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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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Access to Care

  1. The system has the capacity and processes in place to ensure CYSHCN have geographic and timely access to primary and specialty services, including in-network and out-of-network providers; physical, mental and dental health care providers; pediatric primary care and pediatric subspecialists; children’s hospitals; pediatric regional centers where available; and ancillary providers.1
  2. Reasonable access requirements and wait times are in place for routine, episodic, urgent, and emergent physical, oral, and mental health and habilitative services. Same-day appointments are made available for urgent care services.2
  3. Transportation assistance is provided to families with difficulties accessing needed medical services.3
  4. Satellite programs, electronic communications, and telemedicine are used to enhance access to specialty care and regional pediatric centers of excellence, where available, and other multidisciplinary teams of pediatric specialty providers.4
  5. Written policies and procedures are in place that describe how CYSHCN choose and/or are assigned to a primary care provider (PCP) and how they may change their PCP.5
  6. Pediatric specialists who have a demonstrated clinical relationship as the clinical coordinator of all care for the child, including health supervision and anticipatory guidance, are able to serve as a primary care provider (PCP).6
  7. A documented process is in place for how to access pediatric specialists (face-to-face or via telemedicine) specified in a child’s plan of care. (See Domain 4, Medical Home, Care coordination system standards for specifics on plans of care)
  8. All health insurance programs cover medically necessary services, which are defined as services for “the prevention, diagnosis, and treatment of an enrollee’s disease, condition, and/or disorder that results in health impairments and disability; the ability for an individual to achieve age-appropriate growth and development; the ability for an enrollee to attain, maintain, and retain functional capacity; and the opportunity for an enrollee receiving long term services and supports to have access to the benefits of community living, to achieve person centered goals, and live and work in the setting of their choice.”.78
  9. Comprehensive 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. 8910
  10. Authorization processes take into account the unique needs of CYSHCN and are simplified to promote access to services.10
  11. Families of CYSHCN are able to access second opinions from qualified health care providers without restrictions to such opinions.10

The National Association of Insurance Commissioners (NAIC) defines habilitation services as “health care services that help a person keep, learn, or improve skills and functioning for daily living.”11

  1. 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 - Appendix O. Unpublished.
  2. National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2011, Appendix 2: NCQA’s PatientCentered Medical Home (PCMH) 2011 and CMS Stage 1 Meaningful Use Requirements.
  3. Adapted from Rhode Island CEDARR program standards and the standard language for the Rhode Island CEDARR Family Centers (not the health plans). Unpublished.
  4. Vigil J, Kattlove J, Litman R, Marcin J, Calouro C, Kwong, M. Realizing the Promise of Telehealth for Children with Special Health Care Needs. Palo Alto, CA: Lucile Packard Foundation for Children's Health, August 2015. Accessed April 2017. http://www.lpfch.org/sites/default/files/field/publications/realizing_the_promise_of_telehealth.pdf
  5. Michigan Department of Community Health. Michigan Managed Care Contract: Contract Changes for Fiscal Year 2013. Section 1.022(H)(2). Unpublished.
  6. McManus M, Rosenbaum S. Evaluating Managed Care Plans for Children with Special Health Needs: A Purchaser’s Tool. Optional Purchasing Specifications for Medicaid Managed Care for CYSHCN. Grant #MCJ-39R006, Maternal and Child Health Bureau. Health Resources and Services Administration, Department of Health and Human Services.
  7. Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability (81 FR 27497). https://www.federalregister.gov/documents/2016/05/06/2016-09581/medicaid-and-childrens-health-insurance-program-chip-programs-medicaid-managed-care-chip-delivered
  8. Pediatrics Committee on Health Care Financing. Policy statement: Essential contractual language for medical necessity in children. Pediatrics. 2013: 132(2): 398-401. http://pediatrics.aappublications.org/content/pediatrics/132/2/398.full.pdf
  9. Colorado State’s definition of habilitative services. The National Academy for State Health Policy. http://connectforhealthco.com/COHBE/media/COHBE/PDFs/Federal%20Comms/EHB-Comment-Ltr-12-26-12.pdf (corresponds to number 41 in PDF)
  10. Rosenbaum S. Lucile Packard Children’s Foundation for Children’s Health. Issue brief: Habilitative services coverage for children under the essential health benefit provisions of the Affordable Care Act. Available at: http://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?article=1003&context=sphhs_policy_briefs Updated May 2013. Accessed on Oct. 4, 2013.
  11. National Association of Insurance Commissioners. Glossary of health insurance terms. Available at: http://www.naic.org/documents/committees_b_consumer_information_ppaca_glossary.pdf