5101:1-38-06 Medicaid: pregnancy related services (PRS).

(A) All medicaid eligible pregnant women are able to receive enhanced pregnancy related services from their medical providers. These services include extensive counseling and education, nutrition counseling, nutrition intervention, and care coordination.

(1) Care coordination services are delivered by the medical provider and are intended to facilitate the pregnant woman's access to necessary medical, social, educational, nutritional, and other services. Care coordination is also intended to minimize fragmentation of care without limiting the pregnant woman's freedom of choice of participating medicaid providers. If the pregnant woman is enrolled in a medicaid-contracting managed care plan(MCP), she will access the services through her MCP's network of providers.

(2) From the date of identification of pregnancy through sixty days after the end of the pregnancy (i.e., date of delivery, date of spontaneous abortion, or date of federally funded induced abortion), the county department of job and family services (CDJFS), in cooperation with the woman's MCP, when applicable, shall provide support services to complement medical services when the woman makes a request or the CDJFS is made aware of the woman's need.

(B) Pregnancy related services (PRS) definitions.

(1) "Potentially eligible women" are all medicaid eligible recipients identified as pregnant who do not have medical verification of pregnancy.

(2) "Eligible women" are all medicaid eligible pregnant recipients who have been medically verified as pregnant.

(3) "Date of identification of pregnancy" is the date that the medicaid eligible recipient states verbally or in writing that she is pregnant or is reported to be pregnant, or the date the CDJFS otherwise learns of the pregnancy.

(4) "Medical providers" are physicians, hospitals, clinics, home health agencies, rural health clinics, outpatient health facilities, federally qualified health centers, nurse midwives, and nurse practitioners who are medicaid enrolled service providers or are part of a medicaid-contracting MCP's provider network.

(5) "Support services" are non-medical services offered or provided by the CDJFS to assist the medicaid eligible recipient and may include arranging or providing transportation, making appointments, accompanying the woman to her appointment with her medical provider, and making referrals to community and other social services. Support services will be coordinated with the pregnant woman's medicaid-contracting MCP where applicable.

(6) "Pregnancy related services unit/worker" is the staff person or primary liaison within a unit in the CDJFS responsible for the implementation of the pregnancy related services program.

(C) Pregnancy identification.

(1) The CDJFS shall take steps to maintain a community network that is adequate to identify, recruit, and refer potentially eligible women for early prenatal care in both fee-for-service and managed care counties.

(2) CDJFS staff must refer as soon as possible all potentially eligible women to the PRS unit/worker.

(3) Referrals must be made through a standardized procedure developed by the CDJFS as described in paragraph (K) of this rule.

(4) The referral procedure shall utilize the healthchek and pregnancy assessment form (JFS 03528, effective 6/2003) whenever available; or, at a minimum, shall include the woman's name, case number, estimated date of delivery (when known), and the name and telephone number of the PRS worker.

(D) Recruitment to early prenatal care.

(1) The CDJFS shall take steps to ensure that every potentially eligible woman is under a medical provider's care as soon as possible after her pregnancy has been identified.

(2) A woman enrolled in a medicaid-contracting MCP shall be advised to contact her MCP's member services for options in obtaining her prenatal care services.

(3) For every potentially eligible and every eligible woman, the following steps are to be taken:

(a) Inform the woman of the importance of early prenatal care. A copy of the "Healthy Start For a Healthy Baby" brochure (JFS 08062, effective 4/2005) or other written material approved by the bureau of consumer and program support (BCPS) must be given to the woman or her parent or caretaker.

(b) The following benefits of early prenatal care shall be explained using clear and non-technical language:

(i) Increasing the mother's well-being during pregnancy;

(ii) Reducing the risk to the mother's health;

(iii) Helping prevent complications and minimize discomfort;

(iv) Helping identify danger signals for early labor or miscarriage;

(v) Increasing the likelihood of having a healthy baby;

(vi) Reducing the risk of birth defects; and

(vii) Providing education on how to take care of the baby.

