chip perinatal texas health and human services commission
TRANSCRIPT
CHIP Perinatal
Texas Health and Human Services Commission
Page 2
Table of Contents
• Introduction• Eligibility• Benefits• Referrals• Application• Enrollment• Renewals• Resources
Introduction
Page 4
Program History
• Overview:Authorized by Texas Legislature in 2005The state is using a federal provision that allows
states to provide Children’s Health Insurance Program coverage to unborn children.
Page 5
Definition of “Perinatal” and Program Description
• What does “Perinatal” mean? Perinatal refers to the period around childbirth, especially the
months before and after delivery.
• CHIP Perinatal provides prenatal care to unborn children of pregnant women with a household income up to 200 percent of the federal poverty level (FPL) and who are not eligible for Medicaid.
• Once born, the child will receive benefits that are similar to the traditional CHIP benefits for the remainder of the 12-month coverage period.
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Program Features
• Twelve months of continuous coverage from the time eligibility is determined. Example: If the baby is enrolled when the mother is four
months pregnant and the child is born at full term (9 mths), the baby will have six months of prenatal care (including the month enrolled), and six months of CHIP coverage upon delivery.
• No waiting period for coverage. The 90-day waiting period that applies in traditional CHIP does not apply to CHIP Perinatal.
• No fees for clients. The co-payments that apply to traditional CHIP do not apply to CHIP Perinatal.
• No asset test.
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Comparison of CHIP Perinatal to Traditional CHIP
CHIP Perinatal
• No asset test.• No 90-day wait.• No cost sharing.
• 12-month eligibility period.
Traditional CHIP
• Asset test applies• 90-day waiting period.• Enrollment fee and co-
pays, if applicable.• 6-month eligibility period
Eligibility
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Eligibility: Who qualifies?
• The unborn children of uninsured pregnant women who are Texas residents and: Have a household income greater than 185 percent FPL,
and at or below 200 percent FPL. Have a household income at or below 200 percent FPL, but
do not qualify for Medicaid because of immigration status.
Currently, many potential CHIP Perinatal clients receive prenatal care through Title V.
• An applicant is not eligible for CHIP Perinatal if she gives birth prior to an eligibility decision.
Benefits
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Who Provides CHIP Perinatal Benefits?
• CHIP Perinatal is available statewide, and is provided through select CHIP Perinatal health plans.
• Each health plan will recruit a network of providers for prenatal care, which includes: Obstetricians Family practitioners General practitioners Clinics
• CHIP Perinatal provider network for newborns consists of same type of providers as traditional CHIP.
• All providers are listed in the health plan’s provider directory, which is provided to clients upon enrollment in their enrollment packet.
Nurse Midwives Nurse practitioners Internists
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CHIP Perinatal Health Plans
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Jefferson
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Washington
Robertson
Waller
Brazoria
Matagorda
Fort Bend
Harris
Galveston
Chambers
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Harris CHIP O-SA
Bexar CSA
Lubbock SDA
Harris CSA
El Paso CSA
CHIP PerinatalService Areas
with HHS Regions (in red)
Effective J anuary 1, 2007
Dallas CSA
HHSC, Medicaid/CHIP Managed Care OperationsMarch 2006
10
1
9
Palo Pinto
Comanche
Hamilton
2
El Paso
McMullen
Maverick
8
Travis CSA
Orange
Sabine
Newton
34
Colorado
7 5Houston
Lubbock CHIP O-SA
Tarrant CSA
Nacogdoches
San Jacinto
Jasper
6
Nueces CSA
Webb CSA
Core Service Area (CSA)
Optional Addition to CSA (O-SA) for CHIP Perinatal
Non-HMO model for CHIP Perinatal(EPO model)
Bexar CHIP O-SA
11Nueces CHIP O-SA
Superior
FirstCareSuperior
Amerigroup
Parkland
Superior
Community Health Choice
El Paso FirstSuperior Health Plan
Community Health Choice
Superior
Superior
Mercy
Community FirstSuperior
Community FirstSuperior
El Paso O-SASuperior El Paso First
SuperiorTravis CHIP O-SA
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Benefits
• Up to 20 prenatal care visits (more if medically necessary) First 28 weeks of pregnancy – 1 visit every 4 weeks 28 to 36 weeks of pregnancy – 1 visit every 2-3 weeks 36 weeks to delivery – 1 visit per week Additional visits allowed if medically necessary
• Prescriptions based on CHIP formulary • Case management and care coordination• Ultrasound of the baby if doctor orders one• Labor with delivery of child. Preterm labor that does not result in
a birth and false labor are not covered benefits. • 2 postpartum visits for mother after baby is born• Regular check-ups, immunizations, and prescriptions for baby
after leaving the hospital.
