Ill. Admin. Code tit. 89 § 140.485

Current through Register Vol. 48, No. 45, November 8, 2024

Section 140.485 - Healthy Kids Program

a) Program Description

1) The Healthy Kids Program is the Early and Periodic Screening, Diagnosis and Treatment Program mandated by the Social Security Act (see 42 USC 1396 a(43), 1396d(4)(B) (Supp. 1987)). The goals of the program are to:

A) improve the health status of Medicaid-eligible children ages birth through 20 years through the provision of preventive medical care and early diagnosis and treatment of conditions threatening the child's health;

B) reduce the long term costs of medical care to eligible children; and

C) effective for dates of service on or after July 1, 2014, comply with the evidence-based practices detailed in the American Academy of Pediatrics Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, Third Edition (2008), American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village IL 60007, http://brightfutures.aap.org.

2) The Department strives to achieve these goals by offering the following services at no cost to an eligible child, except as may be limited by a spend down requirement:

A) periodic and interperiodic health, vision, hearing and dental screening services to meet the health care needs of children (see Section 140.488(a) through (d));

B) immunizations against childhood diseases (see Section 140.488(e) );

C) diagnostic laboratory procedures as described in Section 140.488(f);

D) further diagnosis or treatment necessary to correct or ameliorate defects and physical or mental illnesses or conditions which are discovered or determined to have increased in severity by a provider as the result of a periodic or interperiodic health, vision, hearing or dental screening;

E) effective for dates of service on or after July 1, 2014, referral for dental care beginning at age one; and

F) assistance in locating a provider, scheduling an appointment and in arranging transportation to and from the source of medical care.

3) The Department also strives to protect each eligible person's right to freedom of choice regarding participation and selection of a health care provider and the right to continuity of care.

b) Eligibility. Services are available to those persons listed in Section 140.3, except that those persons must be under 21 years of age at the time of receiving the services.

c) Provider Participation. Providers of Healthy Kids services must be duly licensed or certified according to applicable federal or State law or rule and be enrolled in the Illinois Medical Assistance Program to provide one or more Healthy Kids Program services as authorized in Title XIX of the Social Security Act and the Illinois Medical Assistance Program State Plan (as set forth in Sections 140.11 through 140.835 ).

d) Program Activities and Services

1) Informing Clients. The Department shall inform eligible persons in writing about the benefits of preventive health care, the services which are available, and procedures by that eligible persons may request and receive assistance in identifying an enrolled provider, scheduling an appointment or arranging transportation to and from the source of medical care. Effective July 1, 1990, the Department shall also notify Medicaid-eligible pregnant women, postpartum women during the six months after termination of pregnancy, women up to one year postpartum who are breastfeeding their infants or children below the age of five years of their potential eligibility for receiving services through the Special Supplemental Food Program for Women, Infants and Children which is administered by the Illinois Department of Public Health (IDPH). The informing of eligible persons shall be done as described in the timeliness standards contained in Section 140.487.

2) Periodic Medical Screenings. The Department will pay for a series of periodic medical screenings scheduled from a person's birth through age 20. The periodicity schedule of screenings is contained in Section 140.488. The Department will pay for additional health screenings when necessary for:

A) enrollment in school;

B) enrollment in a licensed day care program, including Headstart;

C) placement in a licensed child welfare facility, including a foster home, group home or child care institution;

D) attendance at a camping program;

E) participation in an organized athletic program;

F) enrollment in an early childhood education program recognized by the Illinois State Board of Education;

G) participation in a Women, Infant and Children (WIC) program; or

H) is requested by a child's parent, guardian or custodian, or is determined to be necessary by social services, developmental, health, or educational personnel.

3) Dental Screenings

Effective for dates of service on or after July 1, 2014:

A) A dental screening shall be included as part of the well child visit at the appropriate intervals.

B) A physician shall refer children to a dentist for routine and periodic preventive dental care within six months after the eruption of the first tooth or by age one.

C) The periodicity schedule for dental screening services is contained in Section 140.488. The Department will pay for one dental screening per age period unless a second screening is medically necessary.

4) Vision Screening

A) The Department will pay for vision screening services and diagnosis and treatment for defects in vision, including glasses.