(4) For each eligible woman, the CDJFS should complete the JFS 03528 to identify her own and her children's needs for services, or the form may be mailed to the woman for completion. In managed care counties, the CDJFS will share the assessment form information with the medicaid-contracting MCP in which the woman chooses to enroll.

(5) If needed, the CDJFS shall provide a list of medicaid prenatal care providers available to the community and/or information about medicaid-contracting MCPs in managed care counties.

(6) The CDJFS shall provide, assist, or offer the following support services:

(a) Transportation or arranging transportation in accordance with paragraph (H) of this rule through the CDJFS or medicaid-contracting MCP, if available;

(b) Making an appointment with a medical provider. If the pregnant woman chooses to enroll or is already enrolled in a medicaid-contracting MCP, she must go to a provider in her MCP;

(c) Accompanying the woman to the medical provider's office;

(d) Making referrals as needed for non-medical services (e.g., women, infants and children (WIC), social services, community services) and (where applicable) coordinating these services with the pregnant woman's medicaid-contracting MCP;

(e) To ensure the enrollment of an infant born to an eligible woman, all pregnant women shall be informed of the healthchek program in accordance with rule 5101:1-38-05 of the Administrative Code; and

(f) When a woman's medical provider contacts the CDJFS by telephone or in writing that the woman has a non-medical need (e.g., child care, clothing, etc.), appropriate referrals shall be made and assistance provided with appointments, when necessary.

(g) If the CDJFS needs additional medical information from the assistance group, it may be necessary to obtain a signed authorization which is health insurance portability and accountability act of 1996 (HIPAA) compliant, as outlined in rule 5101:1-37-01.1 of the Administrative Code.

(E) Identification of pregnant women not receiving prenatal care.

(1) The CDJFS shall develop ways to identify potentially eligible and eligible women who are not receiving prenatal care. The system shall be described as per the guidelines in paragraph (K) of this rule and approved by ODJFS/BCPS. In counties with medicaid-contracting MCPs, the guidelines should include plans for coordination of efforts between the CDJFS and the MCPs to identify and monitor which pregnant women are not receiving prenatal care services.

(2) When the CDJFS identifies any potentially eligible women or eligible women who are not receiving prenatal care services, they shall as soon as possible attempt to make contact with them. Contacts shall be made face-to-face, by telephone, or by home visits. As a final step, when efforts to make personal contact have been unsuccessful, written correspondence shall be sent to inform the woman about the importance of prenatal care and to request that she contact the CDJFS or, when applicable, her MCP's member services for assistance.

(3) Support services listed in paragraph (D)(6) of this rule are also available for the potentially eligible woman's initial pregnancy related visit.

(F) Care compliance.

(1) When problems have developed in the delivery of care to eligible women, care compliance services can facilitate patient access to the services recommended in order to promote a healthy pregnancy.

(2) The CDJFS can be notified by telephone or by a written report from an eligible woman's medical provider when the woman has missed appointments or other problems have developed in the delivery of her care.

(3) Medicaid-contracting MCPs are responsible for follow-up of their enrollees' missed appointments. However, when the MCP's attempts to contact the eligible woman are unsuccessful, the MCP should contact the PRS coordinator in the woman's county of residence for assistance. Upon notification that the woman has missed appointments or there were other problems in the delivery of her care, the CDJFS shall establish contact with the woman according to paragraph (E) of this rule. The CDJFS shall inform the woman's medical provider or her MCP about the outcome of the contact.

(G) Support services documentation and reports.

(1) Documentation shall be maintained in a case file for each potentially eligible and eligible woman. The file shall consist of permanent records, either hard copy or computer stored, containing the following information, when appropriate:

(a) The CDJFS's copy of the prenatal risk assessment form (JFS 03535, effective 2/2003) or other prenatal risk assessment form, when available from the woman's medical provider;

(b) Copies of correspondence received and sent;

(c) Documentation of agency contacts with the pregnant woman, both attempted and established;

(d) Documentation of the MCP in which the pregnant woman is enrolled, if applicable;

(e) Information received from another county when the woman is an intercounty transfer;

(f) Documentation of all service requests made by the woman's medical provider, steps taken by the CDJFS to assure these services are provided, and whether the woman received the services; and

(g) Records of transportation provided.

