Community-Based Organization Directory and Engagement Survey

Dear Community Based Organization,

This statewide Community Based Organization (CBO) survey is being released to capture services your organization provides that address the Social Determinants of Health (SDH) for Medicaid members. Information gathered from this survey will be used to generate a public directory of tier 1, 2, and 3 CBOs to help facilitate partnerships with Managed Care Organizations (MCOs) and Value Based Payment (VBP) Contractors. Responses will also be used to gauge CBO integration and engagement in VBP contracting.

The survey is open to all non-profit, community-based organizations regardless of tier. All CBOs are encouraged to complete this survey even if they have completed one in the past. This new survey will replace the existing CBO directory.

Starred (*) Questions Require a Response

Question Title

* 1. Respondent Information

Name of Organization

VBP Contact Person

VBP Contact Phone

VBP Contact Email

Organization's Website Link

Question Title

* 2. Respondent Attestation

I attest to answer this survey on my organization’s behalf truthfully, and to the best of my ability. I understand that my
responses will be used to determine a self-reported CBO tier designation. I understand that the State will independently review my organization’s tier designation in light of the responses I have given.

Question Title

* 3. List the county or counties your organization serves.

Question Title

* 4. Briefly describe the service(s) your organization provides that address SDH for the NY Medicaid population. Please include any pertinent information such as targeted population, partnerships, etc.

Question Title

* 5. Which of the following SDH category best aligns with the services described above in Q4? Check all that apply.

Poverty

Housing Security and Stability

Employment

Food Security

Transportation

Nutrition

Early Childhood Education and Development

High School Education

Enrollment in Higher Education

Language and Literacy

Social Cohesion

Civic Participation

Perceptions of Discrimination and Equity

Incarceration/Institutionalization

Access to Health Care

Access to Primary Care/Trusted Provider

Health Literacy

Affordable/Quality Housing

Environmental Conditions

Access to Healthy Foods

Crime and Violence

Other

Other (please specify)

Question Title

* 6. Which of the following CBO Tier is your organization?

Tier 1: Non-profit, non-Medicaid billing. E.g. housing, social services, religious organizations, food banks

Tier 2: Non-profit, Medicaid billing, non-clinical service providers. E.g. transportation providers, care coordination providers

Tier 3: Non-profit, Medicaid billing, clinical and clinical support service provider; licensed by a State agency

Unsure

Question Title

* 7. Is your organization part of a legally formed community-based organization (CBO) Independent Practice Association (IPA)/ network/consortium/HUB?

Yes

I Don't Know

If YES, name the CBO IPA/network/consortium/HUB (please use full name and, if applicable include website link).

Question Title

* 8. If known, please identify the Managed Care health plan that the majority of people you serve are enrolled in. Click HERE for MCO list by county. Please use commas to list more than one health plan.