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Texas Health and Human Services Commission

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1 Texas Health and Human Services Commission
CHIP Perinatal Texas Health and Human Services Commission

2 Table of Contents Introduction Eligibility Benefits Referrals
Application Enrollment Renewals Resources

3 Introduction

4 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.

5 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. CHIP Perinatal: Who does What? CHIP Perinatal health plans: recruit and pay CHIP Perinatal providers, provide Member Handbook to clients, answer client benefit questions, prepares a provider directory, and helps clients with provider selection CHIP Perinatal provider: Provides prenatal care and health care services to baby Health and Human Services Commission: Oversees the state contract with the health plan; oversees state contract with Texas Access Alliance Texas Access Alliance: CHIP Vendor – processes CHIP Perinatal applications, oversees enrollment process into CHIP Perinatal The child can apply for Medicaid anytime after birth, but not encouraged unless serious medical issues might make the child eligible for SSI.

6 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.

7 Comparison of CHIP Perinatal to Traditional CHIP
No asset test. No 90-day wait. No cost sharing. 12-month eligibility period. Traditional CHIP Asset test applies 90-day waiting period. Enrollment fee and co-pays, if applicable. 6-month eligibility period

8 Eligibility

9 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. Medicaid coverage for pregnant women goes up to 185% FPL. Coverage can be for teens, also – there is no age limit.

10 Benefits

11 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 General practitioners 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. Nurse Midwives Nurse practitioners Internists This slide, first bullet, you can tailor for the health plans in your area.

12 CHIP Perinatal Health Plans

13 Benefits Up to 20 prenatal care visits (more if medically necessary)
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 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.

14 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).

15 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.

16 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. Can add the names of the health plans to the second bullet, if you’d like.

17 Referrals

18 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.

19 Application

20 Application Applications will be available at many places:
Dialing KIDS-NOW ( ). Online at: HHSC Benefits offices. Call to find an office. Participating community-based organizations. Call KIDS-NOW to find an office.

21 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 or by calling Those who wish to apply for other benefits in addition to CHIP Perinatal ,should use: Form H1010, the Application for Assistance Clients can call for more assistance.

22 What Documentation is Needed?
Verification of income is the only required item. 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

23 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. Pregnant women determined to be eligible only for CHIP Perinatal can self-declare immigration status.

24 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. Making a Medicaid application would not be encouraged unless the baby appears to be eligible for SSI, or has more serious health care needs that may not be covered by CHIP.

25 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. Immigration status of the mother does not matter for purposes of CHIP Perinatal, because coverage is for unborn child. However, if mother has insurance coverage, it is assumed those benefits would also extend to her unborn child. Explain the application, and show them the app. Show them that sections 3 and 4 have to do with applying for children’s insurance, and 9 deals with assets, so are not applicable to CHIP Perinatal.

26 Application: Important Things to Know
How does an applicant verify the status of their application? By calling KIDS-NOW Due to confidentiality reasons, information on the status of an application can only be given to the applicant or an authorized representative.

27 Applications: How to Order
Bulk supplies of applications are available for ordering. Order applications on-line by going to the following website: Click on the information for community-based organizations and health plans.

28 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

29 Application Processing
HHSC has 15 business days to process the application from the day it is received.

30 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

31 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.

32 Enrollment

33 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. If you are in an area with only one health plan, go ahead and modify slide to incorporate the plan’s name.

34 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 KIDS-NOW ( ) 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 KIDS-NOW to switch health plans. In areas with a health plan choice, go ahead and create a new bullet with the choice of plans in your area.

35 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

36 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

37 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. 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.

38 Picking a provider Choosing a primary care provider for baby
Once baby is born, client will need to notify the program by calling 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.

39 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.

40 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, 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. Recommend a slide with the health plan names and phone numbers for member services.

41 Renewal

42 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. Applications submitted directly to TAA from the client and the CBOs only require 1 check stub as verification for the pregnant woman and regular CHIP kids. If the client goes directly to a local HHSC benefits office, they may be asked to provide four check stubs (Medicaid policy) in order to determine Medicaid ineligibility for a US Citizen or eligible immigrant prior to deeming to CHIP Perinatal. However, once they are deemed the vendor does not request additional verification from the client. They use the deem information to process the application.

43 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.

44 Reporting an address change
Clients can inform CHIP Perinatal of address changes by calling

45 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.

46 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.

47 Resources Client Fact Sheets (English and Spanish)
Brochures (Coming soon) Community health worker/Promotoras training Applications Office posters (Coming soon) Website: (click on CHIP Perinatal in the middle of the page)

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