Maternal and Child Health Provider Participation Requirements

Section 140 Section 140.924  Maternal and Child Health Provider Participation Requirements a)         Primary Care Providers 1)         Basic Requirements Maternal and Child Health primary care providers may include physicians, Advanced Practice Registered Nurses meeting all requirements set forth in Section 140.435, Federally Qualified Health Centers (FQHCs), hospital clinics per Section 140.461(f) and encounter rate clinics per Section 140.461(b).  Maternal and Child Health providers shall meet the qualifications (see Section 140.12) as are applicable for all medical providers under the Illinois Medical Assistance Program and, with the exception of APRNs, shall meet all of the following requirements: A)        maintain hospital admitting privileges; B)        maintain delivery privileges if providing care to pregnant women; C)        be enrolled and in good standing with the Medical Assistance Program; and D)        complete a Maternal and Child Health Primary Care Provider Agreement, or have been enrolled as a provider under the Healthy Moms/Healthy Kids Program, in which they agree to: i)          provide periodic health screening (EPSDT), including age appropriate immunizations, and primary pediatric care as needed for children served in their practice, consistent with guidelines published by the American Academy of Pediatrics or American Academy of Family Physicians; ii)         provide obstetrical care and delivery services as appropriate for pregnant women served through their practice, consistent with guidelines published by the American College of Obstetricians and Gynecologists or the American Academy of Family Physicians; iii)        provide risk assessments for pregnant women and/or children; iv)        provide medical care coordination, including arranging for diagnostic consultation and specialty care; v)         communicate with the case management entity; vi)        maintain 24-hour telephone coverage for assessment and consultation; and vii)       provide equal access to quality medical care for assigned clients. AGENCY NOTE:  FQHCs are federally exempt from subsections (a)(1)(A) and (B). 2)         Advanced Practice Registered Nurse Requirements A)        The requirements described in subsections (a)(1)(A) and (B) of this Section apply to the physician or practitioner with whom the APRN has a collaborative or written practice agreement. B)        The requirements described in subsections (a)(1)(C) and (D) of this Section apply to the enrolled APRN. 3)         Special Requirements In addition to the basic requirements described in subsection (a)(1), encounter rate clinics as Maternal and Child Health providers shall be required to meet the following additional requirements: A)        Meet the qualifications for an encounter rate clinic, as described in Section 140.461(b); and B)        Be owned, operated, managed, or staffed by a hospital that also operates a Maternal and Child Health clinic, as described in Section 140.461(f), or be located in a county with a population exceeding 3,000,000 that is part of an organized clinic system consisting of 15 or more individual practice locations, of which at least 12 are Federally Qualified Health Centers, as defined in Section 140.461(d). 4)         The Department will consider requests from physicians who are unable to meet the hospital admitting privileges criteria for enrollment in the Maternal and Child Health Program if the physician has executed a formal agreement with another physician to accept referrals for hospital admissions.  Requests will also be considered from physicians who do not have delivery privileges but wish to provide obstetrical care.  The request will be reviewed by the Department or its designee to determine whether the physician should be enrolled as a PCP into the Program.  At the discretion of the Department or its designee, the requesting physician may be asked to appear for an interview and/or an on-site visit may be made by the Department or its designee.  For consideration to be given, the requesting physician must submit the following information and supporting documentation in a format specified by the Department or its designee that provides the following: A)        Complete name, mailing address, Illinois practice license number and Medicaid provider number, if any; B)        Declared practice specialty; C)        Listing of all practice locations; D)        Name and location of hospitals applied to for admitting privileges; E)        Status of each request, i.e., pending or closed (if closed, a reason must be given by the hospital for not granting privileges); F)         If application has never been made, a statement explaining why; G)        Name of physician with whom a formal agreement has been effected; H)        Illinois license number of Medicaid enrolled physician with hospital admitting privileges and name of hospitals where admitting privileges are in effect; and I)         Copy of formal agreement. 5)         The request is to be dated by the provider and forwarded to the Department of Healthcare and Family Services, Provider Participation Unit, P.O. Box 19114, Springfield, Illinois 62794-9114. b)         Case Management Providers Case management providers' qualifications shall be in accordance with 77 Ill. Adm. Code 630.  Case management will be provided to ensure access to medical care and better compliance with medical recommendations.