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Hospital Benefits
• For women with income between 186 and 200 percent FPL: All hospital expenses related to labor with delivery are covered by
the CHIP Perinatal program.
• For women with income at or below 185 percent FPL (the majority of CHIP Perinatal clients): Women with incomes at or below 185 percent FPL must apply and
be determined eligible for Emergency Medicaid to ensure coverage for labor with delivery.
• How can you help? Let women know that depending on their income, they might have to apply for Emergency Medicaid to cover their hospital stay. Tell them to bring their information with them to the hospital (like proof of income).
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What Services are Not Covered?
• Labor without delivery of the baby (false labor).• A mother’s hospital visit for services not
related to labor with delivery, such as a broken arm NOTE: Client may apply for Emergency Medicaid to receive
emergency services that are not covered by CHIP Perinatal. However, not all may qualify.
• Specialty care for the mother, such as care for asthma or heart conditions, treatment for mental health or substance abuse, or cardiac care.
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Benefits
• More information about CHIP Perinatal benefits for the unborn child is available in:
CHIP Perinatal health plan Member Handbook - mailed to member by the health plan after enrollment.
Referrals
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Referrals
• If a pregnant woman needs services not included in CHIP Perinatal, providers may refer her to community clinics and other providers who currently serve this population or uninsured populations.
Application
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Application
• Applications will be available at many places: Dialing 1-877-KIDS-NOW (1-877-543-7669). Online at: www.CHIPMedicaid.org HHSC Benefits offices. Call 2-1-1 to find an office. Participating community-based organizations. Call 1-877-
KIDS-NOW to find an office.
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Application
• If a client only wishes to apply for CHIP Perinatal, it is recommended that the children’s insurance application be used. It is found at www.CHIPmedicaid.org, or by calling 1-877-543-7669.
• Those who wish to apply for other benefits in addition to CHIP Perinatal ,should use:
Form H1010, the Application for Assistance• http://www.dads.state.tx.us/handbooks/texasworks/forms/index.asp?form=H1010-A • http://www.dads.state.tx.us/handbooks/texasworks/forms/index.asp?form=H1010-B
• Clients can call 2-1-1 for more assistance.
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What Documentation is Needed?
• Verification of income is the only required item. One pay stub in the last 60 days; Letter from an employer stating monthly income; Last income tax return (including schedule C, if filed); Cash assistance receipt; Most recent social security statement; or Child support check stub or receipt.
• Similar to traditional CHIP, there are no deductions for childcare expenses, child support payments, alimony payments, or disabled adult care expenses
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Application
• During the application process, HHSC will ask for identity and citizenship verification (new federal Medicaid requirements). Why? Because HHSC checks eligibility for Medicaid first,
then CHIP, then CHIP Perinatal.
• If the applicant (pregnant woman) is an undocumented non-citizen, HHSC does not require her to provide or apply for a Social Security Number.
• Verification of citizenship is required for Medicaid, but not for CHIP Perinatal.
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Application: Important Things to Know
• Those with private insurance will not qualify for CHIP Perinatal.