B) The periodicity schedule for vision screenings is contained in Section 140.488. The Department will pay for one vision screening per age period, except when a second screening is determined to be medically necessary.

5) Hearing Screening. The Department will pay for hearing screenings and diagnosis and treatment for defects in hearing, including hearing aids. The periodicity schedule for hearing screenings is contained in Section 140.488. The Department will pay for one hearing screening per age period, except when a second screening is determined to be medically necessary.

6) Immunizations. The Department will pay for the immunization of eligible children against childhood diseases. The list of covered immunizations is contained in Section 140.488(b).

7) Diagnostic Procedures

A) Lead Screening

i) The Department requires that lead screening shall be performed in compliance with the Lead Poisoning Prevention Act [410 ILCS 45 ]. Children between the ages of six months to six years should be screened for lead poisoning at priority intervals. Screenings and medical follow up shall be performed in accordance with the "Guidelines for the Detection and Management of Lead Poisoning for Physicians and Health Care Providers", published by the Illinois Department of Public Health. These guidelines recommend that those children at highest risk be screened on a regular basis. High risk environmental situations include housing built before 1978, housing that is being renovated or remodeled, or that is in deteriorating condition. Children six years and older shall also be screened, when medically indicated or appropriate.

ii) The Department will pay for lead screening as indicated in subsection (d)(7)(A)(i) or as required for admission by a day care center, day care home, preschool, nursery school, kindergarten, or other child care facility or educational facility licensed by the State.

iii) The Department will pay for epidemiological study of the child's living environment when the child has been diagnosed as having an elevated blood lead level for the purpose of identifying the source of lead exposure.

B) The Department will pay for the administration of all other medically necessary diagnostic procedures performed during or as the result of medical screenings.

8) Treatment. The Department shall pay for necessary medical care (see Section 140.2 ), diagnostic services, treatment or other measures medically necessary (e.g., medical equipment and supplies) to correct or ameliorate defects, and physical and mental illnesses and conditions which are discovered or determined to have increased in severity by medical, vision, hearing or dental screening services.

9) Assistance Services. The Department shall, upon request, provide assistance to eligible children and their parent, guardian or custodian to locate a provider, schedule an appointment or arrange transportation to and from the source of medical care.

10) Timeliness Standards. The timeliness standards in Section 140.487 will govern the completion of required activities and services.

e) Reimbursement to Providers

1) Fee-for-service. Provider's enrolled in the Maternal and Child Health Program, as described in Subpart G, will receive enhanced rates for certain services, as described in Section 140.930(a)(1). Payment will be made at the provider's usual and customary charges or the established Department rates (see Section 140.400) , whichever is less, for providers not enrolled in the Maternal and Child Health Program. Reimbursement for the administration of immunizations to an eligible person will be made at rates established by the Department. The provider will receive replacement vaccines as explained in subsection (e)(3).

2) Claims. Claims for reimbursement shall be submitted on the form and in a manner specified by the Department.

3) Vaccine Replacement Program. When a provider administers an immunization to an eligible child, the vaccines are replaced to the provider through the Vaccine Replacement Program which is administered jointly by the Department and the IDPH. Providers must be annually certified for participation in the Vaccine Replacement Program by IDPH before receiving replacement vaccines. Information on the Vaccine Replacement Program and certification procedures (set forth at 42 CFR 51 b), may be obtained by contacting:

Immunization Vaccine Replacement Program

Illinois Department of Public Health

525 West Jefferson Street

Springfield, Illinois 62761

f) Limitations on Services. Services under the Healthy Kids Program shall only be available to persons in the age groups from birth through age 20. Coverage of and payments for services shall be consistent with the requirements of section 1905 of the Social Security Act ( 42 USC 1396 d) as it relates to the Early and Periodic Screening, Diagnosis and Treatment Program.

g) Record Requirements. The provider shall comply with record requirements as set forth in Section 140.28.

Ill. Admin. Code tit. 89, § 140.485

Amended at 20 Ill. Reg. 4345, effective March 4, 1996

Amended at 38 Ill. Reg. 23623, effective 12/2/2014