Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 635 - FAMILY PLANNING SERVICES CODE › Appendix C - Family Planning Services Application Packet

Current through Register Vol. 48, No. 28, July 12, 2024
Checklist for Completing the FY90
Family Planning Services Application
Check ( ) the following item for completeness before submitting
				your application for processing. Each must be addressed, filled in or attached
				as indicated.
CHECKLIST MUST BE SUBMITTED WITH APPLICATION.
Cover Sheet Attachment A
Complete Sections
2
Applicant Organization
___________
3
Applicant Certification
___________
4
Type of Organization
___________
5
Grant Support Requested
___________
6
Type of Application
___________
7
Legislative District
___________
8
Date of Submission
Health Care Plan
#10 complete narrative
___________
#11 define target area
___________
#12 list clinic(s) names(s) and days/hours
						  of operation
___________
#13 complete budget in accordance with the
						  attached budget and expenditures category definitions
___________
Checklist - FY 90
#14 complete cost analysis by IDPH
						  methodology
___________
Between Page 5 & 6 attach schedule of
						  discounts and sliding fee scale with charges based upon 1989 Poverty
						  Guidelines.
___________
#15 complete
three (3)
objectives
___________
Complete attached Plans to Achieve
						  Objective/Program Progress Report Forms
three (3)
___________
Attachment A
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
535 WEST JEFFERSON STREET
SPRINGFIELD, ILLINOIS 62761
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
				GRANT
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Illinois Department of Public Health
Division of Family Health
Budget Category Definitions
Personal Services
"The item personal services', means the reward or recompense
				made for personal services rendered by an employee of the delegate agency in
				support of this project, or any amount required or authorized to be deducted
				from the salary of any such person or any retirement or tax law, or both, or
				deductions from the salary of any such person under the Social Security
				Enabling Act, or deductions from the salary of such person. Any employee is
				anyone who receives the fringe benefits offered by the delegate agency.
Contractual Services
"The item contractual services', means and includes: (a)
				Expenditures, incident to the current conduct and operation of an office,
				department, or agency in direct support of this project for postage and postal
				charges, telephone expenses, printing, office conveniences and services,
				exclusive of supplies as herein defined: (b) Expenditures of $5,000 or less for
				repair or maintenance of property or equipment, utility services, professional
				or technical services; (c) Expenditures pursuant to multi-year lease,
				lease-purchase or installment purchase contracts for duplicating equipment
				authorized by the contract."
Travel
"The item travel', shall include any expenditure directly
				incident to official travel by employees of the project, involving
				reimbursement to travelers or direct payment to private agencies providing
				transportation or related services."
Supplies
"The item supplies' means and includes expenditures in
				connection with current operation and maintenance for the purchase of articles
				of a consumable nature which show a material change or appreciable depreciation
				with first usage, repair parts, and including tools and equipment having a unit
				value not in any instance exceeding $50, but does not include any expenditure
				for library books or expenditure included in 'permanent improvements'."
Equipment
(purchase exceeding $100)
"The item equipment', shall mean and include all expenditures
				for library books, and expenditures, having a unit value exceeding $100, for
				the acquisition, replacement or increase of visible tangible personal property
				of a non-consumable nature."
Patient Care
"The item patient care' means services necessary for the care
				of patients that the delegate can not provide other than by an outside vendor.
				This includes medical and social service contracts.
IDPH (1987)
Illinois Department of Public Health
Division of Family Health
Expenditures per Category
Listed below are examples of the most common charges shown
				under their appropriate category. If you have any other type of expense, please
				do not hesitate to call for assistance in placing it in the correct
				category.
I. Personal Services
1. Fringe benefits
2. Salaries
II. Contractual Services
1. Advertising costs
2. Building and ground maintenance
3. Conference and registration fees
4. Contractual employees
5. Copy machine rental
6. Insurance (building, fire, theft and
				malpractice)
7. Legal services and accounting fees
8. Postage (including stamps)
9. Printing
10. Rent or lease of space of property
11. Repair and maintenance of furniture and
				equipment
12. Statistical and tabulation services (data
				processing)
13. Subscriptions
14. Telephone
15. Utility cost
III. Supplies
1. Contraceptives
2. Educational and instructional materials
3. Medical supplies
4. Office supplies
5. Pamphlets
IV Travel
1. Lodging
2. Per diem
3. Travel expense (mileage, train, or air
				fare)
V Patient Care
1. Lab Work
2. Nurse practitioner for patient care (contracted
				out)
3. Physicians for patient care (contracted
				out)
VI Equipment
1. All equipment that is purchased
IDPH (1987)
Agency Name ___________________
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT
						  (continued)
DATE FROM:
THROUGH
14. COST ANALYSIS AND FEES
INSTRUCTIONS: Complete the cost analysis
						  following the cost analysis manual instructions. Attach a copy of your agency's
						  Schedule of Discounts and sliding fee schedule with charges based upon the 1990
						  federal poverty guidelines.
(a)
Service/Procedure
(b)
Serv. Util.
(c)
RVS
(d)
Total Serv. Units
(e)
Total Cost/Cost Ctr.