• For the children’s insurance application, just one pay stub issued in the past 60 days is needed.
• Pregnancy is self-declared. No proof of pregnancy is required for CHIP Perinatal.
• A parent or guardian has the right to file a Medicaid application at any time after the baby is born.
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Application:Important Things to Know
• Applicants should not skip any questions. Skipping a question may cause their application to pend.
• If a question does not apply to the applicant, fill in N/A (not applicable).
• If faxing an application, fax only one at a time. • Those with a supply of old children’s insurance
applications will be encouraged to throw away the old versions, and use the new applications.
• If applying only for CHIP Perinatal using the children’s insurance application, clients can skip sections 3, 4, and 9.
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Application: Important Things to Know
• How does an applicant verify the status of their application?
By calling 1-877-KIDS-NOW
Due to confidentiality reasons, information on the status of an application can only be given to the applicant or an authorized representative.
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Applications: How to Order
Bulk supplies of applications are available for ordering. Order applications on-line by going to the following website:
http://www.chipmedicaid.org
Click on the information for community-based
organizations and health plans.
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Submitting an Application
Completed applications can be returned in three ways:
• Faxing the completed and signed application to the number on the application cover page/instructions (Children’s Insurance Application), or on the application (Integrated Application)
• Mailing the completed and signed application to the address on the application cover page/instructions (Children’s Insurance Application), or on the application (Integrated Application)
• Returning the application to an HHSC eligibility office. Children’s Insurance Application, Form H1010-Application for
Assistance, and Integrated Application
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Application Processing
• HHSC has 15 business days to process the application from the day it is received.
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Application Processing: Missing Information
• If an application is pended for missing information, the client will be sent a “missing information” letter telling them what information is needed to complete their application.
• Clients have 10 days from the date on their missing information letter to provide the information needed.
• If the client does not provide the information in the required timeframe, they may be required to apply again
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Emergency Medicaid
• Women at or below 185 percent FPL will need to apply for Emergency Medicaid to cover labor with delivery. These women will apply for Emergency Medicaid when they
are admitted into the hospital, and hospital staff or on-site eligibility workers will assist in this process.
How can you tell a client’s FPL? By looking at their health plan identification card. Those at or below 185% FPL will have under hospital billing a statement, “Texas Medicaid Healthcare Partnership (TMHP)” along with the address and/or phone number.
Enrollment
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Enrollment: Areas with One Health Plan
• Once eligibility is determined, the unborn child will be enrolled in a CHIP Perinatal health plan.
If there is no choice of CHIP Perinatal health plan (only one plan participates in the area), the CHIP Perinatal child will be automatically enrolled into that health plan.
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Enrollment: Choice of Health Plan
In areas with more than one health plan choice, clients will have 15 calendar days to select a health plan. Families may call 1-877-KIDS-NOW (1-877-543-7669) to select a plan or can mail their enrollment form.
HHSC will select a health plan on the client’s behalf if client does not choose a health plan within the 15-day timeframe. When this occurs, the family is allowed to request a different health plan as long as they do so within 30 days of the health plan assignment. Families can call 1-877-KIDS-NOW to switch health plans.
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Enrollment: Materials clients receive
AREAS WITH ONE HEALTH PLAN• Clients will receive in the mail the following:
In one mailing: a welcome letter, a provider directory for the health plan listing all providers that a woman can go to for prenatal care, and a client fact sheet. The provider directory can be used to select a provider.
In separate mailings, the health plan will send the client a health plan identification card and a member handbook, explaining benefits.
Babies will receive a unique ID upon birth. Client needs to inform CHIP Perinatal of the birth by calling 1-800-647-6558
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Enrollment: Materials clients receive
AREAS WITH HEALTH PLAN CHOICE If multiple health plans in their area:
• In one mailing: an enrollment packet. Packet will include a welcome letter, instructions on how to select a health plan, enrollment form and provider directories, as well as a fact sheet.
