What is CHIP perinatal coverage?
CHIP perinatal coverage provides care to unborn children of pregnant women who are not eligible for Medicaid and who have household income up to 200 percent of the federal poverty income level (FPIL). Once born, the child will receive Medicaid or CHIP benefits, depending on their income.
Who is eligible?
Unborn children of pregnant women who:
- Have a household income greater than 185 percent of the federal poverty level (FPL) and at or below 200 percent of the FPL.
- Have a household income at or below 200 percent of the 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 of the FPL may be eligible for coverage under Medicaid's Pregnant Women program.
How long does the eligibility and enrollment process take?
Texas Health and Human Services (HHS) staff have 15 business days to process the application from the day they received it. Once eligibility is determined, the pregnant woman enrolls in a CHIP perinatal health plan on behalf of her unborn child. She has 15 calendar days to select a health plan from the day she gets a letter stating she can get CHIP perinatal benefits. If she does not choose a medical plan within the 15-day timeframe, HHS will choose one for her.
When does a woman's coverage start?
Coverage begins on the first day of the month in which eligibility is determined. For example, if a woman submitted an application Feb. 23, and eligibility was determined March 10, coverage would start March 1.
What are the CHIP perinatal benefits for the unborn child?
CHIP perinatal coverage includes:
- Up to 20 prenatal visits
- During the first 28 weeks of pregnancy ― 1 visit every 4 weeks
- During weeks 28 to 36 ― 1 visit every 2 to 3 weeks
- 36 weeks to delivery ― 1 visit per week
- Additional prenatal visits are allowed if they are medically necessary
- Some laboratory testing, assessments, planning services, education and counseling
- Prescription drug coverage based on the current CHIP formulary, including prescription prenatal vitamins
- Diabetic supplies available through pharmacies with a physician prescription
- Hospital facility charges and professional services charges related to the delivery.
- For women with income from 186-200 percent of the FPL:
- Both hospital and professional service charges paid through the CHIP perinatal health plan
- For women with income at or below 185 percent of the FPL (this income range represents the majority of CHIP perinatal clients):
- Professional service charges paid through CHIP
- Hospital facility charges paid through Emergency Medicaid (Note: Emergency Medicaid will need to be established before a claim can be paid to a Medicaid provider. See "How is a hospital reimbursed for labor with delivery charges for CHIP perinatal patients with incomes at or below 185 percent of the FPL?")
- For women with income from 186-200 percent of the FPL:
- 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.
- Once a child is discharged from the initial hospital admission, the child receives the traditional CHIP benefit package, or Medicaid, depending on their income. CHIP or Medicaid benefits include regular checkups, immunizations and prescriptions for the baby after he or she leaves the hospital.
- Depending on income, the newborn may get Medicaid from birth to their 1st birthday. Most CHIP perinatal infants qualify for Medicaid. If the baby is eligible to get Medicaid, the mother will receive a letter and Form H3038P in the mail before delivery.
What services are not covered?
CHIP perinatal provides a basic prenatal care package. Participating health plans will distribute a provider manual that includes covered and non-covered (excluded) benefits. Below are examples of non-covered services:
- Inpatient hospital care for the mother of the unborn child that is not related to labor with delivery, such as a serious injury, illness and more
- Labor without delivery of the baby (false or premature labor)
- Most outpatient specialty services, such as mental health and substance abuse treatment, asthma management, and cardiac care
A pregnant woman may apply for Emergency Medicaid in emergency situations. However, the bar-coded Form H3038P that HHS mails to a pregnant woman with income at or below 185 percent of the FPL only may be used to apply for Emergency Medicaid for her labor with delivery. She may not use her bar-coded H3038P, mailed by HHS, for services such as:
- Labor with no delivery (false labor or premature labor)
- Other non-delivery emergency services, such as hospitalization for a serious injury, illness and more
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 pregnant woman get services not covered under CHIP perinatal?
Community clinics and other providers who currently serve the covered population, such as Title V providers, may provide services that are not benefits of CHIP perinatal.
What are the differences between CHIP perinatal coverage and traditional CHIP?
- The 90-day waiting period that applies in some CHIP cases does not apply to CHIP perinatal.
- Co-payments and enrollment fees that may apply in traditional CHIP do not apply in CHIP perinatal.
How can pregnant women apply?
Providers who want to have applications available in their office can order them can order them online. The application is named Application for Health Insurance & Help Paying Costs; the form number is H1205.
All applicants for CHIP perinatal services will be screened to see if they qualify for Medicaid for Pregnant Women. If they don't qualify for Medicaid, HHS will determine if they qualify for CHIP perinatal coverage.
What other documents do women need to send with their application?