(f)
Avg. Cost/Serv. Unit
(g)
Cost/Serv.
(h)
Fee
Medical Cost Center
Minimal
5.00
/////////////////////////////////
Brief/Intermediate
18.00
/////////////////////////////////
Extended
30.00
/////////////////////////////////
IUD Insertion
30.00
/////////////////////////////////
Diaphragm Fit
15.00
/////////////////////////////////
Sonography
30.00
/////////////////////////////////
X-ray/Lost IUD
24.00
/////////////////////////////////
TOTAL
/////////////////
/////////
/////////////////////////////////
//////////////////
///////
Laboratory Cost Ctr.
HGB/HCT
3.00
/////////////////////////////////
U/A
4.00
/////////////////////////////////
Pregnancy Test
10.00
/////////////////////////////////
VDRL
6.00
/////////////////////////////////
Pap Smear
8.00
/////////////////////////////////
Gonococcal
6.00
/////////////////////////////////
Misc. Culture
6.00
/////////////////////////////////
Bact.Sm./Wet Mount
5.00
/////////////////////////////////
Sickle Cell
5.00
/////////////////////////////////
PP Blood Gluc.
6.00
/////////////////////////////////
Cholesterol Level
6.00
/////////////////////////////////
SMA-12
16.00
/////////////////////////////////
Colposcopy
30.00
/////////////////////////////////
Colp./Biopsy
40.00
/////////////////////////////////
Chlamydia Test
7.00
/////////////////////////////////
TOTAL
/////////////////
/////////
/////////////////////////////////
//////////////////
///////
Pharmacy Cost Ctr.
Orals
1.20
/////////////////////////////////
Creams
2.65
/////////////////////////////////
Jellies
2.65
/////////////////////////////////
Suppositories (ea.)
0.15
/////////////////////////////////
Foams
3.00
/////////////////////////////////
Diaphrams
4.00
/////////////////////////////////
IUD's
50.00
/////////////////////////////////
Basal T&C
10.00
/////////////////////////////////
Sponges (ea.)
1.50
/////////////////////////////////
Condoms (ea.)
0.22
/////////////////////////////////
Meds/Vag.Inf.
5.00
/////////////////////////////////
Meds/STD
5.00
/////////////////////////////////
Contracep Film
2.00
/////////////////////////////////
TOTAL
/////////////////
/////////
/////////////////////////////////
//////////////////
///////
Ed./Couns. Cost Ctr.
1 hr. Indepth
30.00
/////////////////////////////////
Couns./15min.-1hr.
5.50
/////////////////////////////////
TOTAL
/////////////////
/////////
/////////////////////////////////
//////////////////
///////
-5-
3/89
Date Cost Analysis Completed
						  ___________________________
BCRR DATA FROM CY 1989
ATTACH SCHEDULE OF DISCOUNTS AND SLIDING FEE
				SCALE WITH CHARGES UTILIZED BY YOUR AGENCY BASED UPON 1990 REVISED POVERTY
				GUIDELINES
Agency Name _______________
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT
						  (cont'd.) DATE FROM: THROUGH
15. OBJECTIVES INSTRUCTIONS: Complete the objectives
						  below by inserting the numbers that are
appropriate for your agency. Agencies must
						  complete objectives #1 and #2 by inserting the numbers that are appropriate for
						  their agency. #3
must be an individual agency objective
. Also
						  complete the attached Plans to Achieve Objectives/Program Progress Report forms
						  using these numbers and listing the tasks necessary to meet the
						  objectives.
1. Provide family planning services to
						  _____________unduplicated users in need of subsidized
#
family planning services during State Fiscal Year 1991.
						  At least 85% of users will be in the group with income equal to or less than
						  150% of poverty; ________% of all users will be teenagers.
#
2. Provide________ information and education programs
						  for an estimated__________ individuals
#
#
in communities served during State Fiscal Year
						  19___.
3.
Individual Agency Objective
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Illinois Department of Public
						  Health
Attachment A
ILLINOIS FAMILY PLANNING RATE
						  SCHEDULE
Effective July 1, 1990
SERVICE
RATE
SERVICE
RATE
BILLABLE MEDICAL SERVICES
CONTRACEPTIVE DRUGS & SUPPLIES
Minimal Service Exam
5.50
Oral Contraceptives
1.50/cycle
Brief/Intermediate Exam
12.65
Creams
2.00/tube
Extended Exam
26.65
Jellies
1.30 /tube
(Includes $3.50 for provision
Suppositories
.25 each
of basic AIDS education)
Foams
2.00/can
Intrauterine Device Insertion
35.30
Diaphragms
4.50 each
Diaphragm Fit
23.15
Intrauterine Device
84.00 each
Cervical Cap Fit
23.15
Basal Thermometer & Charts
15.00
Sponges
.50 each
Condoms
.15 each
Vag/STD Rx
5.00/medication
Contraceptive Film
2.00/pkg.
