Transcript Leadership Briefing Outline - Health and Human Services

CHIP Perinatal
Texas Health and Human Services Commission
Table of Contents
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Introduction
Benefits
Referrals
Eligibility
Application
Renewals
Resources
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Introduction
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.
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Purpose
• Purpose
 To extend CHIP services to unborn children of nonMedicaid 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.
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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.
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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.
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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.
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Benefits
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
 Nurse Midwives
 Nurse practitioners
 Internists
• 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.
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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
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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
• 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.
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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.)
 Professional service charges paid through CHIP Perinatal health
plan.
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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.
• 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 Member Handbooks - mailed to member.
 CHIP Provider Manual - mailed to provider by health plan.
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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.
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Eligibility
and
Enrollment
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.
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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 2-1-1 to
find an office.
 Participating WIC clinics. Call 2-1-1 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
 The Integrated Application
• www.yourtexasbenefits.com, or
• by calling 2-1-1.
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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.
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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 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.
• Pregnant women determined to be eligible only for CHIP
Perinatal can self-declare immigration status.
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Medicaid Identity and
Citizenship Verification
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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.
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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.
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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.
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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.
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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.
 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
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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.)
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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.
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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.
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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 1-877KIDS-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.
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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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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.
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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
directly to TAA, 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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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.
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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.
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Resources
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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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