3.5 Pediatric Primary Care

Revised October 2019

In specific circumstances where clients meet the income eligibility requirements for Medicaid, however, due to religious reasons, are unable to enroll in Medicaid services, FCM funds may be used to pay for Primary Care costs as outlined below.

Agencies may complete the Pediatric Primary Care Determination Worksheet (Addendum 03.05 Determination Worksheet) for pregnant women, and children to determine if they meet the following criteria:

  1. Family income is at or below 318% of the Federal Poverty Level as determined by the Income Eligibility Guidelines Matrix (Addendum 03.05 Guidelines)
  2. Are otherwise uninsured (i.e. do not have private insurance) and,
  3. Are unable to enroll in state of Illinois Medicaid due to religious reasons.

Once eligibility has been determined, the health department may provide the following services:

  1. prenatal healthcare office visits for FCM enrolled clients,
  2. infants or children under 2 years of age with > 30% developmental delays per Early Intervention (EI) global assessment who need periodic developmental screening;
  3. immunization administration;
  4. vision screening and, or glasses;
  5. hearing screening;
  6. pregnancy testing;
  7. head-to-toe physical assessment (EPSDT visit) on FCM enrolled clients who do not have a recorded EPSDT with their primary care physician;
  8. routine and medically indicated dental services for FCM enrolled infants or pregnant women.

It is expected that Health Departments will keep a monthly record of claims using the Primary Care Monthly Claim Form (Addendum 03.05 Claim Form (docx)). The CPT / Procedure Service code and Reimbursement Rate should be commensurate with the current HFS Fee Schedule which is found at https://www.illinois.gov/hfs/SiteCollectionDocuments/6618SBLHCFeeSchedule.pdf.

The claim form along with completed Determination Worksheets for any clients that claims are being processed for must be submitted to the MCH Nurse Consultant. Once the claims have been approved the agency will complete the Primary Care Quarterly Summary Report (Addendum 05.03 Summary Report (docx)) and submit it along with the Periodic Financial Report (PFR) for the last month of the quarter.

The PFR will include the claim amount documented on the Grant Exclusive line item of the PFR.