§140.488. Periodicity Schedules, Immunizations and Diagnostic Laboratory Procedures

a)         Health Screening Periodicity Schedule.  Eligible clients may receive one periodic health screening during each of the following time periods, except a second screening may be given as explained in Section 140.485(d)(2):

 

1)         birth to two weeks;

 

2)         two weeks to one month;

 

3)         one to two months;

 

4)         two to four months;

 

5)         four to six months;

 

6)         six to nine months;

 

7)         nine to 12 months;

 

8)         12 to 15 months;

 

9)         15 to 18 months;

 

10)         18 to 24 months;

 

11)         two to three years;

 

12)         three to four years;

 

13)         four to five years;

 

14)         five to six years;

 

15)         six to eight years;

 

16)         eight to 10 years;

 

17)         10 to 12 years;

 

18)         12 to 14 years;

 

19)         14 to 16 years;

 

20)         16 to 18 years; and

 

21)         18 to 21 years.

 

b)         Vision Screening Periodicity Schedule

 

1)         Vision screening using age appropriate methods shall be part of all periodic or interperiodic health screenings.

 

2)         Beginning at age three through 20 years, the Department will pay for one vision screening performed by a qualified provider per year for an eligible child.  However, the Department will pay for other such screenings when medically necessary, regardless of a child's age or medical history.

 

c)         Hearing Screening Periodicity Schedule

 

1)         Hearing screening using age appropriate methods shall be part of all periodic or interperiodic health screenings.

 

2)         Beginning at age one year for children at high risk for hearing problems and age three years for all other children, the Department will pay for one hearing screening performed by a qualified provider per year for an eligible child.  However, the Department will pay for other such screenings when medically necessary, regardless of a child's age or medical history.

 

d)         Dental Screenings Periodicity Schedule

 

1)         Effective for dates of service on or after July 1, 2014, the dental periodicity schedule is available at the Department's website at http://www2.illinois.gov/hfs/MedicalProvider/MedicaidReimbursement/

Pages/Dental.aspx.  Examination of a child's oral cavity, including the status of the teeth and gums, shall be part of each periodic or interperiodic health screening.

 

2)         Effective for dates of service on or after July 1, 2014, beginning at age one through 20 years, the Department will pay for one clinical oral examination and one oral prophylaxis not more frequently than once every six months performed by an enrolled dentist.  However, the Department will pay for additional services when medically necessary, regardless of a child's age or medical history.

 

e)         Immunizations.  The following immunizations are available to eligible clients:

 

1)         Diphtheria-Tetanus-Pertussis (DPT) 1;

 

2)         DPT 2;

 

3)         DPT 3;

 

4)         DPT Booster 1;

 

5)         DPT Booster 2;

 

6)         Oral Polio Vaccine (OPV) 1;

 

7)         OPV 2

 

8)         OPV 3;

 

9)         OPV Booster 1;

 

10)         OPV Booster 2;

 

11)         Diptheria-Tetanus (Td) 1;

 

12)         Td 2;

 

13)         Td 3;

 

14)         Td Booster 1;

 

15)         Td Booster 2;

 

16)         Measles;

 

17)         Rubella;

 

18)         Mumps;

 

19)         Measles/Mumps/Rubella (M/M/R);

 

20)         Measles/Rubella; and

 

21)         Haemophilus b Conjugated.

 

f)         Diagnostic Laboratory Procedures.  The Department will pay for covered diagnostic laboratory procedures as medically necessary including but not limited to:

 

1)         Urinalysis, routine (ph specific gravity protein tests for reducing substances such as glucose), with microscopy;

 

2)         Urinalysis routine without microscopy;

 

3)         Chemical, qualitative, any number of constituents;

 

4)         Cholesterol, serum; total;

 

5)         Cholesterol, serum; total and ester;

 

6)         Lead Screening, Blood Lead;

 

7)         Gonadotropin, chorionic quantitative pregnancy test;

 

8)         Gonadotropin, chorionic qualitative pregnancy test;

 

9)         Hematocrit;

 

10)         Hemoglobin Colorimetric;

 

11)         Sickle RBC, reduction slide method;

 

12)         Hemoglobin Electrophoresis;

 

13)         Sickle Hemoglobin;

 

14)         Tuberculosis intradermal;

 

15)         TB Tine Test;

 

16)         Syphilis Test, qualitative;

 

17)         GC Culture Test, bacterial screening only;

 

18)         Culture presumptive, pathogenic organisms screening only;

 

19)         Culture, multiple organisms;

 

20)         Urine culture colony count;

 

21)         Urine bacteria count, commerical kit;

 

22)         Urine bacteria culture, identification, in addition to colony count and commercial kit;

 

23)         Chlamydia Culture;

 

24)         Pap Smear, Cytopathology;

 

25)         Epidemological study of a child's living environment when a child has been diagnosed as having an abnormally high blood lead level;

 

26)         Denver Developmental Screening Test; and

 

27)         Other developmental tests that may be approved by the Department.

 

(Source:  Amended at 38 Ill. Reg. 23623, effective December 2, 2014)