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CHIP PERINATAL COVERAGE

Provider Fact Sheet


The Basics

  1. What is CHIP perinatal coverage?
  2. Who is eligible?
  3. How long does the eligibility and enrollment process take?
  4. When does a client’s coverage start?
  5. What are the CHIP perinatal benefits for the unborn child?
  6. What are the benefits once the child is born?
  7. What services are not covered?
  8. What about postpartum visits?
  9. How does a client obtain services not covered under CHIP perinatal?
  10. What are the differences between CHIP perinatal coverage and traditional CHIP?

The Application

  1. How can pregnant women apply?
  2. Do women who are applying have to provide proof of their pregnancy?
  3. What other documents do women need to send along with their application?
  4. What are common errors made during the application process?
  5. How does a woman return the application?

Enrollment Information

  1. How does a woman enroll in a CHIP perinatal health plan?
  2. How will I know if a pregnant woman or a child is enrolled in CHIP perinatal?
  3. What if I see a CHIP perinatal newborn who has not yet been issued a unique
  4. CHIP perinatal ID card?
  5. Who can be a provider?
  6. What CHIP perinatal health plans will be serving clients in my area?
  7. How are providers reimbursed? What are the reimbursement rates?

Hospital Reimbursement

  1. How is a hospital reimbursed for labor with delivery charges for CHIP perinatal clients with incomes at or below 185% FPL?
  2. How is a hospital reimbursed for labor with delivery charges for CHIP perinatal clients with incomes at 186% FPL up to 200% FPL?
  3. How do I know a client’s FPL?
  4. How does the hospital get the Form H3038?
  5. What if the expectant mother does not bring the bar-coded Form H3038 with her to the hospital?
  6. How does the hospital get the Form H3038 to HHSC?
  7. How will the hospital know if HHSC has received the Form H3038 and Medicaid has been established?
  8. Where can I get information on how to bill for newborns?
  9. Is a Medicaid application needed for the newborn?
  10. What if the baby is in the Neo-natal Intensive Care Unit (NICU)?
  11. Where can I get more information on billing in general?
  12. What are common errors in hospital billing?
  13. How do I report the birth of a newborn receiving CHIP perinatal services?

The Basics

What is CHIP perinatal coverage?
CHIP perinatal provides care to unborn children of pregnant women with household income up to 200% 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.

Who is eligible? 
Unborn children of pregnant women who:

  • Have a household income greater than 185% FPL and at or below 200% FPL.
  • Have a household income at or below 200% FPL but do not qualify for Medicaid because of immigration status.

Women who are U.S. citizens or qualified immigrants with household income at or below 185% FPL may be eligible for coverage under Medicaid’s pregnant women program.

How long does the eligibility and enrollment process take?
HHSC has 15 business days to process the application from the day it is received.  Once eligibility is determined, the unborn child will be enrolled in a CHIP perinatal health plan.  If the woman lives in a service area with more than one health plan choice, she will have 15 calendar days to select a health plan.  If she does not choose a health plan within the 15-day timeframe, HHSC will choose one for the child.

When does a client’s coverage start?
Coverage begins on the first day of the month in which eligibility is determined. For example, if an application was submitted Feb. 23, 2009, and eligibility was determined March 13, 2009, coverage would start March 1, 2009.

What are the CHIP perinatal benefits for the unborn child? 
CHIP perinatal coverage includes:

  • Up to 20 prenatal visits.
    • First 28 weeks of pregnancy ― one visit every four weeks.
    • 28 to 36 weeks of pregnancy ― one visit every two to three weeks.
    • 36 weeks to delivery ― one visit per week.
    • Additional prenatal visits allowed if medically necessary.
  • Some laboratory testing, assessments, planning services, education and counseling.
  • Prescription drug coverage based on the current CHIP formulary.
  • Hospital facility charges and professional services charges related to the delivery.  Preterm labor that does not result in a birth and false labor are not covered benefits.
    • For women with income from 186-200% of the FPL:
      • Hospital facility charges paid through the CHIP perinatal health plan.
      • Professional service charges paid through the CHIP perinatal health plan.
    • For women with income at or below 185% FPL (The majority of CHIP perinatal clients are at or below 185% FPL):
      • Professional service charges paid through CHIP.
      • Hospital facility charges paid through Emergency Medicaid.*
  • More information about CHIP benefits for the unborn child is available in the health plan provider manuals.

