Section 140.487  Healthy Kids Program Timeliness Standards

These timeliness standards for required Healthy Kids services or activities apply regardless of the source from which medical or dental care is provided.

a)         Activity 1:  Informing Eligible Families

1)         Description:

The Department shall inform eligible families in writing about the Healthy Kids Program, including:  the importance of preventive health care; the services which are available; how to request assistance in identifying a willing and qualified provider or how to request assistance in obtaining transportation to and from health care appointments; and that the services are available at no cost to an eligible recipient, except as may be limited by a spenddown requirement.

2)         Timeliness Standards:

A)        At the time of application for public assistance, the applicant will be informed orally by the intake worker and in writing.

B)        An applicant determined to be eligible for benefits shall be informed by mail within sixty (60) calendar days of the date of the determination of eligibility for Medicaid services.

C)        All eligible persons shall be informed annually by mail.

b)         Activity 2:  Notification of a Scheduled Health, Vision, Hearing and Dental Screening Periods

1)         Description:

Eligible persons shall be notified in writing of scheduled health, vision, hearing and dental screening periods.

2)         Timeliness Standard:

The child or the caretaker relative (89 Ill. Adm. Code 101.20) shall receive notification of the next scheduled health, vision, hearing and dental screening periods not less than 10 working days before the date on which the screening period begins as determined by the child's birthday, the Periodicity Schedule and the most recent date of the child's eligibility for services.

c)         Activity 3:  Administration of a Health, Vision, Hearing, or Dental Screening

1)         Description:

A health, vision, hearing or dental screening shall be performed by a provider who is enrolled with the Illinois Medical Assistance Program.

2)         Timeliness Standard:

A health, vision, hearing or dental screening shall occur, to the extent possible, during the next scheduled screening period as determined by the child's birthday, the most recent date of the child's eligibility and the periodicity schedules for screenings.

d)         Activity 4:  Diagnosis

1)         Description:

Diagnosis is the provider's assessment of a child's current state of health or disease.

2)         Timeliness Standards:

A)        The diagnosis shall be made at the conclusion of the screening, except that the diagnosis may be deferred until the provider receives the results of laboratory tests when such tests are required to establish the diagnosis.

B)        The provider shall orally inform the adult responsible for the child of the diagnosis immediately or within 24 hours, unless prohibited by confidentiality rules.  In such cases, the provider shall inform the child of the diagnosis within 24 hours and inform the responsible adult only with the child's written consent.

C)        If the provider suspects that a child has been abused or neglected as defined in the Abused and Neglected Child Reporting Act (Ill. Rev. Stat. 1989, ch. 23, pars. 2051 thru 2061.7), the provider shall immediately make a report to the Illinois Department of Children and Family Services.

e)         Activity 5:  Referral for Treatment

1)         Description:

When a provider determines that a child is in need of treatment for a condition discovered or determined to have increased in severity during a screening, the provider shall arrange to provide the needed treatment directly or shall refer the client for treatment.  Referral for treatment shall include one or more of the following actions:  informing the client (or client's caretaker) of the type of provider from whom treatment should be sought; or providing the client (or client's caretaker) with the name and address of a provider qualified to provide the needed treatment; or making an appointment for the client with a provider qualified to provide the needed treatment.

2)         Upon request of an eligible person or notification by a qualified provider of an eligible person's need for referral assistance as the result of a screening, the Department shall refer the eligible person to a willing and qualified provider for treatment of a diagnosed or suspected condition, whether or not the treatment needed is a covered service.  The eligible person shall be consulted about the referral, except when such consultation may jeopardize the health and safety of the child (e.g., cases of suspected child abuse or neglect).  In making the referral, the Department shall first consider referral of the eligible person to other Federal and State-funded programs (e.g., services to crippled children and alcohol/drug abuse intervention) when such programs may be capable of treating or arranging treatment for the condition.

3)         Timeliness Standard:

Referral, as defined above, shall be made within thirty (30) days of the request or identification of need, except that such referral shall be made immediately when the child is in imminent danger.

f)         Activity 6:  Treatment

1)         Description:

Treatment is the provision of health care needed to correct or ameliorate defects and physical and mental illnesses and conditions discovered or determined to have increased in severity by a qualified provider as the result of a screening.

2)         Timeliness Standard:

Treatment consistent with recognized standards of medical or dental practice shall begin no more than sixty (60) days after the diagnosis of the child's condition, unless medically contraindicated, except that treatment shall begin sooner when the diagnosed condition requires it.

g)         Activity 7:  Scheduling and Transportation Assistance

1)         Description:

Upon oral or written request of a recipient, the Department shall provide assistance to identify a provider, to schedule an appointment with a provider or to arrange transportation to and from the source of medical or dental care.

2)         Timeliness Standards:

A)        The Department shall determine the recipient's need for the requested assistance within ten (10) working days of the request.

B)        The Department shall arrange or provide the needed assistance in time to assure that the recipient receives services within the periodicity schedule or the treatment timeliness standard (Section 140.488).

h)         Activity 8:  Coordination with the Women, Infant and Children (WIC) Special Supplemental Food Program

1)         Description:

The Department shall inform Medicaid-eligible pregnant women, postpartum women during the six (6) months after termination of their pregnancy, women up to one (1) year postpartum who are breastfeeding their infants and children below the age of five (5) years in writing of the availability of WIC Program benefits and procedures for accessing WIC services.

2)         Timeliness Standards

A)        The Department shall in writing inform individuals found eligible for Medicaid services and who are also eligible for WIC Program services of the availability of WIC Program benefits and procedures for accessing such services within sixty (60) days of such persons being determined eligible for Medicaid services.

B)        The Department shall also annually notify such persons in writing of the availability of WIC Program benefits and procedures for accessing such services.

(Source:  Amended at 15 Ill. Reg. 298, effective December 28, 1990)