Fillable Hiv-affinity-group-interest-form HIV Health Improvement Affinity Group: Expression of Interest Form

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Hiv-affinity-group-interest-form HIV Health Improvement Affinity Group: Expression of Interest Form

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HIV Health Improvement Affinity Group
Expression of Interest Form
State:
The HIV Health Improvement Affinity Group aims to improve health outcomes—including rates of sustained virologic
suppression--among Medicaid and CHIP beneficiaries living with HIV. To accomplish these goals, the group supports state
collaborations between public health and Medicaid programs to improve the availability, accessibility, and quality of HIV
prevention and care services delivered to HIV-infected Medicaid and CHIP enrollees.
A. Your Project and Goals
1. The HIV Health Improvement Affinity Group will focus on improving health outcomes among Medicaid
and CHIP enrollees who are living with HIV in order to improve health and prevent transmission of HIV. Has
your state Medicaid program previously undertaken activities in this area or are you currently engaged in
related activities?
No, our state Medicaid program has not yet undertaken work to improve health outcomes among Medicaid
and CHIP enrollees living with HIV. (Note: Previous work in this area is not required to participate.)
Yes, our state Medicaid program has previously undertaken work to improve health outcomes among
Medicaid and CHIP enrollees living with HIV.
If yes, please describe your efforts in this area and indicate the extent to which state public health partners
(including HIV prevention and care programs) were involved as partners in this work
2. Briefly describe the project that will be the focus of your participation in this Affinity Group.
3. What results does your state hope to achieve by November 2017?
4. Has your state already started work on this project?
Yes No
If yes, what is the current status of the project?
5. Is there any specific technical assistance your state will need or barriers to your success that you anticipate?
If so, please describe.
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B. Your Team
6. Please identify the state Medicaid staff person who will serve as the point of contact for the team.
Name
Title
Medicaid Agency State
Phone Number
Email Address
7. Please identify team members and their roles within the state.
Name Title Agency
(Attach an additional list if necessary)
C. Leadership Expression of Support
8. Affinity Group state teams are expected to have the support of the Medicaid senior leadership AND the state
AIDS Director to demonstrate the state’s interest in achieving the project’s goals. Please indicate below the
names of the supporting officials.
Senior Medicaid Official
Name
Signature
Title
Agency
AIDS Director
Name
Signature
Title
Agency
Send completed Expression of Interest forms to MedicaidCHIPPrevention@cms.hhs.gov.
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Hiv-affinity-group-interest-form HIV Health Improvement Affinity Group: Expression of Interest Form

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Completed 24 January 2020

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