Program Description, Eligibility Information, Benefits and Key Components
What is CHIP perinatal coverage?
CHIP perinatal provides 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.
When will applications be accepted?
Applications will be accepted beginning Jan. 2, 2007. An application received before Jan. 2, 2007, will not be screened for CHIP perinatal eligibility.
Who is eligible?
Unborn children of pregnant women who:
- Have a household income greater than 185 percent FPL and up
to 200 percent FPL.
- Have a household income at or below 200 percent 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 percent 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, 2007, and eligibility was determined March 13, 2007, coverage would start March 1, 2007.
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 between 186-200 percent FPL:
- Hospital facility charges paid through CHIP.
- Professional service charges paid through CHIP.
- 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.)
- Professional service charges paid through CHIP.
- More information about CHIP benefits for the unborn child is available in the health plan provider manuals.
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.org.
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?
- Twelve months of continuous coverage from the time eligibility is determined. For example, if eligibility is determined when the mother is three months pregnant, the unborn child will have six months of prenatal coverage, and six months of coverage after the birth.
- 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.
Program Application Information
How can pregnant women apply?
Applications are available at many places:
- Health and Human Services Commission benefits offices. Call 2-1-1 to find an office.
- Participating community-based organizations. Call 2-1-1 to find an office.
- Online at www.yourtexasbenefits.com.
Completed applications can be returned at a local Health and Human Services Commission benefits office, by mail or by fax. The fax number and address are listed on the application.
How can providers assist with applications to CHIP perinatal?
Specific training on the application process will be available to providers before implementation of CHIP perinatal. Providers who want to supply applications in their office can order them in bulk at www.hhsc.state.tx.us.
Program Enrollment Information
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 been issued a unique Identification Card yet?
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.
[Health plan and provider contacts]
What health plans will be serving clients in my area?
See the map of health plans.
How will providers be reimbursed? What will the reimbursement rates be?
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. Claim forms and processes vary by health plan. Consult the CHIP perinatal health plan for billing details.
How will hospital professional fees be reimbursed?
All professional fees will be reimbursed by the CHIP perinatal health plan. For billing information, contact the health plan.
How will hospital facility charges be reimbursed? What will the reimbursement rates be?
- Clients with household income at or below 185 percent FPL: Information on hospital reimbursement will be provided in the January/February 2007 Texas Medicaid Bulletin. These claims are Emergency Medicaid claims and will be billed to Texas Medicaid Health Partnership (TMHP). The client’s CHIP perinatal identification card will have billing information on the card.
- Clients with household income between 185-200 percent FPL:Hospital claims will be reimbursed by the CHIP perinatal health plan. The client’s identification card will include billing information.
Will interpreter services be available when serving the client?
The health plan(s) with which you contract will provide the necessary information to obtain this service. Call the health plan’s provider helpline for more information.