Women applying for CHIP perinatal services need to submit the following documents of proof:
Proof of Income
Proof must show current income for each person in the home. Proof can be:
- Pay check stub from the last 60 days showing pay before taxes or deductions (gross pay)
- Last year's tax return
- Proof of self-employment
- Letter from your employer. This letter takes the place of a paycheck stub. It should how much you make now and how often you get paid. It also should include your name, the employer's name, and the employer's signature.
- Social Security statement
Proof of Expenses
Allowable expenses include those allowed under IRS rules. Allowable expenses include:
- Alimony paid
- Educational expenses/student loan interest
- Moving expenses
- Tuition or GI Bill deduction
- Educator expenses
- IRA deduction
- Health Savings Account
Proof can only be the federal income return from the previous year with the exception of alimony. Alimony paid also can be verified by:
- Divorce decree
- Court order
- Court records
- Statement from the person who is receiving the alimony
What are common errors made during the applications process?
- Incomplete applications. Women who apply should provide an answer to all questions on the application, even if the answer is N/A or Not Applicable or $0.
- No signature on the application.
- Failure to send in all documents of proof that are required. These documents need to be sent in with the application. If 1 or more of these documents is missing, HHS cannot process the application. Applications that are missing documents or information may be denied if the person applying doesn't send in the material quickly.
How does a woman return the application?
The quickest way to complete and return an application is to complete the application online at YourTexasBenefits.com.
A paper application can be sent by fax or mail or delivered in person. The application should include all needed documents listed above under Proof of Income and Proof of Expenses.
Fax the completed and signed application, along with required information, to 1-877-447-2839. Dial and send each application separately. Do not send several applications together in a bundle or batch.
Mail the completed application and copies of required information to:
Texas Health and Human Services Commission
P.O. Box 14600
Midland, TX 79711-4600
Finished applications and copies of required information can be turned in to a local HHS benefits office. To find the office nearest you, call 2-1-1 or 1-877-541-7905; after you pick a language, press 2.
How does a woman enroll in a CHIP perinatal health plan?
Once a woman is found to be eligible for CHIP perinatal services, her unborn child must be enrolled in a health plan. The woman has 15 calendar days to select a health plan. The 15-day window opens the day she receives a letter from HHSC saying she qualifies for CHIP perinatal services on behalf of her unborn child. If she does not choose a health plan within the 15-day timeframe, HHS will choose one for her.
Once she has enrolled, the woman will receive an ID card from her health plan that specifies CHIP Perinatal Program.
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 ID card from her health plan that specifies CHIP Perinatal Program.
Following delivery, most babies born to a CHIP perinatal mother will switch to Medicaid from date of birth. Newborns that remain in the CHIP Perinatal program for the duration of their 12-month coverage period will receive a health plan ID card that specifies CHIP Perinatal Program.
What if I see a CHIP perinatal newborn who has not yet been issued a unique ID card?
Because most CHIP perinatal newborns change to Medicaid from their date of birth, their moms typically need to enroll the baby in a STAR health plan after they are born. Once enrolled, they will receive a new STAR health plan ID, as well as a Your Texas Benefits Medicaid card. Even if the baby does not have a Medicaid card or a STAR health plan ID, you can verify the baby's Medicaid eligibility (and STAR health plan, if applicable) by doing one of the following:
- Check the provider website at www.yourtexasbenefitscard.com
- Call 1-800-925-9126
- Go to TexMedConnect on the TMHP website
There is a gap between the time the child is born and he or she is enrolled in a STAR health plan. During this gap, newborn claims will be paid with traditional, fee-for-service Medicaid.
For babies who remain in CHIP perinatal after birth, contact the health plan that provided prenatal care under CHIP perinatal.
Who can be a provider?
Physicians, community clinics and providers who offer prenatal care within their scope of practice can provide CHIP perinatal prenatal care. This includes obstetricians/gynecologists, family practitioners, general practitioners, nurse practitioners, internists, nurse midwives or other qualified health care providers.
Those who can provide CHIP perinatal care for newborns are the same types of providers as traditional CHIP.
CHIP perinatal care is provided by all CHIP health plans throughout the state. Health plans 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.
What CHIP perinatal health plans are in my area?
How are providers reimbursed? What are the reimbursement rates?
To be reimbursed, providers must participate in a health plan's network. Reimbursement rates will be negotiated between the provider and the health plan per contractual agreements. Providers will submit claims directly to the health plan for payment. (Exception: Certain claims for patients at or below 185 percent of the FPL must be submitted to the Texas Medicaid Health Partnership [TMHP]. See more details under Hospital Reimbursement.) Claim forms and processes vary by health plan. Consult the CHIP perinatal health plan for billing details.
How is a hospital reimbursed for labor with delivery charges for CHIP perinatal patients with incomes at or below 185 percent of the FPL?
