CYSHCN Survey

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1. My child's diagnosis is

1. My child's diagnosis is

2. Here is a list of services your child may use. Please tell us whether Medicaid pays for some or all (even if Medicaid is the secondary coverage), if you have any out-of-pocket costs for the service, and how much. And then use the drop down box to tell us how often

	How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Primary care (pediatrician or family doctor)	2. Here is a list of services your child may use. Please tell us whether Medicaid pays for some or all (even if Medicaid is the secondary coverage), if you have any out-of-pocket costs for the service, and how much. And then use the drop down box to tell us how often Primary care (pediatrician or family doctor) How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Specialty care	Specialty care How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Medications	Medications How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Diagnostic tests	Diagnostic tests How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Diagnostic x-rays and other radiology	Diagnostic x-rays and other radiology How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Physical therapy	Physical therapy How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Speech therapy	Speech therapy How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Occupational therapy	Occupational therapy How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
In home/in school nursing	In home/in school nursing How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
In home/in school nurse's aide	In home/in school nurse's aide How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Medical equipment	Medical equipment How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Medical supplies	Medical supplies How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Outpatient behavioral health	Outpatient behavioral health How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Wraparound services (TSS, etc.)	Wraparound services (TSS, etc.) How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Other behavioral therapies/psychiatrist/psychologist	Other behavioral therapies/psychiatrist/psychologist How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?
Other	Other How often	Does Medicaid pay?	Do you have out of pocket costs?	If you have out of pocket costs, how much per service?

Other (please specify)

3. Do you pay a premium (or have $ deducted from your pay) for your child to be on your private health insurance?

3. Do you pay a premium (or have $ deducted from your pay) for your child to be on your private health insurance? Yes

No

4. If yes, how much do you pay for your child's coverage? (Remember, health insurance premiums can include the cost for the employee, the husband or wife and the child or children. If you don't know exactly, an estimate is fine.)

	Amount	How often?
Amount	4. If yes, how much do you pay for your child's coverage? (Remember, health insurance premiums can include the cost for the employee, the husband or wife and the child or children. If you don't know exactly, an estimate is fine.) Amount Amount	How often?

5. Does your child receive services from Birth to 3 Early Intervention?

5. Does your child receive services from Birth to 3 Early Intervention? Yes

No

6. Does your child receive special education services under an IEP?

6. Does your child receive special education services under an IEP? yes

no

7. If yes, did the School District ask you

	yes	no
To enroll your child in Medicaid?	*7. If yes, did the School District ask you To enroll your child in Medicaid? yes	To enroll your child in Medicaid? no
For your permission to bill Medicaid?	For your permission to bill Medicaid? yes	For your permission to bill Medicaid? no

8. Does your child receive services through any of these waivers?

	yes	no
Early Intervention	*8. Does your child receive services through any of these waivers? Early Intervention yes	Early Intervention no
PFDS	PFDS yes	PFDS no
Consolidated	Consolidated yes	Consolidated no

9. Please tell us a little about your family

Counting the child you told us about, siblings and the parents who live with the child, how many people are in your family?

9. Please tell us a little about your family Counting the child you told us about, siblings and the parents who live with the child, how many people are in your family? 2

3

4

5

6

more than 6

10. What is the family's annual income?

10. What is the family's annual income? less than $20,000

between $20,000 and $40,000

between $40,000 and $60,000

between $60,000 and $80,000

between $80,000 and $100,000

more than $100,000

Does your income change from month to month?

Does your income change from month to month? yes

no

Is there anything else you'd like to tell us? (For instance, that you have substantial out of pocket costs that are not reflected in the available answers, that you rely on family members to provide care, etc.)

Is there anything else you'd like to tell us? (For instance, that you have substantial out of pocket costs that are not reflected in the available answers, that you rely on family members to provide care, etc.)

CYSHCNExit this survey

*1. My child's diagnosis is

2. Here is a list of services your child may use. Please tell us whether Medicaid pays for some or all (even if Medicaid is the secondary coverage), if you have any out-of-pocket costs for the service, and how much. And then use the drop down box to tell us how often

3. Do you pay a premium (or have $ deducted from your pay) for your child to be on your private health insurance?

4. If yes, how much do you pay for your child's coverage? (Remember, health insurance premiums can include the cost for the employee, the husband or wife and the child or children. If you don't know exactly, an estimate is fine.)

5. Does your child receive services from Birth to 3 Early Intervention?

6. Does your child receive special education services under an IEP?

7. If yes, did the School District ask you

8. Does your child receive services through any of these waivers?

9. Please tell us a little about your familyCounting the child you told us about, siblings and the parents who live with the child, how many people are in your family?

10. What is the family's annual income?

Does your income change from month to month?

Is there anything else you'd like to tell us? (For instance, that you have substantial out of pocket costs that are not reflected in the available answers, that you rely on family members to provide care, etc.)

CYSHCN
Exit this survey

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1. My child's diagnosis is

9. Please tell us a little about your family

Counting the child you told us about, siblings and the parents who live with the child, how many people are in your family?