System Principles, Standards and Key Questions for Assessment of State Systems of Care for CYSHCN DOMAIN: ACCESS TO CARE 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.) The system has the capacity to Yes Title V 0 None ensure CYSHCN geographical (IF YES) How effective are those State Medicaid 1 Weak and timely access to appropriate policies and procedures? CHIP 2 Moderate Not effective Strong primary and specialty services, 1 Health Plan/Insurer 3 including in-network providers 2 Somewhat effective Provider (please specify) and timely referrals to 3 Very effective Family/Consumer physical, mental and Other (please specify) dental care providers, pediatric primary care and pediatric OPTIONAL: Why? subspecialists, children’s hospitals, pediatric regional No for score, above ) (Select “0” centers where available, and Not applicable to my organization ancillary providers. Enter Score: Enter Score:
System Principles, Standards and Key Questions for Assessment of State Systems of Care for CYSHCN DOMAIN: ACCESS TO CARE 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. The system has the capacity to ensure CYSHCN geographical and timely access to appropriate primary and specialty services, including in-network providers and timely referrals to physical, mental and dental care providers, pediatric primary care and pediatric subspecialists, children’s hospitals, pediatric regional centers where available, and ancillary providers. 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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