* Emergency Medicaid will need to be established for these women before a claim can be paid to a Medicaid provider. See “How is a hospital reimbursed for labor with delivery charges for CHIP perinatal clients with incomes at or below 185% federal poverty level (FPL)?

What are the benefits once the child is born?

  • Two postpartum visits for the mother.
  • Depending on the family’s income level, hospital facility charges for labor with delivery and the newborn’s first hospital admission may or may not be covered by CHIP perinatal. The covered services available before the child is discharged from the hospital are explained in more detail in the health plan provider manuals.
  • Once a child is discharged from the initial hospital admission, the child receives the traditional CHIP benefit package.  A full list of covered benefits is available at www.chipmedicaid.com/english/cover.htm.

What services are not covered?
CHIP perinatal provides a basic prenatal care package.  Participating health plans will distribute a provider manual that includes the covered and non-covered (excluded) benefits.  Examples of non-covered services include:

  • Inpatient hospital care for the mother of the unborn child that is not related to labor with delivery, such as a broken arm.
  • Labor without delivery of the baby (false labor).
  • Most outpatient specialty services, such as mental health and substance abuse treatment, asthma management and cardiac care.

What about postpartum visits?
Two postpartum care visits are covered under CHIP perinatal.  The health plans will negotiate reimbursement rates with participating physicians and providers.

How does a client obtain services not covered under CHIP perinatal?
Community clinics and other providers who currently serve the covered population may provide services that are not benefits of CHIP perinatal.

What are the differences between CHIP perinatal coverage and traditional CHIP?

  • The asset test that is used in processing other higher income CHIP cases does not apply to women who are applying for CHIP perinatal.  
  • No waiting period for coverage. The 90-day waiting period that applies in some CHIP cases does not apply to CHIP perinatal.
  • No fees for clients. The co-payments that apply to some other CHIP services do not apply to babies with CHIP perinatal coverage. 

The Application

How can pregnant women apply?
Providers who want to have applications available in their office can order them in bulk by sending an e-mail with shipping information to txorderapps@maximus.com.
Clients can also obtain applications by:

  • Calling 1-877-KIDS-NOW (1-877-543-7669).
  • Visiting www.CHIPmedicaid.org.
  • Picking up a copy from a participating community-based organization. To find an organization in your county, visit the “How to Apply” page of www.CHIPmedicaid.org and look for the “Need Free Help?” section.
  • Visiting www.yourtexasbenefits.com, and clicking on “Request an application.” (Client should use the Children’s Medicaid/CHIP application.)
  • Picking up a copy at a Health and Human Services Commission benefits office. Call 2-1-1 to find an office or visit www.yourtexasbenefits.com and click on “Find an HHSC benefits office.”
  • Picking up a copy at a Women, Infants and Children Nutrition Program (WIC) office. Call 2-1-1 or 1-800-942-3678 to find an office.

Do women who are applying have to provide proof of their pregnancy?
Effective Feb. 1, 2009, a woman who is applying for CHIP perinatal services must send with her application a Report of Pregnancy (Form H3037). The form verifies the woman’s pregnancy by asking for information like the mother’s due date and the number of babies the mother is expecting. The form must be signed by the woman’s doctor, nurse, or another medical professional acting on behalf of the doctor.

As an alternative to the Report of Pregnancy form, a woman can submit a letter signed by her doctor providing the same information asked for in the form. If a woman sends in an application without this form or the alternative letter, HHSC cannot process the application.

What other documents do women need to send along with their application?
Besides the Report of Pregnancy form, women applying for CHIP perinatal services need to submit the following documents of proof:

  • Proof of income

    Proof must show current income for each person in the home. Proof can be:

    • Pay check stub from the last 60 days showing pay before taxes or deductions (gross pay).
    • Most recent IRS tax return with schedule C if filed. 
    • Proof of self employment.
    • Letter from your employer.  This letter should include your current income, and how often you get paid.  It should also include your name, the employer’s name, and the employer’s signature.
    • Social Security statement.
    • Child support check stub or receipt.
    • TANF forms.


  • Proof of expenses

    Proof can be receipts for:

    • Child care expenses, including the cost of transportation to and from daycare.
    • Expenses to care for an adult with a disability.
    • Child support payments.
    • Alimony payments.

