Pediatric specialists who have a Yes Title V 0 None demonstrated clinical 1 Weak (IF YES) How effective are those State Medicaid relationship as the clinical policies and procedures? CHIP 2 Moderate coordinator of care for a 1 Not effective Health Plan/Insurer 3 Strong CYSHCN, among other 2 Somewhat effective Provider (please specify) responsibilities, are able to 3 Very effective Family/Consumer serve as a primary care provider Other (please specify) (PCP) for CYSHCN. OPTIONAL: Why? No for score, above ) (Select “0” Not applicable to my organization Enter Score: Enter Score: Freedom of choice in selecting a Yes Title V 0 None primary care provider and (IF YES) How effective are those State Medicaid 1 Weak written policies and procedures policies and procedures? CHIP 2 Moderate describing how enrollees 1 Not effective Health Plan/Insurer 3 Strong choose and are assigned to a 2 Somewhat effective Provider (please specify) PCP, and how they may change 3 Very effective Family/Consumer their PCP is in place. Other (please specify) OPTIONAL: Why? No for score, above ) (Select “0” Not applicable to my organization Enter Score: 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:
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