| PRIMARY MEDICAL CARE SERVICES |
| 1. General Primary Medical Care (other than listed below) |
100.0% |
0.0% |
0.0% |
100.0% |
| 2. Diagnostic Laboratory (technical component) |
80.0% |
80.0% |
80.0% |
100.0% |
| 3. Diagnostic X-Ray Procedures (technical component) |
80.0% |
20.0% |
100.0% |
100.0% |
| 4. Diagnostic Tests/Screenings (professional component) |
80.0% |
20.0% |
60.0% |
100.0% |
| 5. Emergency medical services |
80.0% |
0.0% |
20.0% |
100.0% |
| 6. Urgent medical care |
100.0% |
0.0% |
20.0% |
100.0% |
| 7. 24-hour coverage |
80.0% |
0.0% |
20.0% |
100.0% |
| 8. Family Planning |
100.0% |
0.0% |
60.0% |
100.0% |
| 9. HIV testing and counseling |
20.0% |
60.0% |
40.0% |
100.0% |
| 10. Testing for Blood Lead Levels |
20.0% |
40.0% |
80.0% |
100.0% |
| 11. Immunizations |
100.0% |
0.0% |
40.0% |
100.0% |
| 12. Following hospitalized patients |
100.0% |
0.0% |
20.0% |
100.0% |
| OBSTETRICAL AND GYNECOLOGICAL CARE |
| 13. Gynecological Care |
100.0% |
0.0% |
0.0% |
100.0% |
| 14. Prenatal care |
80.0% |
0.0% |
40.0% |
100.0% |
| 15. Antepartum fetal assessment |
60.0% |
0.0% |
40.0% |
100.0% |
| 16. Ultrasound |
20.0% |
20.0% |
80.0% |
100.0% |
| 17. Genetic counseling and testing |
0.0% |
0.0% |
100.0% |
100.0% |
| 18. Amniocentesis |
0.0% |
0.0% |
100.0% |
100.0% |
| 19. Labor and delivery professional care |
60.0% |
0.0% |
80.0% |
100.0% |
| 20. Postpartum care |
80.0% |
0.0% |
80.0% |
100.0% |
| SPECIALTY MEDICAL CARE |
| 21. Directly observed TB therapy |
40.0% |
0.0% |
60.0% |
100.0% |
| 22. Respite Care |
0.0% |
0.0% |
100.0% |
100.0% |
| 23. Other Specialty Care |
0.0% |
0.0% |
100.0% |
100.0% |
| DENTAL CARE SERVICES |
| 24. Dental Care - Preventive |
40.0% |
0.0% |
60.0% |
100.0% |
| 25. Dental Care - Restorative |
40.0% |
0.0% |
100.0% |
100.0% |
| 26. Dental Care - Emergency |
40.0% |
0.0% |
60.0% |
100.0% |
| 27. Dental Care - Rehabilitative |
20.0% |
0.0% |
100.0% |
100.0% |
| MENTAL HEALTH/SUBSTANCE ABUSE
SERVICES |
| 28. Mental Health Treatment/Counseling |
80.0% |
20.0% |
100.0% |
100.0% |
| 29. Developmental Screening |
100.0% |
0.0% |
80.0% |
100.0% |
| 30. 24-hour Crisis Intervention/Counseling |
20.0% |
0.0% |
100.0% |
100.0% |
| 31. Other Mental Health Services |
0.0% |
0.0% |
80.0% |
80.0% |
| 32. Substance Abuse Treatment/Counseling |
80.0% |
20.0% |
100.0% |
100.0% |
| 33. Other Substance Abuse Services |
20.0% |
20.0% |
100.0% |
100.0% |
| 33a. Comprehensive mental health / Substance abuse screening |
20.0% |
0.0% |
100.0% |
100.0% |
| OTHER PROFESSIONAL SERVICES |
| 34. Hearing Screening |
80.0% |
0.0% |
80.0% |
100.0% |
| 35. Nutrition Services Other than WIC |
80.0% |
40.0% |
40.0% |
100.0% |
| 36. Occupational or Vocational Therapy |
0.0% |
0.0% |
100.0% |
100.0% |
| 37. Physical Therapy |
0.0% |
20.0% |
100.0% |
100.0% |
| 38. Pharmacy - Licensed Pharmacy staffed by Registered Pharmacist |
60.0% |
40.0% |
80.0% |
100.0% |