What are common errors made during the application process?

  • Incomplete applications. Women who apply should provide an answer to all questions on the application, even if the answer is “N/A or Not Applicable” or “$0.”
  • No signature on the application.
  • Failure to send in all documents of proof that are required. These documents need to be sent in with the application. If one or more of these documents are missing, HHSC cannot process the application. Applications missing documents or information may be denied if the person applying doesn’t send in the material quickly.

How does a woman return the application?
A finished application can be sent by fax, mail, or in person. The application should include all needed documents (listed above).

Fax
Fax the completed and signed application, along with required information to our toll-free fax number, 1-877-542-5951. Fax each application one-by-one – in other words, dial and send each one separately. Do not send several applications together in a bundle or batch.

Mail
Mail the completed application and copies of required information to:
Texas Health and Human Services Commission
P.O. Box 14200
Midland, TX 79711-9901

In person
Finished applications and support documents can be turned in to a local HHSC benefits office. Call 2-1-1 to find an office or go to the HHSC Benefits Office search feature on this website.


Enrollment Information

How does a woman enroll in a CHIP perinatal health plan?
Once eligibility is determined, the unborn child will be enrolled in CHIP perinatal.  If the woman lives in a service area with more than one health plan choice, she will have 15 calendar days to select a health plan.  If she does not choose a health plan within the 15-day timeframe, HHSC will choose one for the new baby.

A pregnant woman with CHIP perinatal coverage for her unborn child will receive an ID card from her health plan that specifies “CHIP Perinatal Program” on the card. Following delivery, the newborn will receive a health plan ID card that specifies “CHIP Perinatal Program” on the card.

If you see a newborn before the baby has been issued a health plan ID card, contact the baby’s health plan for billing information.  It will be the same health plan that provided prenatal care.

CHIP perinatal coverage begins on the first day of the month in which eligibility is determined.  For example, if an application was submitted September 23, 2009, and eligibility was determined October 13, 2009, coverage would start October 1, 2009.

How will I know if a pregnant woman or a child is enrolled in CHIP perinatal?
A pregnant woman with CHIP perinatal coverage for her unborn child will receive an identification card from her health plan that specifies “CHIP Perinatal Program” on the card.  Following delivery, the newborn will receive a health plan identification card that specifies “CHIP Perinatal Program” on the card.
 
What if I see a CHIP perinatal newborn who has not yet been issued a unique CHIP perinatal ID card?
If you see a newborn before the baby has been issued a health plan identification card, contact the baby’s health plan for billing information.  It will be the same health plan that provided prenatal care.

Who can be a provider?
The CHIP perinatal provider network for prenatal care is limited to physicians, community clinics and providers who provide prenatal care within their scope of practice. This includes obstetricians/gynecologists, family practitioners, general practitioners, nurse practitioners, internists, nurse midwives or other qualified health care providers. 

The CHIP perinatal provider network for newborns consists of the same types of providers as traditional CHIP.

CHIP perinatal care will be provided by select CHIP health plans throughout the state.  Participating health plans will recruit physicians and providers for their respective networks. To become part of a network, physicians and providers must meet requirements of the respective health plan, such as credentialing standards, and have a contract with the health plan.

What CHIP perinatal health plans will be serving clients in my area?
See the map showing CHIP perinatal health plan service areas.
See the list of CHIP perinatal health plans and provider contacts.

How are providers reimbursed? What are the reimbursement rates?
To be reimbursed, providers must participate in a health plan’s network. Reimbursement rates will be negotiated between the provider and the health plan. Providers will submit claims directly to the health plan for payment. (Exception: Hospital facility claims for mothers and newborns at or below 185% FPL must be submitted to the Texas Medicaid Health Partnership (TMHP). See more details on this under “Hospital Reimbursement.”) Claim forms and processes vary by health plan.  Consult the CHIP perinatal health plan for billing details. 


Hospital Reimbursement

How is a hospital reimbursed for labor with delivery charges for CHIP perinatal clients with incomes at or below 185% of the federal poverty level (FPL)?
Women with CHIP perinatal coverage who have income at or below 185% of the FPL no longer need to apply for Medicaid at the time of delivery to cover their hospital stay. Instead, the hospital will need to fill out and send HHSC the mother’s bar-coded Emergency Medical Services Certification (Form H3038). This form asks for the dates the woman received emergency medical services (labor with delivery). Once HHSC receives the completed Form H3038, Emergency Medicaid coverage will be established for the mother for the period of time reflected on the form.

