Transcript Leadership Briefing Outline - Health and Human Services

CHIP Perinatal Hospital Training
Texas Health and Human Services Commission
March 27, 2007
Table of Contents
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Program History/Overview
Eligibility: Who Qualifies?
Coverage
Who Provides CHIP Perinatal Benefits
Benefits
Services not Covered
Emergency Medicaid
Hospital Billing
Vital Statistics
Hospital Claims Filing
Newborn Screening Changes
CHIP Perinatal Resources
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Program History
• Overview:
 Authorized by Texas Legislature in 2005 (Texas
2006-2007 General Appropriations Act, Article II,
Health and Human Services Commission, Rider
70).
 Texas is operating under a federal provision that
allows states to provide Children’s Health
Insurance Program (CHIP) coverage to unborn
children.
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CHIP Perinatal Overview
• CHIP Perinatal provides prenatal care to unborn children of
pregnant women with household income at or below 200
percent of the federal poverty level (FPL) and who are not
eligible for Medicaid Pregnant Women’s program.
• 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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Eligibility: Who qualifies?
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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.
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An applicant is not eligible for CHIP Perinatal if she gives birth prior to
an eligibility decision.
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Coverage
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Coverage starts on the 1st of month the unborn child is determined
eligible, and lasts for 12 months.
 Example: Application is filed February 20, 2007, and eligibility is finalized
March 12, 2007. Coverage would start March 1, 2007.
 If baby is enrolled when mother is four months pregnant, and is born at full
term, the baby will have six months of prenatal care (including month of
enrollment) and six months of CHIP coverage upon delivery.
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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
card indicating “CHIP Perinatal,” that will also contain the baby’s unique
identification number for the program. (This number will be separate
from the mother’s identification number.)
Clients must notify CHIP Perinatal of the birth by calling 1-800-6476558. The CHIP Perinatal program will need to know: date baby was
born, baby’s gender, and baby’s name.
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Who Provides
CHIP Perinatal Benefits?
• CHIP Perinatal is available statewide, and is provided through
select CHIP Perinatal health plans. For information on the
health plans in your area, and provider relations contacts, visit
the CHIP Perinatal website at:
http://www.hhsc.state.tx.us/chip/perinatal/index.htm
• Each health plan recruits a network of providers for prenatal
care, and for newborns. The network for prenatal care includes
obstetricians, clinics, family practitioners, general practitioners,
nurse midwives, nurse practitioners, and more.
• CHIP Perinatal provider network for newborns consists of the
same type of providers as traditional CHIP.
• The CHIP Perinatal network also includes hospitals.
• All providers are listed in the health plan’s provider directory,
which is provided to clients upon enrollment in their enrollment
packet.
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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
Parker
Upton
Pecos
Jeff Davis
10
Eastland
Callahan
Runnels
Tom Green
Reagan
Coleman Brown
Irion
3
Rusk
Navarro
Travis CSA
Harrison
Superior
Panola
Anderson Cherokee
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
Kendall
Uvalde
Fayette
Caldwell
Comal
Bandera
8
Frio
Liberty
Waller
Austin
6
Harris
Colorado
Guadalupe
Gonzales
Orange
Jefferson
Chambers
Harris CHIP O-SA
Fort Bend
Lavaca
Medina
Zavala
Hardin
Montgomery
Washington
Bastrop
Hays
Bexar
Galveston
Wharton
Community Health Choice
Brazoria
Wilson
De Witt
Atascosa
Jackson
Karnes
Matagorda
Victoria
Maverick
Community First
Superior
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
Webb
Community First
Superior
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
Coke
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
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Prescriptions based on CHIP formulary
Case management and care coordination
Ultrasound of the baby when medically indicated
Labor with delivery of child for clients at certain income levels.
(See hospital benefits for more details.)
• 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:
 All hospital facility and professional charges covered by
CHIP Perinatal, and paid by the CHIP Perinatal health plan.
• For women with income at or below 185 percent FPL:
 Women must apply for Emergency Medicaid in order for the
hospital facility charges to be considered for payment by
Medicaid. Hospital facility charges are not covered by the
CHIP Perinatal program for this income group.
 Professional fees are covered under CHIP Perinatal, and are
paid by the CHIP Perinatal health plan.
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What Services are Not
Covered?
• Preterm labor that does not result in a birth and 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 be
considered for 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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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 contact information for the Texas Medicaid Health
Partnership (TMHP) listed for hospital billing. Those at 186200% FPL will have the health plan contact information for
hospital billing.
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Emergency Medicaid
• When assisting a woman in applying for
Emergency Medicaid for her labor and
delivery, it is not necessary to also apply for
Medicaid for the baby.
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Medicaid: Special
Circumstances
• Although a woman can file a Medicaid application for
her infant any time after birth, this is not necessary
because the baby has 12 months of continuous
coverage under CHIP Perinatal. This coverage
continues after discharge from the hospital.
• Exception:
 A hospital may wish to assist a client in filing a “regular”
Medicaid application for the baby if the baby has medical
conditions that are not normal for a newborn, and could
benefit from the Medicaid benefit package.
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Hospital Billing
• For women with income between 186 and 200
percent FPL:
 All hospital facility and professional charges must be billed to
the CHIP Perinatal health plan.
• For women with income at or below 185 percent FPL:
 Women must apply for Emergency Medicaid in order for the
hospital facility charges to be considered for payment by
Medicaid. Hospital facility charges are not a covered benefit
under CHIP Perinatal for this income group.
 Professional fees are a covered benefit of CHIP Perinatal,
and are paid by the CHIP health plan.
