77 Ill. Adm. Code 635.APPENDIX C
C Family Planning Services Application Packet
Section 635.APPENDIX C Family Planning Services
Application Packet
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
PROGRAM
TITLE:
Family Planning Services
BRIEF
SUMMARY:
To provide comprehensive
family planning services pursuant to the application and assurances
submitted
by the grantee. Such services will be delivered in accordance with the
Department's applicable rules
entitled
Title 77: Public Health, Chapter I: Department of Public Health, Sub
Chapter: Maternal and Child Health
Part
635 Program Content and Guidelines for Title X Family Planning Services
APPLICANT ORGANIZATION
:
4.
TYPE OF ORGANIZATION
:
N
AME:
LOCAL HEALTH DEPARTMENT
ADDRESS:
PRIVATE NON-PROFIT AGENCY
OTHER ___________________________
5.
GRANT SUPPORT REQUESTED
:
TELEPHONE:
(
)
BEGINNING
ENDING
AMOUNT
FEIN
NUMBER:
PROJECT
DIRECTOR:
6.
TYPE OF APPLICATION
:
INITIAL
CONTINUATION
REVISION
7.
LEGISLATIVE DISTRICT
FINANCE
OFFICER:
CONGRESSIONAL
LEGISLATIVE
(State Senate)
REPRESENTATIVE
APPLICANT CERTIFICATION
:
(State Representative)
To the best of my
knowledge, the data and
statements in this application
are true and
correct. The applicant
agrees to comply with
all State/Federal statutes
and Rules/Regulations
applicable to the program.
8.
DATE OF SUBMISSION
:
Month
Date
Year
AUTHORIZED OFFICIAL:
9.
IMPORTANT NOTICE
:
This state agency is
requesting disclosure of information that is necessary to accomplish the
statutory purpose as outlined under Illinois Revised Statutes, Ch. 127, Par.
137 et. seq. Failure to provide this information may prevent this form from
being processed. This form has been approved by the Forms Management Center.
Date
Signature
4/88
Agency Name
APPLICATION AND PLAN FOR
PUBLIC HEALTH PROGRAM GRANT (cont'd.)
DATE
FROM: THROUGH
10.
HEALTH CARE PLANS
INSTRUCTIONS:
Complete a narrative
summarizing the major features of the project including: 1. statement of
need, 2. characteristics of the target area including other Family Planning
Resources, 3. methods used to conduct program and 4. measure its success.
USE ADDITIONAL SHEETS IF
NECESSARY
3/89
Agency Name
APPLICATION AND PLAN FOR
PUBLIC HEALTH PROGRAM GRANT (cont'd.)
DATE
FROM: THROUGH
11.
GEOGRAPHIC SERVICE AREA
INSTRUCTIONS:
Define your target service
area by listing county(ies) or community(ies) served.
12.
CLINIC(S) SCHEDULE(S)
INSTRUCTIONS:
List all clinics by name,
address and days/hours of operation.
Clinic(s) Names(s)/Address(es)
Days/Hours of Operation
USE ADDITIONAL SHEETS IF
NECESSARY
3/89
Agency Name
APPLICATION AND PLAN FOR
PUBLIC HEALTH PROGRAM GRANT - (continued)
DATE
FROM: THROUGH
13.
BUDGET
INSTRUCTIONS:
All funds must be identified
and assigned to categories in accordance with the budget and expenditures
category definitions.
CATEGORY
Family Planning Award
Title XIX
Patient Fees
Other Funds
TOTAL
Budget
Budget
Budget
Budget
Budget
1.
Personal Services
2.
Contractual Services
3.
Supplies
4.
Travel
5.
Patient Care
6.
Equipment
*
7.
Total
*Details must be provided
below. Use additional sheets if necessary.
3/89
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 8270_______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
USE ADDITIONAL SHEETS IF
NECESSARY
3/89
FAMILY PLANNING SERVICES
PLANS TO ACHIEVE OBJECTIVES
PROGRAM PROGRESS REPORT
AgencyJune
2, 2025________________
Project Period
July 1, 1990 – June 30, 1991
Objective
#1
Provide family planning services 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.
S C H E D U L E
Tasks to Meet Objective
JUL
AUG
SEP
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
Status
of Task
FAMILY PLANNING SERVICES
PLANS TO ACHIEVE OBJECTIVES
PROGRAM PROGRESS REPORT
Agency____________________________
Project Period
July 1, 1990 – June 30, 1991
Objective
#2 Provide
Information and education programs for an estimated individuals in
communities
served during State Fiscal Year 1991.
S C H E D U L E
Tasks to Meet Objective
JUL
AUG
SEP
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
Status
of Task
FAMILY PLANNING SERVICES
PLANS TO ACHIEVE OBJECTIVES
PROGRAM PROGRESS REPORT
Agency____________________________
Project Period
July 1, 1990 – June 30, 1991
Objective
#3
S C H E D U L E
Tasks to Meet Objective
JUL
AUG
SEP
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
Status
of Task
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