The hospital will need to complete and submit the mother's bar-coded CHIP Perinatal - Emergency Medical Services Certification (Form H3038P) to establish Emergency Medicaid for labor with delivery. This form is mailed to the woman before her delivery, and she is instructed to bring it with her to the hospital when she delivers. The form includes a place to add the dates the woman received emergency medical services (labor with delivery). Once HHS receives the completed Form H3038P, emergency Medicaid coverage will be established for the mother for the period of time reflected on the form, and her baby will receive 12 months of Medicaid coverage from date of birth.
In these situations, facility charges for both mom and the newborn are billed to TMHP. Professional charges for the mother are always billed to the CHIP perinatal health plan, while professional charges for the newborn are billed to TMHP.
How is a hospital reimbursed for labor with delivery charges for CHIP perinatal patients with incomes at 186-200 percent of the FPL?
For women in this income group, both the labor with delivery and services to the newborn are billed to the CHIP perinatal health plan. Emergency Medicaid is not required for billing facility charges.
How do I know who to bill?
Claims for the Mother
- Facilities that need to bill TMHP (Medicaid) should look at the patient's CHIP perinatal health plan ID card. It should have TMHP or Medicaid Claims Administrator under Hospital Facility Billing.
- Facilities that need to bill the CHIP perinatal health plan should find the health plan's name under Hospital Facility Billing.
For professional charges associated with the delivery, providers should bill the CHIP perinatal health plan.
Claims for the Newborn
If the mother's CHIP perinatal plan ID card has TMHP or Medicaid Claims Administrator under Hospital Facility Billing, any charges for the newborn should be billed to TMHP.
If the mother's card has the health plan's name listed under Hospital Facility Billing, the newborn charges should be billed to the CHIP perinatal health plan.
If the mother's CHIP perinatal plan ID card has TMHP or Medicaid Claims Administrator under Hospital Facility Billing, the provider should bill the newborn's professional charges to TMHP.
If the mother's CHIP perinatal plan ID card contains the health plan's name under Hospital Facility Billing, the CHIP perinatal health plan should be billed.
If the mother fails to bring her CHIP perinatal plan ID card, providers can call 800-645-7164 to obtain the patient's health plan and coverage dates. This hotline cannot provide the patient's CHIP Perinatal ID number or the patient's FPIL. Contact the patient's health plan for help with these aspects.
How does the hospital get the Form H3038P?
The pregnant woman will receive a bar-coded Form H3038P from HHS a month before the baby's due date. She will be instructed to take the form with her to the hospital when she's ready to deliver. Once the baby is born, the physician or a nurse present during delivery will need to complete the form. The form is typically faxed to HHS on the patient's behalf during her hospital stay.
What if the expectant mother does not bring the bar-coded Form H3038P with her to the hospital?
The hospital can download, complete and submit a Form H3038P that is not bar-coded. In this case, hospital staff should make a copy of the mother's CHIP perinatal ID card and send that copy with the completed Form H3038P or write the mother's CHIP perinatal ID number at the top of the form. The mother's name on the H3038P must match the name on the CHIP perinatal ID card.
Failure to provide the mother's CHIP perinatal ID number, or writing in a name that doesn't match the mother's perinatal ID card, could delay processing and require the mother to go through the entire Medicaid application process, delaying reimbursement.
How does the hospital submit Form H3083P to HHSC?
Send each application separately. Do not send several applications together in a bundle or batch.
Texas Health and Human Services Commission
P.O. Box 15100
Midland, TX 79711-5100
How will the hospital know if HHSC has received Form H3038P and Medicaid has been established?
The hospital can call 2-1-1 48 hours from the time they fax the completed form. If the form is mailed, the hospital should wait at least 5 business days before calling. When calling 2-1-1, press option #2 after the language prompt, and then option #2 again. Providers should be prepared to provide their National Provider Identifier, as well as the patient's CHIP perinatal case number. Providers also can go to TMHP's website to verify the patient's Medicaid eligibility. Note that TMHP cannot verify CHIP perinatal eligibility.
Is a Medicaid application needed for newborns?
No, a facility only needs to submit Form H3038P to establish 12 months of Medicaid for the baby from date of birth. The mother receives this form in the mail, and is instructed to bring it with her to the hospital. A new application with new supporting documentation is not required. HHSC will use the information on Form H3038P, as well as income and other information provided when the mother originally applied for CHIP perinatal.
What are common errors in hospital billing?
- Billing the wrong entity.
- Not reporting the birth.
- Reporting the wrong dates of service.
How do I report the birth of a newborn receiving CHIP perinatal services?
It is important that hospitals report the birth of a newborn within 5 days of delivery. For more details on how to report a birth, visit the Texas Department of State Health Services Birth Registrars website.