2186 Planning For Health Babies®

Georgia State Seal

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Planning For Health Babies®

Effective Date:

November 2023

Chapter:

2100

Policy Number:

2186

Previous Policy Number(s):

MT 63

Updated or Reviewed in MT:

MT-71

Requirements

The Center for Medicare and Medicaid Services (CMS) approved a 10-year extension in August 2019 to the Planning for Healthy Babies® (P4HB) 1115 Demonstration Wavier. This wavier expands the provision of family planning services to women who are Georgia residents, women between the ages of 18 and 44, who do not qualify for other Medicaid benefits and any other insurance coverage with the exception of vision or dental insurance, including Medicare Part A or Part B of Title XVIII of the Social Security Act or CHIP which is known as Peach Care for Kids®. P4HB is not recognized as Minimum Essential Coverage (MEC) as outlined in section 5000A(f)(1)(A)(ii) of the Internal Revenue Code of 1986. This program became effective on January 1, 2011.

Basic Considerations

Family Planning (FP) 181

Uninsured women, ages 18 through 44, who have family income up to and including 211 percent of the FPL, who are not otherwise eligible for Medicaid or CHIP, including women losing Medicaid pregnancy coverage at the conclusion of the 12th month extended postpartum period. Individuals must enroll in a managed care plan to receive family planning and family planning-related services.

Inter-Pregnancy Care (IPC) 180

Uninsured women ages 18 through 44, within three years of delivery of a VLBW baby, who have income up to and including 211 percent of the FPL, who are not otherwise eligible for Medicaid or CHIP. Women in the IPC component must enroll in a managed care plan to receive Family Planning and IPC services.

Resource Mothers (RM) 182 & 183

Women, ages 18 through 44, who have income at or below 211 percent of the FPL, within three years of delivery of a VLBW baby, and who qualify under Medicaid State plan. Women who qualify under the Low-Income Medicaid, “Parent Caretaker” Medical Assistance, or the Aged Blind and Disabled Classes of Medical Assistance.

Primary Goals

The primary goals of the P4HB program are to reduce Georgia’s low birth weight (less than 2500 grams or 5 lbs. 8 oz) and very low birth weight (less than 1500 grams or 3 lbs. 5 oz) rates; reduce the number of unintended and high-risk pregnancies in Georgia, and to reduce Medicaid costs by reducing the number of unintended pregnancies. To provide access to IPC health services for eligible women who have previously delivered a VLBW baby and to increase child spacing intervals through effective contraceptive use.

CMO Enrollment

Members approved for Family Planning services are auto assigned or passively enrolled into a CMO automatically through an algorithm. The member will have the opportunity to participate in a choice change period immediately after being auto assigned. if she does not want the health plan that is chosen for her, she can change to another health plan. The member will have 90 days from the start date of her health plan to change to a new health plan.

Services will not begin until the member is enrolled in a CMO.

Family Planning Services

Family planning services include medically necessary services and supplies described in section 1905(a)(4)(C) of the Act related to the following:

  • FDA-approved methods of contraception

  • Sexually transmitted infection (STI)/sexually transmitted disease (STD) testing,

  • Pap smears and pelvic exams.

  • The laboratory tests done during an initial family planning visit for contraception include a Pap smear, screening tests for STIs/STDs, blood count, and a pregnancy test.

  • Additional screening tests may be performed depending on the method of contraception desired and the protocol established by the clinic, program, or provider. Additional laboratory tests may be needed to address a family planning problem or need during an inter-periodic family planning visit for contraception

  • Drugs, supplies, or devices related to women’s health services described above

  • Contraceptive management, patient education, and counseling.

Family planning-related services and supplies are defined as those services provided as part of, or as follow-up to, a family planning visit. Such services are provided because a “family planning-related” problem was identified and/or diagnosed during a routine or periodic family planning visit. The following are examples of the family-planning-related services:

  • Colposcopy (and procedures are done with/during a colposcopy) or repeat Pap smear performed as a follow-up to an abnormal Pap smear which is done as part of a routine/periodic family planning visit.

  • Drugs for the treatment of STIs, except for HIV/AIDS and hepatitis, follow-up visit/encounter for the treatment/drugs, and subsequent follow-up visits to rescreen for STIs based on the Centers for Disease Control and Prevention (CDC) guidelines may be covered.

