Page 34

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 34

Primary and preventive health benefits do not include pre- pregnancy family reproductive services and supplies, or prescription medications prescribed only for the purpose of primary and preventive reproductive health care.

CHIP Perinatal Program: • Prenatal care and prepregnancy family services and supplies are limited to an initial visit and subsequent prenatal (antepartum) care visits that include: one visit every four weeks for the first 28 weeks of pregnancy; one visit every two to three weeks from 28 to 36 weeks of pregnancy; and one visit per week from 36 weeks to delivery. More frequent visits are allowed as medically necessary. • Limit of 20 prenatal visits and 2 postpartum visits (maximum within 60 days) without documentation of a complication of pregnancy. More frequent visits may be necessary for high-risk pregnancies. High-risk obstetrical visits are not limited to 20 visits per pregnancy. Documentation supporting medical necessity must be maintained in the physician’s files and is subject to retrospective review. • Subsequent visits must include: interim history (problems, marital status, fetal status), physical examination (weight, blood pressure, fundal height, fetal position and size, fetal heart rate, extremities) and laboratory tests (urinanalysis for protein and glucose every visit; hematocrit or hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy; multiple marker screen for fetal abnormalities offered at 16 to 20 weeks of pregnancy; repeat antibody screen for Rh negative women at 28 weeks followed by Rho immune globulin administration if indicated; screen for gestational diabetes at 24 to 28 weeks of pregnancy; and other lab tests as indicated by medical condition of client).

6.2.10.

Inpatient mental health services, other than services described in 6.2.18, but including services furnished in a state-operated facility and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) Covered, medically necessary inpatient mental health services include, but are not limited to, mental health services furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated facilities, as well as neuropsychological and psychological testing.