CHAPTER 1140. HEALTHY BEGINNINGS PLUS
PROGRAM
GENERAL PROVISIONS Sec.
1140.1. Purpose.
1140.2. Definitions.
SCOPE OF BENEFITS
1140.21. Scope of benefits for the categorically needy.
1140.22. Scope of benefits for the medically needy.
1140.23. Scope of benefits for State Blind Pension recipients.
PROVIDER PARTICIPATION
1140.41. Participation requirements.
1140.42. Ongoing responsibilities of providers.
PAYMENT FOR HBP SERVICES
1140.51. General payment policy.
1140.52. Payment conditions.
1140.53. Limitations on payment.
1140.54. Noncompensable services and items.
UTILIZATION CONTROL
1140.71. Scope of claims review procedures.
ADMINISTRATIVE SANCTIONS
1140.81. Provider misutilization.Authority The provisions of this Chapter 1140 issued under sections 201.1, 443.2(2) and 443.3 of the Public Welfare Code (62 P. S. § § 201.1, 443.2(2) and 443.3), unless otherwise noted.
Source The provisions of this Chapter 1140 adopted December 13, 1991, effective upon publication and apply retroactively to April 1, 1990, 21 Pa.B. 5733, unless otherwise noted.
GENERAL PROVISIONS
§ 1140.1. Purpose.
The MA Program provides payment for HBP services rendered to eligible recipients by practitioners enrolled as qualified providers under the Program. Payment for HBP services is subject to this chapter, Chapter 1101 (relating to general provisions) and the limitations established in Chapter 1150 (relating to MA Program payment policies) and the MA Program Fee Schedule.
§ 1140.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Care coordinator—An individual employed by the qualified provider to serve as the client’s primary contact and facilitator of multidisciplinary communication.
HBP—Healthy Beginnings PLUS Program—An enhanced, comprehensive package of prenatal and postpartum services provided to eligible MA recipients by enrolled qualified providers.
HBP service—A comprehensive package of services for pregnant women consisting of the following:(i) Basic services provided to clients enrolled in HBP, including care coordination, medical and obstetrical, nutritional, psychosocial and health promotion.
(ii) High risk maternity services provided to individual clients in response to an identified medical or obstetrical risk requiring services to be provided with greater frequency and of longer duration.
(iii) Special services provided to individual clients on as-needed basis, generally in response to an identified medical or obstetrical, nutrition or psychosocial risk.
Qualified provider—A provider or practitioner formally enrolled in the HBP and designated as eligible to provide HBP services.
SCOPE OF BENEFITS
§ 1140.21. Scope of benefits for the categorically needy.
Categorically needy recipients are eligible for medically necessary HBP services compensable under the MA Program.
§ 1140.22. Scope of benefits for the medically needy.
Medically needy recipients are eligible for medically necessary HBP services compensable under the MA Program.
§ 1140.23. Scope of benefits for State Blind Pension recipients.
State Blind Pension recipients are not eligible for HBP services, unless they are also categorically or medically needy.
PROVIDER PARTICIPATION
§ 1140.41. Participation requirements.
In addition to the participation requirements established in Chapter 1101 (relating to general provisions), HBP providers are required, as a condition of participation, to have a current MA provider agreement. HBP providers shall formally enroll in the HBP Program. To participate, HBP providers shall have an approved qualified provider application and shall satisfy the requirements contained in this section, consistent with the implementation plan delineated in each provider’s approved qualified provider application.
(1) The qualified provider, whether enrolled in the MA Program as a hospital obstetrical clinic, community health center, migrant health center, rural health center, birthing center, family planning clinic, home health agency or private obstetrical or family practice, even if providing other types of medical care, have a concentration of specialization in prenatal services.
(2) The qualified provider shall employ one or more care coordinators who:
(i) Have had clinical experience in maternity care.
(ii) Can determine nutrition risks of applicants for the Pennsylvania Women, Infants and Children (WIC) Program.
(iii) Are onsite during the client’s prenatal care visits to perform initial and periodic risk assessments and timely health promotions.
(iv) Are available at the clinic to coordinate all aspects of the client’s care, including reinforcement of postpartum health promotion that was initiated post delivery in the hospital; that is, postpartum physical and psychological changes, lactation, parent-infant care and interim family planning method information.
(3) A care coordinator shall be assigned to each client to serve ongoing as the client’s primary contact and facilitator of multidisciplinary communication. The care coordinator shall be a registered nurse with clinical maternity care experience or a physician assistant. Other types of health care practitioners may serve as care coordinators if they have the HBP required maternity care experiences and training as stated in the Department’s Healthy Beginnings Plus Maternity Services Manual, Section II: ‘‘Program Requirements, Staff Qualifications’’ (Manual). The qualified provider would be required to give assurances of the individuals’ qualifications to function as care coordinators.