  • Drugs for vaginal infections/disorders, other lower genital tract and genital skin infections/disorders, and urinary tract infections, where these conditions are identified/diagnosed during a routine/periodic family planning visit. A follow-up visit/encounter for the treatment/ drugs may be covered.

  • Other medical diagnoses, treatment, and preventive services that are routinely provided pursuant to family planning services in a family planning setting.

Treatment of major complications arising from a family planning procedure such as:

  • Treatment of a perforated uterus due to an intrauterine device insertion

  • Treatment of severe menstrual bleeding caused by a Depo-Provera injection requiring dilation and curettage

  • or Treatment of surgical or anesthesia-related complications during a sterilization procedure.

Inter-Pregnancy Care Services

In addition to the family planning and family planning-related services described above, women who are enrolled in the IPC component are also eligible for the benefits described in the table below.

Services Notes / Limitations

Primary care

Limited to 5 office/outpatient visits per year

Management and treatment of chronic diseases

Substance use disorder treatment (detoxification and intensive outpatient rehabilitation)

Limited Dental

Services are limited to exams and cleanings every six months; x-rays every 12 months; and simple extractions; and emergency dental services.

Prescription Drugs (non-family planning)

Prescription drug coverage is limited to the IPC formulary.

Non-emergency medical transportation

Only available for beneficiaries eligible under the IPC component.

Case management/Resource Mother Outreach

Resource Mother Services

Women served under the IPC and Resource Mother components will have access to Resource Mother Outreach. The purpose of the Resource Mother Outreach is to provide peer services in coordination with a nurse case manager. The Resource Mother provides a broad range of paraprofessional services to P4HB participants in the Interpregnancy Care component of the Planning for Healthy Babies Program and their families. The Resource Mother performs certain aspects of case management including the provision of assistance in dealing with personal and social problems and may provide supportive counseling to P4HB participants and their families and/or serve as a liaison for social services.

Card

PH4B recipients will receive specific color CMO cards for each category and will have specific Aid Categories listed in GAMMIS as follows:

  • Family Planning-181, pink CMO card

  • Inter-Pregnancy Care-180, purple CMO card

  • Resource Mother Parent/Caretaker Medicaid-182, yellow CMO card

  • Resource Mother ABD/SSI Medicaid-183, yellow CMO card

Policy Requirements

Applicants for P4HB must meet the following eligibility requirements:

  • Age – women ages 18 (month of 18th birthday) through 44 (month of 45th birthday)

  • Must be able to become pregnant

  • Georgia resident

  • Citizenship/Immigration Status/Identity

    • Reasonable opportunity policy applies (refer to Section 2215)

    • The signed Streamline application meets the declaration of citizenship requirement, so a separate declaration is not required.

  • Third-Party Liability (TPL), DMA285 is not required if there is no TPL.

  • Income up to and including 211 percent of the FPL based on MAGI Rules. Individuals that meet on tax filer criteria are potentially eligible to receive coverage based on the MAGI Medical Assistance policy. Refer to Section 2245, Filer Status/Specified Relative Relationship and Section 2610 - Magi Budget Groups/Assistance Units

  • Limited to 24 months for (180-IPC and 181 and 182-RM services) for each reported VLBW baby and will be disenrolled after 2 years of participation.

  • No retroactive (three months prior) coverage

  • No Emergency Medical Assistance (EMA) coverage

  • Must report changes within 10 days

  • A woman enrolled in P4HB who becomes pregnant can apply for Presumptive Eligibility (PE) Pregnant Women Medical Assistance. Her P4HB services will be terminated the same day of her pregnancy eligibility.

  • Post-partum women who were on Medicaid coverage and enrolled in a Georgia Families Care Management Organization (CMO) at delivery will be automatically cascaded to the appropriate aid category and enrolled in the plan with which they were affiliated. These women will be afforded the opportunity to choose a new CMO if desired.

  • If a member has an active P4HB case 180 or 181 but does not apply for PE Pregnant Women Medical Assistance until after she delivers her baby. There must be a “Continuing Medicaid Determination” (CMD) for the member to cascade from P4HB to Pregnant Women Medicaid. Refer to 2052 Continuing Medicaid Determination.