• A health plan identification card, once she has made a selection
• A health plan member handbook, after she selects a health plan.
Babies will receive a unique ID upon birth. Client needs to inform CHIP Perinatal of the birth by calling 1-800-647-6558
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Picking a provider
Choosing a prenatal care provider• Clients can choose a provider from the health plan’s
provider directory. If the client already has an OB/GYN, family practice doctor or clinic that she likes, she should look at the directory to see if her provider is in the health plan’s network.
• A client can call the health plan’s member services hotline for help in choosing a provider.
• If a provider is not selected, a woman will not be defaulted to a provider. She can go to any provider listed in the directory.
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Picking a provider
Choosing a primary care provider for baby• Once baby is born, client will need to notify the
program by calling 1-800-647-6558. The CHIP Perinatal program needs to know the date the baby was born, the baby’s gender, and the baby’s name.
• Client will need to choose a Primary Care Provider (PCP). A PCP can be a doctor, a nurse practitioner, a clinic, or a physician assistant.
• Clients may choose a provider from the health plan’s provider directory. Call the health plan’s Member Services hotline for a directory or help choosing a provider.
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Siblings on CHIP
• If there are other children in the household on traditional CHIP, they will be moved to the CHIP Perinatal health plan effective the first possible month.
• All of the children in the household will be in one health plan.
• There is no cost for CHIP Perinatal program services; however, the children (siblings) on traditional CHIP continue to pay fees or co-payments, if required.
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CHIP Perinatal Coverage
• Coverage starts on the 1st of month the unborn child is determined eligible. Example: Application is filed February 20, 2007, and eligibility is
finalized March 12, 2007. Coverage would start March 1, 2007.
• Pregnant woman will receive a health plan Identification Card in the mail indicating “CHIP Perinatal.”
• After birth, the baby will receive his/her unique health plan identification indicating “CHIP Perinatal.”
• If client does not receive their health plan identification card, she should call her health plan.
• If a newborn is seen by a provider before the baby has been issued a health plan identification card, the provider should contact the baby’s health plan for billing information. It will be the same health plan that provided prenatal care.
Renewal
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Renewal
• Family will receive an application packet in 10th month of coverage.
• Family should fill in the information and return upon completion. They will need to include verification of income. One paycheck in the last 60 days. This will prevent delays in
processing time.
• CHIP Perinatal infant will be screened for Medicaid and CHIP. If found CHIP eligible, will be subject to co-payments and fees, if required.
• It is recommended that applications be submitted to the address on the children’s insurance application cover page/instructions rather than an HHSC eligibility office.
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Renewal
• If a newborn is found eligible for CHIP, but there are other children in the family who are currently enrolled in CHIP, the coverage end date for the newborn will be changed so it matches the coverage end date for the family’s other CHIP enrolled children.
• This means the newborn may not receive the full six months’ coverage before they need to renew. The advantage is that all of the children in the
household will have the same renewal and coverage dates.
• Families will need to ensure that all of the renewal information has been completed for all children in the household, including the newborn before it is returned.
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Reporting an address change
Clients can inform CHIP Perinatal of address changes by calling 1-800-647-6558
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How Can Community Health Workers Help?
• Provide clients with applications and fact sheets.• Tell clients about the program.• Provide application assistance, when possible, or
refer to entities that can assist. (Help applicants with completing the application, and review to ensure that all required information is provided.)
• Answering basic client questions.• Encouraging clients to renew their coverage on time.
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How can community health workers help?
• The health plans usually contact newly enrolled moms to determine if there are any high risk conditions.
• However, community health workers can also refer clients to a health plan by calling the health plan’s Member Services hotline.
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Resources
• Client Fact Sheets (English and Spanish)• Brochures (Coming soon)• Community health worker/Promotoras training • Applications• Office posters (Coming soon)• Website: http://www.hhsc.state.tx.us/ (click on
CHIP Perinatal in the middle of the page)