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CHIP Perinatal

CHIP Perinatal. Texas Health and Human Services Commission. Table of Contents. Introduction Benefits Referrals Eligibility Application Renewals Resources. Introduction. Program History. Overview:

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CHIP Perinatal

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  1. CHIP Perinatal Texas Health and Human Services Commission

  2. Table of Contents • Introduction • Benefits • Referrals • Eligibility • Application • Renewals • Resources

  3. Introduction

  4. Program History • Overview: • Authorized by Texas 2006-2007 General Appropriations Act (Article II, Health and Human Services Commission, Rider 70). • The State will be using a federal provision that allows states to extend Children’s Health Insurance Program (CHIP) coverage to unborn children . • Required submission of a State Plan Amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS). • Submitted SPA to CMS on Nov. 22, 2005, and received CMS approval on May 26, 2006.

  5. Purpose • Purpose • To extend CHIP services to unborn children of non-Medicaid eligible women. • Scope • Benefits and eligible services are limited to prenatal and postpartum care. • Goal • To enroll the unborn child in CHIP as soon as possible.

  6. Advantages • Encourages prenatal care and improves health outcomes for newborns. • Reduces uncompensated care at hospitals. • Allows the State to draw down the higher CHIP match rate for services currently provided by Medicaid (60.66 percent vs. 72.46 percent). • Implementation provides a net costs savings to state.

  7. Program Description • CHIP Perinatal provides prenatal care to unborn children of pregnant women with 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 duration of the 12-month coverage period. Benefits include: • regular check-ups, • prescription drugs, • shots, etc.

  8. Program Features • Twelve months of continuous coverage from the time eligibility is determined. • Example: If eligibility is determined when mother is three months pregnant, the unborn child has six months prenatal care, and six months of coverage after birth under CHIP Perinatal. • 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 and asset test that apply to traditional CHIP do not apply to CHIP Perinatal.

  9. Benefits

  10. Who Provides CHIP Perinatal Services? • CHIP Perinatal care will be provided by select CHIP health plans throughout the state. • Each health plan will recruit a network of providers for prenatal care, which includes: • Obstetricians • Family practitioners • General practitioners • 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. • Nurse Midwives • Nurse practitioners • Internists

  11. CHIP Perinatal Health Plans

  12. 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 • Pharmacy, limited laboratory testing, assessments, planning services, education and counseling. • Prescriptions based on CHIP formulary • 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.

  13. Hospital Benefits • For women with income between 186 and 200 percent FPL: • Hospital facility charges covered by CHIP Perinatal, and paid by CHIP Perinatal health plan. • Professional service charges paid through CHIP Perinatal health plan • For women with income at or below 185 percent FPL: • Hospital facility charges paid through Emergency Medicaid. (A client must apply and be determined eligible for Emergency Medicaid for a claim to be paid to a Medicaid provider.) • Professionalservice charges paid through CHIP Perinatalhealth plan.

  14. 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. • Specialty care for the mother, such as care for asthma or heart conditions, treatment for mental health or substance abuse, or cardiac care.

  15. Benefits • More information about CHIP Perinatal benefits for the unborn child is available in: • CHIP Perinatal Member Handbooks - mailed to member. • CHIP Provider Manual - mailed to provider by health plan.

  16. Referrals

  17. 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.

  18. Eligibility and Enrollment

  19. Eligibility: Who qualifies? • The unborn children of 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.

  20. Application

  21. 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 2-1-1 to find an office. • Participating WIC clinics. Call 2-1-1 to find an office.

  22. 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 • The Integrated Application • www.yourtexasbenefits.com, or • by calling 2-1-1.

  23. 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.

  24. 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 is an undocumented non-citizen, HHSC does not require her to provide or apply for an SSN. • While verification of citizenship is required for Medicaid, it is not required for CHIP Perinatal. • Pregnantwomen determinedto be eligibleonly for CHIPPerinatal canself-declare immigration status.

  25. Medicaid Identity and Citizenship Verification • Combined proof of citizenship and identity: • U.S Passport, Certificate of Naturalization (Form N-550 or N-570), or Certification of U.S. Citizenship (Form N-560 or N-561) • Proof of citizenship • U.S. Birth Certificate or U.S. Citizen Identification Card (Form I-179 or I-197). • If you were born in Texas, HHSC may be able to verify your birth certificate through state computer records. • Proof of identity • Current driver’s license, Texas ID card issued by DPS, Work or school ID card with photo • Visit www.hhsc.state.tx.us/medicaid/flyer.pdf for more information on documentation for Medicaid.

  26. Application: Important Things to Know • No applications will be screened for CHIP Perinatal before Jan. 2, 2007. • 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. • Those with private insurance will not qualify for CHIP Perinatal.

  27. Application:Important Things to Know • Those with a supply of old children’s insurance applications will be encouraged to dispose of 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.

  28. Applications: How to Order Applications will be available for ordering starting December 22, 2006. These early orders will not be shipped December 27th, and will be limited to 300 per order. Information on how to order the applications is available at: http://www.chipmedicaid.org. Click on the information for community-based organizations and health plans.

  29. Submitting an Application Completed applications can be returned in three ways: • Faxing the completed and signed application to the number on the application. • Children’s Insurance Application and Integrated Application • Mailing the completed and signed application to the address on the application. • Children’s Insurance Application and Integrated Application • Returning the application to an HHSC eligibility office. • Children’s Insurance Application, Form H1010-Application for Assistance, and Integrated Application

  30. Application Processing • HHSC has 15 business days to process the application from the day it is received. • Applications sent to TAA (the CHIP vendor) will be screened for Medicaid eligibility first, then traditional CHIP, and then CHIP Perinatal. • If it appears the client qualifies for Medicaid: • Women over age 19 will receive a letter with instructions on how to obtain services. • Women under 19 will be referred to Medicaid. • Otherwise, TAA will process and enroll the woman into the appropriate program, if application is complete and woman is found eligible (CHIP or CHIP Perinatal.)

  31. Application Processing • Applications received by Texas Works Advisor staff (eligibility staff), will be screened to determine if the application should be referred to TAA for processing. • Eligibility staff in TIERS offices, or staff processing applications for TIERS clients in a non-TIERS office, must fax Medical Assistance for pregnant women applications to TAA. These applications have a higher priority for processing time.

  32. 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.

  33. Enrollment • 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. • 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 to TAA. • 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.

  34. 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.

  35. 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 loses their health plan identification card, call the CHIP Perinatal health plan for a replacement. • 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.

  36. Renewal

  37. 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 directly to TAA, rather than an HHSC eligibility office.

  38. 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.

  39. Choosing a provider • Client can select a provider from their health plan’s provider directory. • Infant may or may not receive a separate provider directory. • Some plans will send a combined directory upon initial enrollment, others will send a new one after baby is born. This is up to individual health plans. • The parent or guardian will need to select a Primary Care Provider for the baby, by calling the health plan.

  40. How Can Community Groups Help? • Placing applications and fact sheets in your offices. • Informing clients about the program. • Providing application assistance, when possible, or referrals 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. • Putting up posters in office.

  41. Resources • Client and Provider Fact Sheets • CBO training • Promotoras training (dates TBD) • Applications • Website: http://www.hhsc.state.tx.us/ • More information coming soon.

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