(4) If one or more of the care coordinator functions are to be delegated to others, the care coordinator shall retain overall responsibility for these functions. Names and titles of individuals to whom care coordinator functions will be delegated, and the specific functions they will be delegated, shall be identified.
(5) The ratio of clients to care coordinator will be based on the mix of clients requiring basic versus high-risk and special services and coordination of these services. A coordinator may serve not more than 75 clients, unless the qualified provider can provide assurances that a higher number of clients can be serviced without jeopardizing the quality of service provided.
(6) The qualified provider shall provide services for a client within 14 days of the client’s request for an appointment.
(7) The qualified provider shall render by its staff or through a subcontractor the following obstetrical services by an authorized obstetrician, nurse midwife, family practice physician, ob/gyn nurse practitioner, physician assistant or ob/gyn clinical nurse specialist within their legal authority and scope of professional competence. If an MA provider subcontracts for services, the qualified provider shall ensure that the subcontractor, when applicable, meets enrollment and participation requirements as found in Chapter 1101.
(i) Routine antepartum care.
(ii) Intrapartum care, including vaginal and cesarean deliveries, and postdelivery care.
(iii) Ambulatory postpartum examination (4-to-8-week visits that include family planning services appropriate to the client’s needs).
(8) Obstetrical care shall be organized to assure continuity. If hospital inpatient obstetrical care is not provided by the same HBP outpatient obstetrical care professionals, explicit contract terms shall be executed to ensure continuity of care for the client.
(9) Contract terms between the HBP provider and the HBP hospital inpatient obstetrical care professional shall include the following:
(i) Identification of the responsible obstetrical care practitioner in charge, overall, of HBP obstetrical care as well as the individual obstetrical care providers and assurance of the qualifications of each to perform the inpatient hospital services they are being contracted to perform.
(ii) Arrangements for HBP client visits to the inpatient hospital obstetrical suite where delivery is expected.
(iii) Arrangements for timely transmission of copies of the clients’ prenatal records to the expected hospital of delivery.
(iv) Language regarding the content of client discharge summaries and the time frame within which they will be sent to the outpatient provider.
(v) Language regarding communication to be conducted between inpatient hospital staff and the outpatient care coordinator about the status of the HBP clients.
(vi) Procedures for scheduling the 4-to-8-week postpartum obstetrical visit with the outpatient provider following hospital discharge.
(10) The qualified provider shall arrange for basic in-hospital infant care services and outpatient infant care (first visit) provided or directly supervised by a pediatrician, a family practice physician or provided by a pediatric nurse practitioner, who is acting within legal authority. These services may be provided by the qualified provider’s own staff or through a formal referral process. The qualified provider shall explain the benefits of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program to the HBP mother and when the mother is interested in the program make arrangements for enrollment of her infant in EPSDT. It is encouraged that the qualified provider be affiliated with an EPSDT provider when possible.
(11) The qualified provider shall provide by its own staff or through a subcontractor, or be able to provide the following services at the same time and in proximity to the obstetrical services:
(i) Nutrition counseling by a nutritionist or a registered dietitian to clients with obstetrical high-risk conditions. See the Manual for provider qualifications.
(ii) Genetic risk assessment, information and referral by the obstetrical services provider as described in the Manual.
(iii) Outpatient and inpatient obstetrical services to clients with medical or obstetrical high-risk conditions.
(iv) Psychosocial counseling services by a social worker, a professional who performs these services under supervision of the social worker or by an individual who has the experience and competence to perform these services as assured, whose qualifications shall be submitted, by the qualified provider and approved by the Department for clients with psychosocial high-risk conditions, including substance abuse assessment and referral as described in the Manual.
(v) Tobacco smoking cessation counseling by the obstetrical provider or care coordinator.
(12) For each non-English-speaking and hearing-impaired person requesting entrance into the HBP, the qualified provider shall be able to provide interpreter or sign language services.
(13) The qualified provider shall describe provisions that have been made to support play activities for children accompanying clients on prenatal/support service visits.
(14) The qualified provider shall identify problems in the area of transportation, including a pre-assessment of emergency transportation needs of the client, for each client enrolled and describe plans to resolve these problems. This includes a designation and availability of transportation services within the geographic area of the population they serve. In developing solutions to these problems, providers shall consult their county office responsible for administering the MA Transportation Program. A listing of these offices may be found in the Manual.