Cervical Cap
29.95 each
LABORATORY PROCEDURES
STERILIZATION
Hematocrit
3.30
Pre-Counseling
30.00
Hemoglobin
3.30
Female Sterilization
Urinalysis/Dipstick
3.30
(Reimbursement only with prior
Pregnancy Test
8.90
approval from IDPH)
Papanicolaou Smear
8.63
Male Sterilization
Wet Mount/Gram Stain
4.40
(Reimbursement only with prior
Miscellaneous Culture
5.75
approval from IDPH)
Sickle Cell Screening
5.75
Post-prandial Blood Glucose
5.75
Cholesterol Level
6.80
SMA-12 Fasting Level
16.45
Colposcopy
29.75
Colposcopy with Biopsy
39.90
Chlamydia Test
6.50
COMPLICATIONS
BILLABLE COUNSELING
X-rays/Lost IUD
36.40
Indepth/1 Hr.
30.00
Sonography/Lost IUD
60.65
Education/Counseling
5.50
(15 min - 1 hr.)
Poverty Level
Reimbursement
0 - 100%
Full rate + 25%
101 - 150%
85% of full rate + 15%
151 - 200%
One-third of full rate + 15%
201 - 250%
15% only based on one-third rate
Medicaid
25% of full rate
251 - Above
No reimbursement
3947f
4 / 89
Illinois Department of Public Health Family
				Planning Service Definitions
Billable Medical Services
Reimbursement will be provided for the services and procedures
				in this section when prescribed, furnished, directed or supervised by a
				physician. These services are exclusive of laboratory procedures; treatment of
				complications; billable counseling; and provision of contraceptive drugs,
				supplies and devices.
1. Family Planning Minimal (Service) Examination -
				Examination accompanying routine medical revisits to an established client. May
				include IUD check, diaphragm placement check, visualization of vagina and
				cervix, possible palpation, weight and blood pressure.
2. Family Planning Brief/Intermediate Examination -
				Usual examination accompanying problem medical revisits which require a
				physical examination. Services vary and may include pregnancy diagnosis,
				vaginal infection, PID, possible IUD complications, follow up on a breast lump
				or suspicious PAP.
3. Family Planning Extended Examinations - Family
				planning examinations usually accompanying an initial and annual visit.
				Examination includes a complete physical including recto-vaginal examination,
				breast examination, weight and blood pressure.
4. Insertion of IUD - Placement into the uterus (by
				either the push or withdrawal technique) of an FDA approved contraceptive
				device following the sounding of the uterus.
5. Diaphragm Fitting - Selection of appropriate size
				diaphragm based on depth of the vagina and perineal muscle tone.
Laboratory Procedures - The following routine and special
				laboratory services are reimbursable in connection with the physical
				examination and evaluation or if needed as a result of positive history or if
				deemed medically necessary at the time of examination by the attending
				physician or medical director in charge.
1. Hematocrit/Hemoglobin
2. Urinalysis/Dipstick
3. Pregnancy Test
4. Papanicolaou Smear
5. Wet Mount/Gram Stain - (e.g., Trichomoniasis,
				Candidiasis, Gardnerella)
6. Miscellaneous Culture - (e.g. Herpes,
				Urine)
7. Sickle Cell Screening
8. Post-Prandial Blood Glucose
9. Triglycerides Fasting Level Confirmation
				Test
10. SMA-12
11. Colposcopy - Examination of vagina and cervix by
				means of the colposcope.
12. Colposcopy with Biopsy - Examination of vagina
				and cervix by means of the colposcope with removal and examination of
				tissue.
13. Chlamydia Test - Direct smear FA and enzyme
				immunoassay (ELISA)
Complications - Occasionally, complications may develop. Such
				services related to complications will be limited to the following.
1. Sonography/Lost IUD - A record or display
				obtained by ultrasonic scanning for purpose of locating IUD.
2. X-Ray & Interpretation - Up to two x-rays for
				the purpose of determining location of IUD.
Billable Counseling
1. Indepth/1 Hr. Counseling - Counseling designed to
				assist the individual client in understanding and successfully dealing with an
				identified problem. Such counseling may be related to the emotional aspects of
				a medical problem or may involve health education. This service should be
				completed by professional staff such as the public health nurse, health
				educator or social worker. Such counseling may require only one session or may
				involve multiple sessions to insure that the client has developed sufficient
				insight to deal with the related issues. This is not to be understood as a
				patient education session associated with a medical visit. The time expectation
				for delivery of this service is approximately 1 hour.
2. Education/counseling (15 minute to 1 hour) -
				Education or counseling services related to the effective utilization of a
				family planning method and documented in the patient file. Time expectation for
				delivery of this service is approximately 15 minutes.
Contraceptive Supplies and Drugs - Reimbursement
				will be made for the following:
1. Oral Contraceptives
2. Creams
3. Jellies
4. Suppositories
5. Foams
6. Diaphragms
7. IUDs
8. Basal Thermometer & Charts
9. Sponges
10. Condoms
11. Vag/STD Rx
12. Contraceptive Film
Sterilization - The following will be provided under the family
				planning program if sterilization is medically indicated and IDPH gives prior
				approval.
1. Pre-Counseling
2. Female Sterilization
3. Male Sterilization
4. Anesthesia
5. Pathology