  • All P4HB services, FP-181, IPC-180, and RM-182 & 183 are subject to annual renewals.

  • All women between the ages of 18 through 44 must receive notification their application for P4HB has been approved, denied or their P4HB eligibility has been terminated.

  • All pregnant women receiving Medical Assistance under any class of assistance (COA) will be sent a letter in their eighth month of pregnancy from their CMO informing them of the P4HB program. Pregnant women whose Medical Assistance cases are closing and who are not eligible for another COA may be eligible for P4HB Family Planning services.

P4HB Disenrollment

Women who no longer meet the eligibility criteria outlined for the P4HB program will be disenrolled from the P4HB program. These include women who:

  • If a woman becomes pregnant while enrolled, she may be determined eligible for Medicaid in the pregnant woman eligibility group in accordance with 42 CFR 435.916.

  • Women who choose to receive a sterilization procedure and complete all necessary follow-up procedures will be disenrolled.

  • Women receiving IPC services will be disenrolled from the IPC component and enrolled in the family planning-only component after 2 years of participation. Additional deliveries of subsequent VLBW babies will grant an additional two-year enrollment period in the IPC component.

  • Before disenrollment of any beneficiary eligible, there must be an administrative renewals for all affected beneficiaries in order to determine if they qualify for Medicaid eligibility under a different eligibility category prior to termination, required under 42 C.F.R. 435.916(f)(1).

  • Move out of the state

  • Become incarcerated

  • Become unable to become pregnant

  • Women who have aged out

Redeterminations

Redeterminations of eligibility are conducted not more frequently than every 12 months in accordance with 42 CFR 435.916(a).

Enrollment to IPC-180 and RM-181 &182 limited to 24 months

Women applying for IPC 180 and RM 182 & 183 must have delivered a very low birth weight (VLBW) baby within three years. If the member delivers multiple births on the same day or a different day, the birth of the last child delivered is used to count toward the 24 months.

Prior to Exhausting the 24 Months

If an IPC 180 or RM 183 member leaves the program prior to exhausting their 24 months of services; she can reenter the program and reclaim the remaining months. If she delivers and reports another VLBW baby within her remaining 24 months, the clock will reset in Gateway, even if she did not complete her 24 months in a previous case. Any remaining months will be voided after verification of new reported VLBW baby and a new 24 months restarts. An IPC 180 and RM 182 & 183 member cannot exceed 24 months at any given period.

P4HB Required Verification for IPC/RM

What verification is required?

  • Physician’s Statement for P4HB Inter-Pregnancy Care and Resource Mother

    OR

  • Hospital Confirmation of Birth Record that includes birth weight

    OR

  • Care Management Organizations (CMO) Report

    The Care Management Organizations (CMO) report is manually entered in Gateway by the Department of Family Children Services RSM Alma group validating the VLBW baby or disenrollment.

HIPAA

Health Portability and Accountability Act (HIPAA) notification must be mailed to the adult who makes an application for P4HB. If there are additional adults in the household for whom Medical Assistance is being requested a separate HIPAA notice must be sent by the agency determining eligibility.

Hearing Process

Appeals for the P4HB program should follow the Appendix B process for hearings.

Applications

There are several ways an applicant can apply for P4HB:

  • The applicant can apply through the Georgia Gateway Customer Portal at www.gateway.ga.gov/.

  • The applicant can print a streamline application from the website at medicaid.georgia.gov/programs/all-programs/planning-healthy-babies by notating P4HB on the application

  • The applicant can apply by calling 1-877-427-3224 or request an application be mailed to them

  • The application can be returned by fax to 1-912-632-0389

  • The application can be returned to:

    Planning for Healthy Babies®
    PO Box 786
    Alma, GA 31510

    Or

    Division of Family and Children Services
    Customer Contact Center
    PO Box 4190
    Albany, GA 31706

An applicant can obtain an application from their local DFCS or apply at one of the following:

  • Qualified Provider (QP)

  • Qualified Hospital (QH)

  • Department of Public Health (DPH)

  • Federally Qualified Health Centers (FQHC)

  • Rural Health Centers (RHC)