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Vital Statistics
• For women with income at or below 185 percent FPL:
 Hospital providers must submit birth information to the Department
of State Health Services via the Texas Vital Statistics (TVS)
electronic interface or manually in a timely manner so a Patient
Control Number, or PCN, (PCN and Medicaid number are the
same) can be issued for the newborn.
 The only difference in the TVS electronic interface screen is the
field for the mother’s Medicaid number. This field has been
modified to accept both Medicaid and CHIP Perinatal numbers.
Enter the mother’s CHIP Perinatal number into this field (even if the
mother has two numbers – one for Emergency Medicaid, and one
for CHIP Perinatal).
• Hospital providers will not receive a PCN for the newborn once
the PCN is issued, but will receive a PCN for the mother.
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Vital Statistics
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Hospital Claims Filing
• For women with income at or below 185 percent FPL:
 Hospitals must continue to file two Medicaid claims, one for
the mother and one for the newborn.
 Mother: Hospitals should continue their current billing
procedures and file the mother’s claim for labor with delivery
to Medicaid.
 Newborn: Hospitals billing for CHIP Perinatal newborns may
file a claim in one of two ways:
• Claims Filed with the Mother’s PCN
• Claims Filed with the Newborn’s PCN
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Hospital Claims Filing
• Newborn Claims Filed with the Mother’s PCN:
 The newborn’s hospital facility charges can be filed with the
mother’s PCN on a separate claim identifying the charges
for the newborn if the provider has the newborn’s complete
birth name that is a one-to-one match to the information
submitted to the Texas Vital Statistics (TVS) unit at the
Department of State Health Services (DSHS).
 If claims are submitted with the mother’s PCN and the
information doesn’t match the first and last name information
received by TVS and issued for the newborn’s PCN, the
claim will be held for up to ninety (90) days while TMHP
continues to check for an exact match on the eligibility file.
At the end of the 90 days if eligibility for the baby is not
received or a match was never found, the claim will deny.
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Hospital Claims Filing
• Newborn Claims Filed with the Mother’s PCN:
 Hospital providers will need to appeal or re-file denied claims
with the newborn’s PCN and birth name OR they must resubmit with the mother’s PCN and the newborn’s complete
birth name if the claim denies with Evidence of Benefits
message, “CLIENT’S FULL NAME, CLIENT NUMBER, SEX
& DATE OF BIRTH DO NOT MATCH INFORMATION ON
FILE.”
 Mother’s PCN will be sent to the hospital.
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Hospital Claims Filing
• Both inpatient newborn claims and inpatient claims for the
mother should be submitted to TMHP within 95 days from the
date eligibility is added to the system (“add date”), or within 95
days from the discharge, (or “Through Date of Service”) on an
inpatient claim.
• Any hospital services received after the original newborn
hospital discharge will not be considered for reimbursement
under Medicaid, but will be covered under CHIP Perinatal.
• A hospital will be reimbursed under the current reimbursement
methodology with Texas Medicaid for Traditional Acute Care
Medicaid (Program 100), i.e.., DRG or TEFRA.
• Professional Services incurred during the hospital stay are paid
by CHIP Perinatal health plans for all mothers and newborns
regardless of their income.
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Hospital Claims Filing
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Newborn Claims Filed with the Newborn’s PCN:
 Newborn’s PCN is not sent back to the hospital. Hospital providers can
obtain the newborn’s PCN by performing an eligibility inquiry with TMHP via
the portal at www.tmhp.com or calling TMHP.
 A CHIP Perinatal newborn claim will be considered for payment only when
the original admit date is equal to the date of birth.
• Deliveries before midnight and admission to the hospital can be paid on
appeal with appropriate medical documentation.
• Transfers: Newborns transferred from one facility or readmitted to a
facility will be considered for reimbursement if a direct transfer or readmittance within 24 hours has occurred. This stay will be considered
continuous; therefore, all hospital facility charges are eligible for
payment.
 It may be less of a wait for the provider if the claim is submitted with the
newborn’s unique identification number, because if a claim is filed under the
mother’s PCN, the claim must be processed manually, and may be held up
to 90 days while TMHP awaits the receipt of the baby’s eligibility
information.
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Newborn Screening Changes
• Effective February 1, 2007, providers submitting newborn
screening specimens to the state laboratory may now use the
NBS3: Medicaid/Charity Care test card when screening babies
insured by traditional CHIP and CHIP Perinatal.
• Newborn screening refers to the newborn screening for 27
genetic disorders conducted by the state (Department of State
Health Services) laboratory.
• There will be no charge for newborn screening test cards for
Medicaid-eligible, CHIP, CHIP Perinatal or charity care
newborns.
• Hospitals can use the NBS3 Medicaid/CHIP/charity care card for
screens conducted for CHIP and CHIP Perinatal newborns
regardless of their income level (including CHIP Perinatal
clients at 186-200% FPL.)
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Newborn Screening Changes
• To order newborn screening supplies, call 512-4587661, or send a fax to 512-458-7672 to request an
order form. Specify the total number of test cards
(not package amounts) needed by category:
1) NBS3: Medicaid/CHIP/charity care
2) NBS4: Non-Medicaid/non-CHIP/non-charity care;
covered by private insurance
• The laboratory will send the supplies. Use these
supplies to collect the samples and submit to the
state Department of State Health Services laboratory.
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CHIP Perinatal Resources
HHSC website:
http://www.hhsc.state.tx.us/chip/perinatal/index.htm
TMHP general inquiries hotline:
1-800-925-9126
TMHP website:
http://www.tmhp.com/Medicaid/default.aspx
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