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Identification, Screening, Assessment, and Referral

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Eligibility and Enrollment in Health Coverage

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Access to Care

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Medical Home

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Community-Based Services and Supports

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Transition to Adulthood

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Health Information Technology

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Quality Assurance and Improvement

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Eligibility and Enrollment in Health Coverage

  1. Outreach activities to enroll children into insurance coverage include strategies designed and proven to be effective in reaching CYSHCN and their families.1
  2. A comprehensive member services program with specialized staff is available to provide information and assistance to CYSHCN and their families in areas including: covered and non-covered services; additional or supplemental insurance coverage options; eligibility and enrollment questions; navigating the medical and community system of care available for CYSHCN; 2 enrollee status; complaints and grievances; and selection of primary care provider, specialists, or medical homes with experience in serving CYSHCN.3
  3. Information and materials related to insurance program eligibility and enrollment processes are provided in such a manner as to be easily understood by the enrollee’s family.4
  4. Continuity of care is ensured during periods of enrollment and transition, such as changes in or temporary loss of insurance coverage.5
  5. Written policies and procedures are in place at the system level for transitioning CYSHCN between non-network and network providers, including communication with the medical home and family.5
  6. Written policies and procedures are in place allowing CYSHCN who are newly enrolled or have recently changed health plans to continue seeing out-of-network providers for up to six months after enrollment.6

  1. Improving Access to Coverage for Children with Special Health Care Needs in the Face of Health Inequities, a publication of the Catalyst Center: Improving Financing of Care for Children and Youth with Special Health Care Needs, February 2015.
  2. Michigan Department of Community Health. Michigan Managed Care Contract: Contract Changes for Fiscal Year 2013. Section 1.022(H)(2). Unpublished.
  3. Rhode Island Department of Human Services. Rhode Island Department of Human Services Care Management Protocol for Children with Special Health Care Needs. Rhode Island RIte Care Contract. Unpublished. Accessed March 2013.
  4. Illinois Department of Healthcare and Family Services. Health Plan Outreach Guidelines. January 2016. https://www.illinois.gov/hfs/SiteCollectionDocuments/Guidelines021716.pdf
  5. Texas Health and Human Services Commission. STAR Kids Contract Terms. Version 1.3. November 2016. https://hhs.texas.gov/sites/default/files//documents/services/health/medicaid-chip/programs/contracts/star-kids-contract.pdf
  6. Rhode Island Department of Human Services. Rhode Island Department of Human Services Care Management Protocol for Children with Special Health Care Needs. Rhode Island RIte Care Contract. Section 2.08.02.08. Unpublished.