Fillable Eoi-sbh-affinity-group-form QI 201 Action Learning Series: Expression of Interest Form

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Eoi-sbh-affinity-group-form QI 201 Action Learning Series: Expression of Interest Form

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1
Expression of Interest
Medicaid and School-Based Health Services Delivery Affinity Group
CMS is offering a new affinity group for state Medicaid agencies interested in collaborating with
schools and public health to improve access to and the delivery of important preventive health services
for children and adolescents. In the space provided below, please let us know how this affinity group
can support the work your state is already doing as well as new areas you wish to explore in these
critical health delivery areas. Six to eight states will be chosen to participate in the affinity group. All
interested states who submit an Expression of Interest form will be given the opportunity to join the
group expert webinars.
A. Your Project and Goals
1. Does your state Medicaid program currently work with school partners to improve quality
and utilization of health services?
□ Yes ☐ No (Previous work is not required to participate.)
If yes,
please describe your efforts below:
2. Does your state Medicaid agency currently reimburse for any school-based health services? If yes,
please describe the services covered by Medicaid and what authorities your state uses to allow
payment.
□ Yes ☐ No
Services Covered by Medicaid Authorities Used to Allow Payment
3. What results does your state hope to achieve during the 12-month affinity group?
Please list results below:
2
4. Is there any specific assistance your state will need, or are there barriers to your success
that you can anticipate? If so, please describe below.
Specific Assistance Needed Barriers y
ou Anticipate
5. In the list below, please choose the school-based health services subject areas that your state
would be interested in receiving technical assistance during the one-year affinity group
period. Please check all that apply.
□
Core measure improvement (oral health, immunizations, well visits, and Early and Periodic
Screening, Diagnostic, and Treatment)
□
Care coordination between school health personnel and primary care providers
(behavioral health integration, effective use of screening and risk tools, and referrals)
□
Access (consent, youth engagement strategies, and effective local delivery reforms)
□
Data sharing and health information technology issues
□
Financing and sustainability (state authorities, Title V, and billing issues)
□ Other (Describe: ________________________________________________)
B. Your Team
1. Please identify the state Medicaid agency official who will lead your team.
Name
Title
Mailing address
Phone
Email
2. Who else will participate on your team? Please specify names and roles (e.g., quality leader,
data manager, health plan representative, external quality review organization
representative, health care provider, consumer/patient representative, other).
3. Will representatives from your state’s public health department be part of your team? If yes,
please list names and organizations.
Name
Role
3
Name
Organization
4. Will members of the department of education or other school system officials be part of your
team? If yes, please list names and organizations.
Name
Organization
C. Medicaid Senior Leadership Expression of Support
1. State teams are expected to have the support of the Medicaid Medical Director or some other
senior leadership in the agency to demonstrate the state’s interest in achieving the project’s
goals. Please indicate below the name of the senior Medicaid official supporting participation.
Name
Title
Agency
Send completed Expression of Interest forms or any questions about participating to:
MedicaidCHIPPrevention@cms.hhs.gov
by August 23, 2017.
Six to eight states will be chosen to participate. All interested states who submit the EOI will be given the
opportunity to join the group expert webinars.
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Completed 19 November 2019

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