| 39. Pharmacy - Provider Dispensing |
40.0% |
0.0% |
60.0% |
100.0% |
| Total Pharmacy |
80.0% |
40.0% |
80.0% |
100.0% |
| 40. Vision Screening |
80.0% |
0.0% |
80.0% |
100.0% |
| 41. Podiatry |
0.0% |
0.0% |
100.0% |
100.0% |
| 42. Optometry |
0.0% |
0.0% |
100.0% |
100.0% |
| ENABLING SERVICES |
| 43. Case management |
100.0% |
0.0% |
100.0% |
100.0% |
| 44. Child Care (during visit to center) |
0.0% |
0.0% |
80.0% |
80.0% |
| 45. Discharge Planning |
100.0% |
0.0% |
60.0% |
100.0% |
| 46. Eligibility Assistance |
100.0% |
0.0% |
60.0% |
100.0% |
| 47. Environmental Health Risk Reduction (via detection and/or
alleviation) |
80.0% |
0.0% |
40.0% |
100.0% |
| 48. Health education |
100.0% |
0.0% |
100.0% |
100.0% |
| 49. Interpretation/Translation services |
80.0% |
60.0% |
40.0% |
100.0% |
| 50. Nursing home and assisted-living placement |
60.0% |
0.0% |
40.0% |
100.0% |
| 51. Outreach |
100.0% |
0.0% |
40.0% |
100.0% |
| 52. Transportation |
60.0% |
20.0% |
40.0% |
100.0% |
| 53. Out Stationed Eligibility Workers |
0.0% |
0.0% |
100.0% |
100.0% |
| 54. Home Visiting |
20.0% |
0.0% |
80.0% |
100.0% |
| 55. Parenting Education |
60.0% |
0.0% |
60.0% |
100.0% |
| 56. Special Education Program |
0.0% |
0.0% |
100.0% |
100.0% |
| 57. Other |
0.0% |
0.0% |
0.0% |
0.0% |
| PREVENTATIVE SERVICES RELATED TO TARGET CLINICAL
AREAS |
| I. Cancer |
| 58. Pap Test |
100.0% |
0.0% |
40.0% |
100.0% |
| 59. Fecal occult blood test |
80.0% |
0.0% |
20.0% |
100.0% |
| 60. Sigmoidoscopy |
40.0% |
0.0% |
80.0% |
100.0% |
| 61. Colonoscopy |
0.0% |
0.0% |
100.0% |
100.0% |
| 62. Mammograms |
0.0% |
20.0% |
100.0% |
100.0% |
| 63. Smoking cessation program |
60.0% |
0.0% |
60.0% |
100.0% |
| II. Diabetes |
| 64. Glycosylated hemoglobin measurement for people with diabetes |
60.0% |
20.0% |
40.0% |
100.0% |
| 65. Urinary microalbumin measurement for people with diabetes |
60.0% |
20.0% |
40.0% |
100.0% |
| 66. Foot exam for people with diabetes |
100.0% |
0.0% |
0.0% |
100.0% |
| 67. Dilated eye exam for people with diabetes |
0.0% |
0.0% |
100.0% |
100.0% |
| III. Cardiovascular Disease |
| 68. Blood pressure monitoring |
100.0% |
0.0% |
0.0% |
100.0% |
| 69. Weight reduction program |
60.0% |
20.0% |
20.0% |
60.0% |
| 70. Blood cholesterol screening |
60.0% |
20.0% |
20.0% |
100.0% |
| IV. HIV/AIDS (See line 9. HIV testing and
counseling) |
| V. Infant Mortality (See line 14. Prenatal
Care) |
| 71. Follow-up testing and related health care services for abnormal
newborn bloodspot screening |
20.0% |
0.0% |
100.0% |
100.0% |
| VI. Immunizations (See line 11.
Immunizations) |
| OTHER SERVICES |
| 72. WIC Services |
0.0% |
0.0% |
100.0% |
100.0% |
| 73. Head Start services |
0.0% |
0.0% |
100.0% |
100.0% |
| 74. Food bank/delivered meals |
0.0% |
0.0% |
100.0% |
100.0% |
| 75. Employment/Educational Counseling |
0.0% |
0.0% |
100.0% |
100.0% |
| 76. Assistance in obtaining housing |
0.0% |
0.0% |
100.0% |
100.0% |
