Transcript Leadership Briefing Outline

CHIP Perinatal
Texas Health and Human Services Commission
Table of Contents
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Introduction
Eligibility
Benefits
Referrals
Application
Enrollment
Renewals
Resources
Page 2
Introduction
Program History
• Overview:
 Authorized by Texas Legislature in 2005
 The state is using a federal provision that allows
states to provide Children’s Health Insurance
Program coverage to unborn children.
Page 4
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.
Page 5
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.
Page 6
Comparison of CHIP Perinatal to
Traditional CHIP
CHIP Perinatal
Traditional CHIP
• No asset test.
• No 90-day wait.
• No cost sharing.
• Asset test applies
• 90-day waiting period.
• Enrollment fee and copays, if applicable.
• 6-month eligibility
period
• 12-month eligibility
period.
Page 7
Eligibility
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.
Page 9
Benefits
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  Nurse Midwives
 General practitioners Nurse practitioners
 Internists
 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.
Page 11
CHIP Perinatal Health Plans
CHIP Perinatal
Dallam
Sherman
Hartley
Moore
Oldham
Potter
Ochiltree
Lipscomb
Hutchinson Roberts
Hansford
Hemphill
Lubbock CHIP O-SA
Superior
Service Areas
with HHS Regions (in red)
Effective January 1, 2007
Carson
1
Deaf Smith
Gray
Tarrant CSA
Wheeler
Amerigroup
Randall
Armstrong
Donley Collingsworth
Dallas CSA
Parmer
Castro
Swisher
Briscoe
Hall
Childress
Parkland
Hardeman
Bailey
Lubbock SDA
Hale
Lamb
Floyd
Motley
Cottle
Wilbarger
Wichita
Foard
FirstCare
Superior
Clay
Cochran Hockley
Crosby
Lubbock
King
Dickens
Baylor
Knox
Montague
Archer
Cooke
Grayson
Lamar
Fannin
Red River
Bowie
Delta
Yoakum
El Paso O-SA
Superior
El Paso First
Loving
Winkler
Ward
Culberson
Garza
Kent
Stonewall
Haskell Throckmorton Young
Gaines
Dawson
Borden
Scurry
Fisher
Jones
Andrews
Martin
Howard
Mitchell
Nolan
Taylor
Ector
Crane
Reeves
Midland Glasscock Sterling
2
Palo
Pinto
Shackelford Stephens
Upton
Pecos
Jeff Davis
10
Coke
Parker
Eastland
Callahan
Runnels
Coleman Brown
Irion
3
Rusk
Navarro
Zavala
Superior
Panola
Shelby
Nacogdoches
Limestone
Robertson
San Augustine
Sabine
Angelina
Houston
Leon
Falls
7
Trinity
Madison
Milam
Polk
Walker
Brazos
Grimes
Williamson
Travis
Blanco
5
Jasper
Newton
Tyler
Travis CHIP O-SA
Superior
San Jacinto
Lee
Fayette
Caldwell
Comal
Bandera
Frio
Liberty
Waller
Austin
6
Harris
Colorado
Guadalupe
Gonzales
Orange
Jefferson
Chambers
Harris CHIP O-SA
Fort Bend
Lavaca
Medina
8
Hardin
Montgomery
Washington
Bastrop
Hays
Bexar
Galveston
Wharton
Community Health Choice
Brazoria
Wilson
De Witt
Atascosa
Jackson
Karnes
Matagorda
Victoria
Maverick
Community First
Superior
Travis CSA
Harrison
Anderson Cherokee
Kendall
Uvalde
Gregg
Smith
Burleson
Gillespie
Kinney
4
Marion
Freestone
Burnet
Kerr
Real
Upshur
Henderson
Kimble
Edwards
Wood
Ellis
McLennan
Llano
Terrell
Bexar
CHIP O-SA
Rains
Bosque
Menard
Mason
Val Verde
Rockwall
Hamilton
Concho
Cass
Camp
Dallas
Hill
Bell
Sutton
Titus
HopkinsFranklin Morris
Hunt
KaufmanVan Zandt
McCulloch San Saba Lampasas
Schleicher
Collin
Coryell
Crockett
Brewster
Goliad
Dimmit
La Salle
McMullen Live Oak
Calhoun
Bee
Harris CSA
Refugio
Community Health Choice
Aransas
Bexar CSA
San Patricio
Community First
Superior
Webb
Duval
Jim Wells
11
Zapata Jim Hogg Brooks
Core Service Area (CSA)
Nueces
Kleberg
Nueces CHIP O-SA
Superior
Kenedy
Nueces CSA
Starr
Non-HMO model for CHIP Perinatal
(EPO model)
Tarrant
Johnson
Somervell
Erath
Comanche
Tom Green
Reagan
Presidio
Optional Addition to CSA (O-SA) for
CHIP Perinatal
Denton
Mills
9
El Paso CSA
El Paso First
Superior Health Plan
Lynn
Wise
Hood
El Paso
Hudspeth
Terry
Jack
Webb CSA
Mercy
Hidalgo
Willacy
Superior
Cameron
Page 12
HHSC, Medicaid/CHIP Managed Care Operations
March 2006
Benefits
• Up to 20 prenatal care visits (more if medically necessary)
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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
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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.
Page 13
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).
Page 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.
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.
Page 15
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.
Page 16
Referrals
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.
Page 18
Application
Application
• Applications will be available at many places:
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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 1-877KIDS-NOW to find an office.
Page 20
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.
Page 21
What Documentation is
Needed?
• Verification of income is the only required item.
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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
Page 22
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.
Page 23
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.
Page 24
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.
Page 25
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.
Page 26
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.
Page 27
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
Page 28
Application Processing
• HHSC has 15 business days to process the
application from the day it is received.
Page 29
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
Page 30
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.
Page 31
Enrollment
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.
Page 33
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 1-877KIDS-NOW to switch health plans.
Page 34
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
Page 35
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 1-800647-6558
Page 36
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.
Page 37
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.
Page 38
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.
Page 39
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.
Page 40
Renewal
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.
Page 42
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.
Page 43
Reporting an address change
 Clients can inform CHIP Perinatal of address
changes by calling 1-800-647-6558
Page 44
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.
Page 45
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.
Page 46
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)
Page 47