In these situations, facility charges are billed to TMHP. All professional charges are always billed to the CHIP perinatal health plan.

How is a hospital reimbursed for labor with delivery charges for CHIP perinatal clients with incomes at 186% FPL up to 200% FPL?
All charges, both facility and professional, are billed to the CHIP perinatal health plan. Emergency Medicaid is not required for billing facility charges.

How do I know a client’s FPL?
Hospital staff can find the client’s FPL on the client’s CHIP perinatal health plan ID card. If the client’s income is at or below 185% FPL, the card will read, “Bill Texas Medicaid Healthcare Partnership” or “TMHP” under “Hospital Facility Billing.” If the client’s income is above 185% FPL, the card will have the health plan’s billing address and phone number under “Hospital Facility Billing.”

If the client’s health plan ID card is not available, call the client’s health plan for this information.

How does the hospital get the Form H3038?
The expectant mother will receive the bar-coded Form H3038 from HHSC a month before the baby’s due date along with a pre-addressed, postage-paid envelope. She will be instructed to take the form with her to the hospital when she’s ready to deliver. Once the baby is born, hospital staff will need to fill out the form, then fax it to HHSC or give it to the mother to mail back using the pre-addressed envelope. 

What if the expectant mother does not bring the bar-coded Form H3038 with her to the hospital?
The hospital can download, fill out, and send in a Form H3038 that is not bar-coded. In this case, hospital staff should make a copy of the mother’s CHIP perinatal ID card and send that copy with the completed Form H3038 or write the mother’s CHIP perinatal ID number at the top of the form. The mother’s name on the H3038 must match the name on the CHIP perinatal ID card.

Failure to provide the mother’s CHIP perinatal ID number, or writing in a name that doesn’t match the mother’s perinatal ID card, could delay processing and require the mother to go through the entire Medicaid application process, delaying reimbursement.

How does the hospital get the Form H3038 to HHSC?

Fax:
1-877-542-5951.

Fax each application one-by-one – in other words, dial and send each one separately. Do not send several applications together in a bundle or batch.

Mail:
HHSC
P.O. Box 14400
Midland, Texas 78711-4400

How will the hospital know if HHSC has received the Form H3038 and Medicaid has been established?
Once the Form H3038 is completed and sent in, the mother can call 1-800-647-6558 to verify that it has been received (Note: Hospital staff will not be able to get verification by calling this number.) Providers also can go to TMHP’s website to verify client eligibility.

Where can I get information on how to bill for newborns?
For detailed information, visit the Newborn Claims Instruction for Hospitals on the CHIP perinatal website.

Is a Medicaid application needed for newborns?
The newborn does not need a Medicaid application. If the baby’s mother’s income is at or below 185% FPL, a Medicaid number (TP 73) will be established based on the report of the birth, either through the hospital’s birth registry process or by the mother calling CHIP at 1-877-KIDS-NOW to report the birth. This TP 73 Medicaid number assigned to the baby is for hospital billing purposes only and it will become invalid once the baby is discharged from the hospital. The baby’s Medicaid number is not connected to the mother’s Emergency Medicaid coverage.

Although the mother can apply for Medicaid for her baby anytime after delivery, the baby will be placed on Medicaid prospectively, leaving the baby without coverage for the hospital stay. If this occurs, the hospital can still ask HHSC to issue a TP 73 number. To learn more, see the Newborn Claims Instruction for Hospitals.

What if the baby is in the Neo-natal Intensive Care Unit (NICU)?
If the mother applies for Medicaid for her baby and the baby is medically fragile and in the NICU, Medicaid coverage can be established retroactive to the baby’s date of birth. The HHSC eligibility worker must be told that the application is for an infant on CHIP perinatal and the baby is in the NICU.

Where can I get more information on billing in general?
See the “Hospital Training” section on the Provider Training Materials page of this website.

What are common errors in hospital billing?

  • Billing the wrong entity.
  • Not reporting the birth.
  • Reporting the wrong dates of service.

How do I report the birth of a newborn receiving CHIP perinatal services?
Go to the CHIP perinatal website and click on the link for “Vital Statistics Instructions for Hospitals.”
 

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