(2) The CDJFS shall complete quarterly data collection reports in an ODJFS-approved format on the number of support services provided to medicaid eligible pregnant women. The report shall be submitted to ODJFS by the fifteenth day of the month following the end of each quarter.

(H) Transportation.

Transportation shall be provided, as needed, to the initial prenatal medical provider visit for all potentially eligible women. Transportation shall be provided to all eligible women to any medicaid reimbursable service, if needed, from the date of medical verification of pregnancy through the postpartum period, sixty days after the end of the pregnancy. All transportation shall be provided in accordance with the following criteria:

(1) Transportation shall be provided to the medical provider of the woman's choice when the medical provider is generally available or used by other residents of the community. The CDJFS shall also provide needed transportation to any medical provider when referred by another medical provider.

(2) If the woman is enrolled in a medicaid-contracting MCP that provides transportation for its members, the woman shall be referred to her MCP for transportation arrangements. The transportation services shall be provided by the CDJFS if not available from the MCP.

(3) The CDJFS shall provide transportation at the woman's request, at the request of the woman's medical provider, or if the CDJFS staff worker identifies a need.

(I) Infant referrals.

For every infant born to an eligible woman, the following steps shall be taken to assure that the infant is enrolled in the healthchek program, in cooperation with the woman's medicaid-contracting MCP, if applicable:

(1) A pregnant woman shall first be informed about healthchek when she completes the JFS 03528;

(2) She shall be reinformed as soon as possible after the infant's birth or during her or the infant's next reapplication.

(J) Provider recruitment.

(1) The CDJFS shall take steps to recruit and maintain a provider network that is adequate to meet the prenatal care needs of medicaid eligible women. The CDJFS must maintain on file current lists of all participating prenatal providers.

(2) In counties with medicaid-contracting MCPs, the network of participating providers will be contracted through and maintained by the MCP.

(3) It is recognized that the ability of the CDJFS to recruit and maintain an adequate provider network depends on the existence of appropriate providers within a reasonable geographic area.

(K) Documentation requirements.

The CDJFS shall submit in writing, under signature of the CDJFS director, a description of the process and structure of the management of the local PRS program including the name of the contact person and/or coordinator for the program.

The information submitted, shall include the following:

(1) Identify where in the CDJFS table of organization the responsibility for the PRS program is located and the name and title of the contact person or coordinator.

(2) A description of the staff/unit responsible for informing women identified as pregnant of the following:

(a) The PRS program,

(b) The importance of prenatal care,

(c) The availability to assist eligible pregnant women in receiving an initial physician visit,

(3) How the CDJFS tracks identified pregnant women,

(4) Identification of the staff/unit responsible for submission of the pregnancy related services quarterly report (JFS 03539, effective 1/2002) to ODJFS.

(5) Information as to whether the agency will provide transportation to infants during the first year of life.

(6) In counties with medicaid-contracting MCPs, the information submitted under the CDJFS director's signature shall include plans for coordination of efforts between the CDJFS and the MCPs. This may include written agreements between the CDJFS and the medicaid-contracting MCPs with provisions for regularly scheduled meetings, as well as other ideas for county and plan coordination.

(7) All changes or amendments to the CDJFS's description of the process and/or structure shall be submitted in writing to ODJFS under the signature of the CDJFS director within ten working days.

(8) Information submitted under the signature of the CDJFS director can be combined or included with the information submitted as per paragraph (M) of rule 5101:1-38-05 of the Administrative Code.

Effective: 10/15/2005
R.C. 119.032 review dates: 07/29/2005 and 10/01/2010
Promulgated Under: 111.15
Statutory Authority: 5111.01
Rule Amplifies: 5111.01 , 5111.016
Prior Effective Dates: 4/1/88 (emer.), 6/30/88, 10/1/88 (emer.), 12/20/88, 4/1/91, 2/1/92, 5/1/93, 10/1/98, 5/1/02, 10/6/03