(15) The qualified provider shall provide, when necessary, the following services either onsite or in the local community provided by the qualified provider’s own staff or through a subcontractor that is a provider of these programs as described in the Manual:
(i) Prepared childbirth classes.
(ii) Parenting education program.
(16) The qualified provider shall provide, when necessary, the following community/home-based services and support services provided by the qualified provider’s staff or through a subcontractor:
(i) Outreach services for enrollment of eligible women, including casefinding/recruitment from other agencies, and follow-up for missed appointments, home assessment and patient education.
(ii) Home health services by nurses and home health aides for pregnant women and newborn infants.
(iii) Personal care services as previously approved by the Department.
(17) The qualified provider shall provide WIC services, preferably at the same time as maternity services, and obtain a letter from the local WIC Program which states concurrence with the applicant’s proposed strategy for providing WIC services. The qualified provider may be a WIC provider or may offer WIC services through a formal arrangement with the local WIC contractor. The WIC services shall be located onsite or in proximity to the obstetrical services.
(18) If the qualified provider is not a provider of one or more of the following, the provider shall provide, when requested or required, the client with alternative referral sources for the following, preferably in geographic proximity to the qualified provider:
(i) Laboratory services.
(ii) X-ray services.
(iii) Ongoing family planning services.
(19) If the qualified provider is not a provider of one or more of the following, the qualified provider shall have a formal, documented coordination system in place, preferably in geographic proximity to the qualified provider for nonobstetrical services in support of high-risk obstetrical care, such as cardiac, hematology, diabetes, renal, specialized clinical genetics services and psychiatric.
(20) Because there will be clients who need drug and alcohol treatment services, qualified providers shall either develop a formal documented coordination system or a formal agreement between the local single county authority or licensed providers in the provider’s service area responsible for drug and alcohol services, including drug and alcohol inpatient detoxification, drug and alcohol outpatient counseling and, if services exist, for drug and alcohol residential rehabilitation and drug and alcohol partial hospitalization services.
(21) The qualified provider shall provide a smoke free environment in areas onsite where clients receive HBP services.
(22) The qualified provider shall be able to utilize a medical/obstetrical record format acceptable to the Office of MA Programs for HBP clients.
(23) The qualified provider shall agree to incorporate the HBP care coordination record and its supporting documents into its medical/obstetrical record, and shall assure that the medical/obstetrical record with the care coordination record is accessible, on a timely basis, to providers involved in the client’s care.
(24) The qualified provider and subcontractors shall agree to send designated staff persons working in the HBP to attend HBP orientation and other training sessions, as deemed necessary by the Department.
(25) The qualified provider shall agree to make statistical data available to the Department as required for evaluation purposes.
§ 1140.42. Ongoing responsibilities of providers.
Ongoing responsibilities of providers are established in Chapter 1101 (relating to general provisions).
PAYMENT FOR HBP SERVICES
§ 1140.51. General payment policy.
Payment is made for covered services provided by participating HBP providers subject to the conditions and limitations established in this chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program Fee Schedule.
§ 1140.52. Payment conditions.
Payment will be made to an HBP provider for services furnished if:
(1) The provider has been designated by the Department as a qualified provider.
(2) The services billed to the Department are furnished by the HBP provider or a subcontractor.
§ 1140.53. Limitations on payment.
HBP payment limitations are as follows:
(1) Payment for the trimester component includes all prenatal visits during the trimester.
(2) Qualified providers may bill for either the high risk maternity care package or the basic maternity care package for each trimester.
(3) The fee for the applicable trimester maternity care packages includes payment to the practitioner for performing the delivery and postpartum care.
§ 1140.54. Noncompensable services and items.
Payment will not be made for:
(1) Procedures not listed in the MA Program Fee Schedule.
(2) Services and procedures for which payment is available through other public agencies or private insurance plans as described in § 1101.64 (relating to third-party medical resources).
UTILIZATION CONTROL
§ 1140.71. Scope of claims review procedures.
A claim submitted for payment under the MA Program is subject to the utilization review procedures established in Chapter 1101 (relating to general provisions). In addition, HBP providers are instructed by the recordkeeping, quality assurance and program evaluation provisions of Section X, ‘‘Provider Accountability,’’ of the HBP Maternity Manual.
ADMINISTRATIVE SANCTIONS
§ 1140.81. Provider misutilization.
Providers determined to have billed for services inconsistent with this part, to have provided services outside the scope of customary standards of medical practice or to have otherwise violated the standards in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).
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