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. 12, March 22, 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.

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)

ATTACH SCHEDULE OF DISCOUNTS AND SLIDING FEE SCALE WITH CHARGES UTILIZED BY YOUR AGENCY BASED UPON 1990 REVISED POVERTY GUIDELINES

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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