx