Please direct all program related information and questions to:

Glendean Sisk
401 South Clinton, 4th Floor
Chicago, IL  60607
Phone:  312-814-1354
Fax:  312-793-4666
Email:  Glendean.Sisk@illinois.gov

I. Introduction/Definition

The Family Case Management (FCM) Program provides outreach and coordination of medical health, oral health (dental) and social services for low-income families (below 200% of the federal poverty level) with a pregnant woman, infant, or child with special needs (medical, social, psychological, environmental).  The primary goals of the FCM Program are to decrease infant mortality, decrease very low birth rates, and assure access to medical and dental care to eligible families in the State of Illinois.  The services to be provided under Family Case Management will be identified and referred to by the following titles:

  1. Family Case Management - Downstate
  2. Family Case Management - Chicago
  3. HealthWorks - Medical Case Management for DCFS Wards - Downstate
  4. HealthWorks - Medical Case Management for DCFS Wards - Chicago and Cook County
  5. Family Case Management - For High Risk Clients
  6. Family Case management - Cermak Health Services

The Provider will receive notice from the Department under separate letter, specifying which of the service types listed above are to be provided under this contract.

II. Policies & Procedures

All grantee agencies providing Family Case Management Services shall be bound by the Illinois Maternal and Child Health Service Code, 77 Ill. Adm. Code 630 as pertains to FCM (particularly section 630.220) and these service contracts.

III. Contract and Amendment Process

Contract Process

The contract between the Department and the Provider is generally referred to as the Agreement and consists of several parts:

  1. Community Service Agreement, containing the standard contract language used for all Department contracts
  2. Exhibit A, containing Scope of Services/Purpose of Grant
  3. Exhibit B, containing Deliverables
  4. Exhibit C, containing Payment Information
  5. Exhibit D, containing Contact Information
  6. Exhibit E, containing Performance Measures
  7. Exhibit F, containing Performance Standards
  8. Exhibit G, containing State Agency Contracts
  9. Attachment E
  10. The Program Manual, attached by reference to the Agreement, contains the program service provisions.

The Department will initiate the contract by having it online for the Provider to obtain and sign. The Provider will fax signature page to the Department to obtain the Secretary's signature and the Department will return a copy of the executed signature page of the contract to the Provider via pdf email.

Amendment Process

There are two types of amendments to an executed Community Service Agreement.

  1. Letters of increase or decrease - A letter is sent to the Provider from the Department stating the intent to increase or decrease dollars to specific program services existing in the Community Service Agreement. There is no need for the Provider to sign and return this document.
  2. Formal amendments A two-party signed agreement to an executed Agreement is a formal amendment. The following process is required for a formal amendment to be processed:
    1. Adding new program services - An amendment to add a new program service must contain a detailed summary of services to be provided under the executed Community Services Agreement and a method of payment.
    2. Extending the service dates of the Community Services Agreement* - An amendment to extend the service dates of the Community Services Agreement must contain the following information: Agreement number  as it appears on the original Community Services Agreement; Provider name; clause stating the new term of the Agreement; signatures of the Provider and the Secretary of the Department of Human Services.
      *NOTE: A Community Services Agreement end date should only be June 30 due to mandates in the State Finance Act regarding audit  period. Language on pages one through nine in the Community Services Agreement may not be changed.
    3. Extending the service dates of an existing program attachment - An amendment to extend the date of a specific attachment in the existing Community Services Agreement must contain the following information: Agreement number as it appears on the original Community Services Agreement; Provider name; clause stating the new term and the specific attachment name and number; signatures of the Provider and the Secretary of the Department of Human Services.
    4. Changing language within an existing program attachment - An amendment to change language in an existing program attachment of the Community Services Agreement must contain the following information:Agreement number as it appears on the Community Services Agreement; Provider name; clause(s) stating the new language; signatures of the Provider and the Secretary of the Department of Human Services.

IV. Deliverables/Costs/Payments

  1. Payments to the Provider will be made on a prospective basis, rounded to the nearest $100.00. The final prospective payment may be greater or lesser than the previous payments due to rounding.
  2. The Department will compare the amount of the prospective payments made to date with the documented services and expenditures provided to the Department by the Provider. In the event the documented services provided by the Provider do not justify the level of award being provided to the Provider, future payments may be withheld or reduced until such time as the services documentation provided by the Provider equals the amounts previously provided to the Provider. Failure of the Provider to provide timely documentation may result in a reduction to the total award.
  3. The final payment from the Department under this Agreement shall be made upon the Department's determination that all requirements under this Agreement have been completed, which determination shall not be unreasonably withheld. Such final payment will be subject to adjustment after the completion of a review of the Provider's records as provided in the agreement.

V. Provider Responsibilities

Family Case Management - Downstate

  1. Provision of Services
    The Provider will provide case management services to pregnant women, infants and high-risk children as described in the "Maternal and Child Health Services Code," 77.Ill. Adm. Code 630, as amended, which is hereby fully incorporated into this Agreement by reference and also 77 Ill. Adm. Code 630.40 for High Risk Follow-up.  The Provider shall provide services to clients who reside in the geographic area designated by the Department.  For Federally Qualified Health Centers (FQHC), the Provider shall provide case management services to families who reside outside the designated geographic area, if the Provider is providing medical care to the family.  In the geographic area with multiple providers, where a client transfer policy exists, the Providers agree to follow the "Client Transfer Policy".  The Provider shall fully comply with the requirements for certification as a case management agency pursuant to the Maternal and Child Health Services Code. The method to be used for computing the family's eligibility with regard to income is described in the Supplemental Nutrition Program for Women, Infants and Children (WIC) Policy and Procedure Manual.

    The Department will not pay for families enrolled with more than one Provider, except in special situations that require prior approval with the Department. 

    The Provider shall continuously employ at least one registered nurse for the purpose of appropriately assessing the medical risk of clients. 

    Children over the age of one who are not Illinois Department of Children and Family Services (DCFS) Wards or a referral from Adverse Pregnancy Outcome Reporting System (APORS) can only be served if the budget allows.

    1. Case Management (Medicaid Eligible): Case management services provided by the Provider to Medicaid eligible families and Provider identified high-risk Medicaid eligible "children families" shall be paid with Case Management funds. It is expressly understood that the purpose of Medicaid case management is to assist Medicaid enrolled pregnant women, infants and high-risk children in obtaining and complying with medical and dental care. If clients are enrolled with a managed care entity, the case management agency must notify the medical provider in writing the name of the case management agency, the name of the case manager, phone number and address
    2. Case Management (Medically indigent): Case management services provided by the Provider to families who are not eligible for Medicaid services shall be paid with Case Management funds. However, the Provider may elect to use Medically Indigent funds to provide services to Medicaid Eligible clients in the event the Provider serves more Medicaid Eligible clients than it has Medicaid funds to support.
    3. The Provider agrees to maintain certification with the Department as a case management agency in accordance with the requirements of the Maternal and Child Health services Code, as amended.
  2. System Support
    1. Primary Care: Family Case management funds may be used to pay for Primary Care, if there is no other source of payment.  The Provider will provide or arrange for comprehensive prenatal services to medically indigent non-Medicaid women and ambulatory primary health care services to medically indigent children (from birth through 18 years of age) in accordance with the  department's applicable rules in the Maternal and Child Health Services Code.  It is expected that all Medicaid eligible families are offered and provided assistance in applying for coverage.
    2. Outreach: The Provider will conduct outreach activities to potentially Medicaid eligible children or child health insurance eligible children and pregnant women, as defined in the Maternal and Child Health Services Code.
    3. Support Services: The Provider may provide support services to case management clients including, but not limited to: transportation, child care, and prenatal or parenting education programs. The support  services must contribute to the goals and objectives of the Provider's case management program.
    4. Maternal and Child Health Network Development: The Provider will work with the Department to develop a community-based system of preventive, primary and specialty care for women and children that is collaborative, family-centered, culturally competent, comprehensive, coordinated, universal, accessible, developmentally appropriate and accountable.
      1. System development activities could include community-based needs assessment and planning; collaboration with other service providers in the community for service development and integration; participating in Department-sponsored staff development and training activities; consultation with other Department Providers; or program evaluation efforts.
      2. The Provider shall work closely with primary care physicians and dentists and community agencies. Work with primary care physicians and dentists must be directed to increase access to primary health and dental care for eligible children, pregnant women and women of child-bearing age; to ensure these physicians and dentists agree to make referrals for specialty services as they deem appropriate; to increase physician participation in the Maternal and Child Health and Medicaid programs; and to maximize service coordination.
      3. Community agencies that may be included in system development activities are those agencies which provide services to women and children, including providers of specialized services to specific populations, such as services for substance abusing clients, early intervention services or services to children with special health care needs. In particular, this includes the Division of Specialized Care for Children of the University of Illinois; Local Interagency Councils for Early Intervention Services and early intervention service providers; and Child and Adolescent Local Area Networks.
      4. The Provider may use funds from this Agreement to hire an employee for the purpose of engaging in local Maternal and Child Health system development activities within the Provider's service area. The Provider hereby agrees to allow such staff to participate in Department sponsored Maternal and Child Health leadership development activities.
    5. Chicago area providers agree to follow the City of Chicago, County of Cook "Client Transfer Policy."
    6. All clients will be given "All Kids" information and will be given information about "All Kids" application agent closest to them.
    7. All clients will receive education materials about the importance of well-child visits and EPSDT services; to include but not be limited to, immunizations, dental/oral health, lead, etc.
    8. All Medicaid clients will receive information on the availability of free transportation assistance to and from medical care and how to access the transportation. A notice on "free of charge" transportation service assistance will be posted so all clients can view such information. All Providers will market the availability of these transportation services to Medicaid eligible clients by posting signage in client waiting rooms, clinic rooms, etc.
    9. All Medicaid eligible clients will receive copies of the Healthcare and Family Services DentaQuest packets, and Providers will make every effort to link clients with a dentist in their community. DentaQuest packets and other oral health materials can be ordered by contacting DentaQuest or Healthcare and Family Services dental program.
    10. In accordance with the PPMD Act, all women will receive information on post-partum mood disorders; and providers will provide screening and referral as appropriate.  DHS will provide a Post-Partum Depression Brochure to be given to clients.
    11. Licensed health care workers providing Family Case Management (FCM) prenatal care and postnatal care to woman shall screen new mothers for post-partum mood disorder symptoms at a prenatal check-up visit in the third trimester of pregnancy and at the initial postnatal check-up visit thereafter until the infant's first birthday or provide documentation that screening was completed by another licensed provider.

      FCM licensed health care workers providing pediatric care to an infant shall screen the infant's mother for postpartum mood disorder symptoms at any well-baby check-up at which the mother is present prior to the infant's first birthday in order to ensure that the health and well-being to the infant are not compromised by an undiagnosed postpartum mood disorder in the mother.

      FCM licensed health care workers providing prenatal and postnatal care to a woman shall include fathers and other family members, as appropriate; in both the education and treatment processes to help them better understand the nature and causes of postpartum mood disorders.

      All FCM licensed health care workers will provide perinatal depression educational materials to include but not be limited to at minimum the DHS Perinatal Depression Brochure which can be ordered from DHS at no charge to the provider.

      For purposes of the PPMD Act, screenings shall consist of the Edinburg Postnatal Depression Scale, which the new mother shall complete upon checking in for her appointment or the infant's appointment prior to being seen by the physician or other licensed health care worker.

    12. The provider must ensure the FCM Information System (Cornerstone) is fully operational and maintained per state standards.
  3. Risk Screening Tools
    Selected agencies may participate in a project for testing and evaluation of Risk Screening Tools and modification of service delivery requirements.  Criteria for selection and inclusion will be shared with all agencies by May 30th.  All new participating agencies must submit an agency workplan for review and approval by June 30th.  The plan will include a detailed description of how minimum program requirements will be met in the identified service delivery area.  Providers who continue in the project will be required to submit any changes to their workplan by June 15th of each year.  New participating agencies must participate in a mandatory training offered by the end of June.  Program monitoring will be conducted using a review tool developed for the project..
  4. Reports
    1. The Provider will collect the information specified in the Department's Cornerstone reporting system, and use this software package to record and submit to the Department information on case managed families, as well as the activity and expense information specified in the Maternal and Child Health Services Code.
    2. The Provider is responsible for accurate reporting by its employees of the case management activities performed under this Attachment. Each case manager or outreach worker will supply a record of client contacts in detail for the month, in accordance with the Maternal and Child Health Services Code and the Department's Cornerstone reporting system. The Provider agrees to be fully liable for the truth, accuracy and completeness of all reporting. Any submittal of false or fraudulent reports or any concealment of a material fact shall be cause for immediate termination and may be prosecuted under applicable federal and state laws.
    3. The Provider shall provide information specified by the Illinois Department of Healthcare and Family Services to the client's medical care provider or managed care entity to ensure care coordination.
  5. Case Management Time Studies
    1. During one time period of each quarter of the state fiscal year, the Provider shall perform a comprehensive daily time study of all activities. The time study period shall include at least one full pay period or ten consecutive working days, whichever is longer. The time study period for each quarter shall be selected randomly by HFS, who will notify DHS of the 10 day period.  DHS will then send notice out to Providers of the time study period in a Beginning-of-Day message as well as in email to program administrators and coordinators. Such information shall be submitted by the Provider through the Department's Cornerstone reporting system to the Department. This will require completing the Time and Activity Reporting Log; submitting the information specified by the Department; and complete staff and operating expenses in the data collection system. This information must be entered within 30 days after the close of the month in which the time study was conducted. Providers are encouraged to do continuous time studies.  Payments will be held if cost documentation has not been entered into Cornerstone.
    2. During the remainder of each quarter of each fiscal year, the Provider will record all case management encounters with assigned clients by completing the following items on the Time and Activity Reporting Log: 1) date; 2) activity code; 3) contact type; and 4) a contact site. 
    3. Should the Provider believe that one pay period does not accurately reflect the agency's case management activities, the study period may be extended at the Provider's discretion to include the entire month in which the time study period chosen by the Department occurs. 
    4. If directed to do so by the Centers for Medicare and Medicaid Services, the Department will require the Provider to extend the time study period. The Provider agrees to extend the time study period as directed by the Department.
  6. Quality Assurance
    1. The Provider shall maintain a quality assurance process and shall submit to the Department an updated Quality Assurance Plan or Integrated Plan for Maternal Child Health (MCH) Outcomes. This Quality Assurance Plan, or Integrated Plan for Maternal Child Health (MCH) Outcomes shall include a client satisfaction survey. The Quality Assurance Plan is due May 31, 2013.
    2. The Department, or its designee, will monitor the delivery of case management activities through site visits and review of the Department's Cornerstone reporting system data and other documentation as required by the Maternal and Child Health Services Code and this Attachment.
  7. Medicaid Enrolled Clients
    An enrollment list of Medicaid enrolled clients will be provided to the Provider by the Department each month. The Provider will contact and enroll in case management each client currently not being case managed.
  8. Performance Standards
    The Provider must meet the performance standards outlined in the Program Goals below and in the Contract Exhibit E: Performance Measures within the Community Service Agreement.
  9. Program Goals
    The Provider will work toward meeting the following program goals:
    1. Meeting 100% of assigned caseload.
    2. Comprehensive Needs Assessment and Case Management Care Plan: Ninety percent (90%) of all families enrolled in case management shall receive  comprehensive needs assessment and case management care plan within forty-five (45) calendar days of successful contact. This will include the 700, 701, 708 or 707D Cornerstone Assessments. 
    3. Home Visits: At least 75% of families enrolled in case management with one or more children under 12 months of age or a pregnant member shall receive home visits. Home visits will be conducted according to the requirements of the Maternal and Child Health Services Code. A case management home visit to any family member eligible for case management will satisfy the requirement for conducting a home visit to all family members. The 706 Assessment must be completed at the time of the visit.
    4. Face-to-Face Contacts and Referrals: Eighty percent (80%) of all families being case managed shall receive the required face to face contacts and appropriate referral. Referrals include WIC, prenatal or Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services (pediatric primary medical care), as identified in the Maternal and Child Health Services Code.
    5. Medical Care Coordination: Evidence of medical care coordination shall include the following performance standards: childhood immunizations - 90%; EPSDT participation at age one year of age - 80%; adequacy of prenatal care as measured by the Kessner Index and or Kotelchuck Index - 80%; linkage with a Primary Care Provider - 95%; EI referral (if applicable) -100%; and all referrals (specialty care, mental health, housing, etc.) as documented on the Cornerstone system referral screens (RFO1) shall be documented in Provider's electronic files.  The referral field is to be used to type in the reason for referral or to give the client written instructions, and to demonstrate that follow up has occurred.  Clients are to be given a copy of the referral.  The Provider will document the clients completion or failure to complete the referral in the comment section of the RF01 screen. 
    6. All infants (100%) in the FCM program are to receive an objective developmental screening (within the first 12 months of life) using an objective screening tool (i.e. Denver II, Ages & Stages).The Provider should make every effort to coordinate care with the Primary Care Provider, rather than to duplicate services.
  10. Measurement of Performance
    1. The performance of a needs assessment and development of an individualized care plan will be measured through the data reporting system during the scheduled review visit.
    2. The occurrence of home visits will be measured through Department's automated data reporting system. The content of home visits will be measured through annual electronic chart review during the scheduled review visit.
    3. The occurrence of face-to-face contacts will be measured through the Department's automated data reporting system.
    4. Medical Care Coordination will be measured during the scheduled review visit.
    5. Coordination with immunization, EPSDT, prenatal care, WIC and early intervention referral will be measured through agency reports from Cornerstone and performance review.
    6. Objective Developmental Screenings on site or by appropriate referral at least one first 12 months of life.  The occurrence of prenatal and postpartum depression screening will be measured through the Department's automated data reporting system.
  11. Penalties for Failure to Meet Performance Standards
    The Department may impose sanctions for lack of performance to include:
    1. The Provider will be placed on Provisional Certification (pursuant to the Maternal and Child Health Services Code) if the Provider fails to meet all standards as set forth in the Performance Standards presented above for three consecutive months. Provisional Certification can occur at any time during the full certification period if performance standards are not met.  The Provider may be placed on Provisional Certification if the standards set forth in the Maternal and Child Health Code are not met.
    2. If placed on Provisional Certification, the Provider must submit to the Department a written corrective action plan within thirty (30) calendar days of notification of the provisional certification.
    3. If placed on Provisional Certification, the Provider must: a) meet with the Department's Program Review Team and Program coordinator and review the correction action plan; b) submit quarterly reports to the Department on progress toward the corrective action; and c) agree to quarterly site visits by the Department Program staff for the purpose of tracking successful implementation of corrective action plan. If, in the opinion of the Department, sufficient progress is not made toward fulfilling the corrective action plan, monthly reports will be required.
    4. If the Provider fails to meet required standards or fails to submit or adequately perform a corrective action plan by the next scheduled annual site visit, the Provider may face loss of funds through termination for cause or non-renewal of this Agreement.
    5. If the Provider fails to achieve full Certification status for two consecutive certification periods, the Provider may face termination of this Agreement.

Family Case Management - Medical Case Management for DCFS Wards/Downstate

  1. DCFS Ward means a child under the legal care and custody of the Illinois Department of Children and Family Services (DCFS) and who is placed in substitute care. Medical case management refers to medically-related services provided by a person trained or experienced in medical or social services as described in 77 Ill.Adm.Code 630.220, as amended, unless otherwise specified below.
  2. Nothing in this Agreement, or contracts or agreements developed pursuant to this Agreement, shall be construed to identify the Illinois Department of Human Services or the Provider or any Subcontractor Agency as an agent of DCFS, or to assign DCFS responsibilities under the Consent Decree to the Department or the Provider or any Subcontractor Agency.
  3. The Provider will provide medical case management services to all DCFS Wards, birth through age five (5) years, and pregnant DCFS Wards and children of parenting DCFS Wards, residing in the Provider's service area. The Provider will obtain previous health care histories on each DCFS Ward in the care and custody of the Illinois Department of Children and Family Services at the time of the execution of this Agreement and are assigned to the Provider for medical case management services; ensure that DCFS Wards receive preventive health care services; ensure that DCFS Wards select a Primary Care Provider; develop health care plans for inclusion in each DCFS Ward's service plan; and ensure that follow-up health care services are received as medically appropriate.
  4. The Provider shall meet with the Lead Agency at least quarterly to monitor, review and discuss the provider's compliance with the performance standards specified on page 15 in DCFS HealthWorks Lead Agency Program Manual  HealthWorks of Illinois.
  5. The Provider shall follow the DCFS Statewide Medical Protocol for Drug Endangered Children (DEC) in illegal methamphetamine labs and the related outline for role and responsibilities of the HealthWorks Lead Agency and Medical Case Management Agencies. The DEC Protocol addresses the medical needs of the children living in homes where methamphetamine and/or illegal drugs are being manufactured.  This protocol is in conjunction with the Statewide Operational Agreement between DCFS and Illinois Law Enforcement agencies for responding to families involved in drug manufacturing where children are expected to be present or found in the home.
  6. Case Closure
    DCFS Wards assigned to the Provider must remain active cases while the DCFS Ward is in the care and custody of the Department of Children and Family Services and resides in the Provider's service area. Case management activities must be terminated when the DCFS Ward leaves the care and custody of the Department of Children and Family Services or when the DCFS Ward reaches six (6) years of age, (except for pregnant DCFS Wards, who should remain as active cases).
  7. Activities
    Medical case management for DCFS Wards to be provided by the Provider includes the following activities, as described in the Handbook:
    1. Assure that each Ward has selected a HealthWorks of Illinois Primary Care Physician and that the Lead Agency is notified of the selection or any change in the selection. If the selected Primary Care Physician is not enrolled in HealthWorks, the medical case management Provider will provide the Lead Agency with all information needed for recruitment as a HealthWorks Provider;
    2. Assure all follow-up of any medical needs identified in the initial or comprehensive health screenings are completed in an appropriate manner;
    3. Contact with the substitute care giver will occur within 48 hours of assignment;
    4. Develop an Individualized Health Care Plan; provide this to the caseworker only if the caseworker requests care plan.
    5. HealthWorks Health Summary Transfer Tool (for use by Medical management Agency) is to be completed prior to the child's (0-5years of age) Administrative Case Review (ACR) to provide the child welfare worker (DCFS or POS) with a summary of health information in order to ensure that the child's well-being needs are met.  The tool is also to be completed when the medical case management agency change or when the case closes.
    6. Any material received after the 45-day Interim Case Management Period shall be sent to the child's caseworker within three (3) business days of receipt and a copy kept on file.
    7. Participate in administrative case reviews, if requested by the DCFS caseworker, due to anticipated discussion of medical issues; 
    8. Include the biological parents in health care planning, as possible;
    9. Ensure that adolescent DCFS Wards receive family planning counseling and services (if appropriate);
    10. Coordinate Health Care services by assisting in scheduling and arranging transportation to medical services;
    11. Maintain in a local file, records of health services provided to DCFS Wards, ensuring all copies of medical records are sent to the DCFS caseworker within three (3) days of receipt of the documentation of services from providers including information received from the Lead Agency, assure the Primary Care Provider has all required copies of the DCFS medical records for each Ward;
    12. Perform data input of medical case management and medical information using Department's Cornerstone reporting system, ensuring all DCFS client data, including but not limited to, immunization history, EPSDT and HealthWorks of Illinois Primary Care Physician, is entered in Cornerstone System within fifteen (15) business days of receipt of the documentation of services;
    13. Assure effective reassignment and transition of responsibilities for providing medical case management activities to appropriate DCFS and POS agency staff without loss of continuity of health care; and
    14. Assure that the Ward maintains the selection of their HealthWorks of Illinois Primary Care Provider by continuous use of that Provider for all preventive health care services.
    15. Conduct follow-up with substitute care givers, caseworkers and primary care providers to assure compliance with school health requirements for immunizations and well child examinations.
    16. Prepare and submit, for pregnant Wards 6 weeks postpartum, a "report on Prenatal Services and Pregnancy Outcomes" to the Lead Agency.
    17. After Interim Medical Case Management services, conduct follow-up, as requested by the Lead Agency, of health care services for special populations, such as substance-exposed infants, developmentally delayed children, etc.
    18. Provide the signed ordinary and routine medical care consent form that is furnished by DCFS to a Ward's healthcare provider upon request so as to expedite the Ward's access to health services.
  8. Exclusions
    THE PROVIDER WILL NOT BE REQUIRED TO PERFORM THE FOLLOWING ACTIVITIES IN PROVIDING MEDICAL CASE MANAGEMENT SERVICES FOR DCFS WARDS:
    1. Ensure the timely provision of consents for medical treatment of DCFS Wards involving major medical services;
    2. a psychosocial assessment of the DCFS Ward's family;
    3. an assessment of the support systems available to the DCFS Ward's parents or substitute care givers;
    4. case management functions not related to medical care which will be provided by DCFS. In general, DCFS will ensure medical benefits are established under the Medicaid program, ensure that housing, day care  and environmental needs are met and assess job training and employment needs. These activities include:
      1. home visits, for child welfare purposes, except pregnant Wards and the infants up to 1 year of age of parenting Wards;
      2. assisting DCFS Wards in establishing medical benefits under the Medicaid program;
      3. performing an equivalent of an environmental assessment through the DCFS substitute care licensure process;
      4. performing assessments to determine need for social, educational, vocational services;
      5. performing assessments to determine need for transportation services to other than health care services;
      6. assessing need and making referrals of job training and/or employment;
      7. assessing need and making referrals for child care while substitute care giver is working or in school;
      8. communicating with the Provider, substitute caregiver and physician regarding the medical status of DCFS Wards for the development of the individualized health care plan by the Provider for all scheduled DCFS Administrative Case Reviews.
    5. Providers of medical case management services are not responsible for HealthWorks of Illinois (HWIL) Lead Agency activities described in HealthWorks Lead Agencies Program Manual HealthWorks of Illinois.
  9. Performance Standards
    The Provider will provide medical case management services to all DCFS Wards from birth through age five (5) years, pregnant Wards and children of parenting Wards, in accordance with Family Case Management program standards:
    1. at least 95% of all DCFS Wards are linked to a HealthWorks of Illinois Primary Care Physician and the selection is known to the HealthWorks Lead Agency. All Physicians who are not enrolled in HealthWorks will be referred to the Lead Agency for recruitment;
    2. at least 95% of DCFS Wards receive documented medical services according to EPSDT standards, including annual exams for DCFS Wards two (2) years of age and older;
    3. at least 95% of DCFS Wards have documentation entered in the Department's Cornerstone reporting system that they are up to date on needed immunizations;
    4. at least 90% of DCFS eligible Wards have written Individualized Care Plans;
    5. at least 95% of DCFS Wards receive documented needed services including specialty care per the Individualized Health Care Plan;
    6. at least 95% of all written documentation of receipt of health care services (immunizations, EPSDT or annual exams, referrals, acute care services, etc.) has been sent to the child's caseworker within three (3) days of receipt of health documentation;
    7. at least 95% of all Wards with special health care needs according to DCFS guidelines are referred to the DCFS Regional nurse and documentation of the written referral is kept on file;
    8. at least 95% of all Wards assigned to the Provider will have first contact initiated within two (2) business days of assignment;
    9. at least 95% of all Wards in the Provider's jurisdiction shall have successful contact by the case manager within thirty (30) days of assignment.
  10. Reports
    The Provider outside of Cook County will receive, review and utilize the following DCFS reports:
    1. Weekly
      1. Downstate HealthWorks for Children Age Six and Older (new open, new close, provider change)
      2. Downstate HealthWorks for Children Less than Six Years of Age Report (new open, new close, provider change)
      3. Downstate HealthWorks Pregnant Wards Report
    2. Monthly
      1. Downstate HealthWorks parenting Wards and Their Children Report
      2. Downstate HealthWorks for Children Who will turn six within the next 35 days (open cases only)
      3. The Provider will also receive, review, and utilize per the process given above any additional reports developed by the Department and DCFS during the term of this Agreement.

Family Case Management - For High Risk Clients

If the Provider is notified by the Department that they are a "Family Case Management - For High Risk Clients" Provider, the Provider will use Case Management and Title XX Health Support Services funds, if included in this award, to provide case management services to families with high-risk infants identified by the Adverse Pregnancy Outcome Reporting System (APORS); high-risk pregnant women identified by Level III Perinatal Facilities; infants diagnosed with a high-risk condition after newborn hospital discharge; and/or infants and children at medical and/or environmental risk because of an adolescent parent, drug-abusing parent or other high-risk situation identified by the Provider. In addition to Title XX Health Support Services funds, the Provider may use  Medicaid and/or Medically Indigent funds to provide services to high-risk clients.  Providers providing APORS services to APORS clients will survey a random sample of participants to assess their views on services.

  1. Quality Assurance
    This Quality Assurance Plan shall include a client satisfaction survey. Providers providing services to APORS clients will survey a random sample of participants to assess their views on services provided.
  2. Program Goals
    The Provider will work toward meeting the following program goals:
    1. Comprehensive Needs Assessment and Case Management Care Plan: Ninety percent (90%) of all families enrolled in case management for high risk clients shall receive comprehensive needs assessment and case management care plan within forty-five (45) calendar days of successful contact. This will include the 700, 701, 708 or 707D Cornerstone Assessments.
    2. Home Visits: At least 75% of families enrolled in case management for high risk clients with one or more children less than 12 months of age shall receive home visits. Home visits will be conducted according to the requirements of the Maternal and Child Health Services Code. A case management home visit to any family member eligible for case management will satisfy the requirement for conducting a home visit to all family members. The 706 Assessment must be completed at the time of the visit.
    3. Face-to-Face Contacts and Referrals: Eighty percent (80%) of all families being case managed shall receive the required face to face contacts and appropriate referral. Referrals include WIC, prenatal or Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services (pediatric primary medical care), as identified in the Maternal and Child Health Services Code.
    4. Medical Care Coordination: Evidence of medical care coordination shall include the following performance standards: childhood immunizations - 90%; EPSDT participation at age one year of age - 80%; linkage with a Primary Care Provider - 95%; EI referral (if applicable) -100%; and all referrals (specialty care, mental health, housing, etc.) as documented on the Cornerstone system referral screens (RFO1) shall be documented in Provider's electronic files. The referral field is to be used to type in the reason for referral or to give the client written instructions, and to demonstrate that follow up has occurred. Clients are to be given a copy of the referral. The Provider will document the clients' completion or failure to complete the referral in the comment section of the RF01 screen.
    5. All infants (100%) in FCM for high risk clients are to receive an objective developmental screening (within the first 12 months of life) using an objective screening tool (i.e. Denver II, Ages & Stages). The Provider should make every effort to coordinate care with the Primary Care Provider, rather than to duplicate services.
  3. Measurement of Performance
    1. The performance of a needs assessment and development of an individualized care plan will be measured through the data reporting system during the scheduled review visit.
    2. The occurrence of home visits will be measured through Department's automated data reporting system. The content of home visits will be measured through annual electronic chart review during the scheduled review visit.
    3. The occurrence of face-to-face contacts will be measured through the Department's automated data reporting system.
    4. Medical Care Coordination will be measured during the scheduled review visit.
    5. Coordination with immunization, EPSDT, WIC and early intervention referral will be measured through agency reports from Cornerstone and performance review.
    6. Objective Developmental Screenings on site or by appropriate referral at least one first 12 months of life will be measured through agency reports from Cornerstone and performance review.
    7. The occurrence of prenatal and postpartum depression screening will be measured during the scheduled review visit.
  4. Penalties for Failure to Meet Performance Standards
    The Department may impose sanctions for lack of performance to include: The Provider will be placed on Provisional Certification (pursuant to the Maternal and Child Health Services Code) if the Provider fails to meet all standards as set forth in the Performance Standards presented above for three consecutive months. Provisional Certification can occur at anytime during the full certification period if performance standards are not met.
  5. High-risk Infant (APORS) follow-up is governed by IDPH APORS guidelines, and described in detail in the DHS High-risk Infant Follow-up Manual, and in Maternal and Child Health Code 77 Ill. Administrative Code 630.40.

VI. Department Responsibilities

  1. The Department or its designee will notify successful applicants in writing of their agreement to provide FCM services.
  2. The Department or its designee shall provide technical assistance to grantees when requested.
  3. The Department or its designee will monitor the delivery of case management activities through site visits and review of the Department's Cornerstone reporting system data and other documentation as required by the Maternal and Child Health Service Code and the respective service contracts.
  4. An enrollment list of Medicaid enrolled clients will be provided to the Provider (for programs other than Medical Case Management for DCFS Wards/Downstate) by the Department each month. The Provider will contact and enroll in case management each client currently not being case managed.  The enrollment process for Medical Case Management for DCFS Wards/Downstate is described in Section V.  Provider Responsibilities, Family Case Management-Medical Case Management for DCFS wards/Downstate Subsection F-Assignment.

VII. Support Services

Support Services are defined in Section V. Provider Responsibilities and are included in the required scope of services.

VIII. Billing Instructions

  1. Case Management - Compensation documentation for case management services provided by the Provider will be based upon information submitted to the Department via the Department's automated data reporting system. Documentation will be calculated by the Department based on rates established by the Department. The Department will notify the Provider of the applicable rates under separate cover.
  2. Reconciliation of Case Management Payments to Cost - The Provider must demonstrate through the Department's automated data reporting system and cost reporting requirements that payments received from the Department do not exceed the Provider's allowable costs in performing the case management services described in this Attachment. Should the Provider demonstrate allowable costs less than the payment from the Department, the Department may recoup the over payment from the Provider by offset or by requiring direct repayment to the Department, as appropriate.
  3. The Provider hereby waives the right to any reimbursement or further payment for any bill or reimbursement request which is received by the Department more than sixty (60) calendar days after the end of the Agreement period.
  4. If the number of Medicaid cases receiving active case management remains below budgeted case load for three consecutive months, adjustments will be made to reduce subsequent payments.
  5. Primary Care - Compensation documentation for primary care services provided by the Provider will be based upon information submitted on the Department's Primary Care Quarterly Claim Form. Documentation will be calculated by the Department based upon services provided at established Illinois Department of Public Aid rates. The Provider shall submit the Primary Care Quarterly Claim Form to the following address:
    1. Mailing Address
      Tom Evering, Accountant
      100 South Grand Ave East 2nd FL
      Springfield, IL  62762
      Phone:  217-557-2936
    2. Fax
      217-524-2491
    3. Email
      tom.evering@illinois.gov
  6. The Provider agrees to maintain certification with the Department as a case management agency in accordance with the requirements of the Maternal and Child Health Services Code, as amended.
  7. If the Provider fails to report required data for three consecutive months, the monthly prospective payments may be withheld until such time that all required data has been received by the Department.
  8. System Support Services shall use the standard expenditure documentation form as stated in Section VII of the Attachment, Reporting Requirements.

Expenditure Documentation Form Instructions

Expenditure Documentation Form

IX. Program Monitoring

Programs operated by the Provider under this contract will be evaluated by the Department to review the program's progress according to stated goals, measurable objectives and administrative operations.

X. Program Budget

Providers agree to establish and utilize a budget approved by the Provider's Board of Directors.

XI. Appendices/Forms

Not applicable.