DCS Comprehensive Health Plan

Maternity, Postpartum, and Family Planning Services

Statement/Purpose

This policy outlines maternity, postpartum, and family planning services provided to DCS Comprehensive Health Plan (DCS CHP) members.

Definitions

High-Risk Pregnancy: Refers to a condition in which the mother, fetus, or newborn is, or is anticipated to be, at increased risk for morbidity or mortality before or after delivery.

Long-Acting Reversible Contraceptives (LARC): Reversible methods for family planning that provide effective contraception for an extended period of time with little or no maintenance or user actions required, including intrauterine devices and subdermal and implantable contraceptives.

Maternity Care: Any covered services related to pregnancy to include, but not be limited to, medically necessary preconception counseling, identification of pregnancy, medically necessary education and prenatal services for the care of the pregnancy, treatment of pregnancy-related conditions, labor and delivery services, and postpartum care.

Maternity Care Coordination: Consists of the following maternity care related activities: determining the member’s medical or social needs through a risk assessment evaluation; developing a plan of care designed to address those needs; coordinating referrals of the member to appropriate service providers and community resources; monitoring referrals to ensure the services are received; and revising the plan of care, as appropriate.

Maternity Care Provider: The following are provider types who may provide maternity care when it is within their training and scope of practice:

• Arizona licensed allopathic and/or osteopathic physicians who are obstetricians or general practice/family practice providers.

• Physician Assistants.

• Nurse Practitioners.

• Certified Nurse Midwifes, and

• Licensed Midwives.

Postpartum: For individuals determined eligible for 12-months postpartum coverage, postpartum is defined as the period that begins on the last day of pregnancy and extends through the end of the month in which the12-month period following termination of pregnancy ends. For individuals determined eligible for 60-days postpartum coverage, postpartum is the period that begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of the pregnancy ends. Quality measures used in maternity care quality improvement may utilize different criteria for the postpartum period.

Postpartum Care: Health care provided in the postpartum period to assess and treat the member’s physical, psychological, and social well-being after pregnancy, regardless of how a pregnancy ends. Services include but are not limited to, addressing chronic medical conditions (e.g., hypertension, diabetes, mood disorders), family planning, and a plan to transition to parenthood and well-woman or preventative care. Postpartum care visits are an ongoing process that should align with recommendations from the American College of Obstetricians and Gynecologists (ACOG). AHCCCS AMPM Policy 410

Prenatal Care: The provision of health services during pregnancy which is composed of three major components:

• Early and continuous risk assessment,

• Health education and promotion, and

• Medical monitoring, intervention, and follow-up.

Policy

Maternity care services include a continuum of care from preconception counseling through postpartum care. Services are comprehensive and address both the medical and psycho-social needs of each member. Services are provided in a manner which accommodates each member’s cultural and linguistic needs, by qualified providers in accordance with the most current American College of Obstetricians and Gynecologists (ACOG) standards for obstetrical and gynecological services.

DCS CHP covers maternity care, postpartum and family planning services for members of childbearing age which include but are not limited to:

• Medically necessary preconception counseling;

• Pregnancy prevention;

• Sexually transmitted infection counseling and treatment;

• Family planning services, education and outreach;

• Identification of pregnancy;

• Medically necessary education and prenatal services for the care of pregnancy;

• Treatment of pregnancy-related conditions, labor, and delivery services; and

• Postpartum care including the identification and treatment of postpartum depression.

There is no copayment or other charge for pregnancy-related services. Medically necessary transportation is available for members to pregnancy related services.

Members may choose to obtain family planning services and supplies from any appropriate provider. Prior authorization to obtain family planning services and supplies from an out of network provider is not needed.

Procedure

Maternity Care Management

All DCS CHP members identified as pregnant are enrolled in high risk maternity care management immediately upon notification. Pregnant members are identified via claims reporting, other Medical Management (MM) and Utilization Management (UM) processes or by health care providers.

Pregnant members are monitored throughout the perinatal period and up to 12 months postpartum by an assigned maternity care manager. Maternity care managers are registered nurses who provide comprehensive interventions that address medical issues that place the member and fetus at risk. Maternity care managers provide member specific education through mailings, outreach, and appointment reminder calls, as well as analysis of progress in meeting maternity performance benchmarks.

In addition to care managers, many other internal departments within the health plan are also involved in processes that support maternity care for DCS CHP members.

Maternity Care Providers (Physicians and Practitioners)

DCS CHP encourages pregnant members to promptly select a qualified maternity care provider (physicians and practitioners). The provider may be either the member’s Primary Care Provider (PCP), if experienced in caring for pregnancies, or an obstetrician who provides only maternity care for the member, while the member’s PCP retains responsibility for the member’s general health care.

DCS CHP pregnant members are considered high risk; therefore, delivery services are provided in a hospital setting. All cesarean sections and inductions prior to 39 weeks gestation require documentation of medical necessity.

Maternity Care providers are responsible for:

• Complying with the highest standards of care recommended by the American College of Obstetrics and Gynecology (ACOG), including the use of a standardized comprehensive medical risk assessment tool identifying psychosocial, nutritional, medical and education factors, and ongoing monitoring;

• Coordinating the member’s maternity care needs throughout the pregnancy;

• Screening pregnant members for substance use:

  • through the Controlled Substances Prescription Monitoring Program (CSPMP) once a trimester, and for those members receiving opioids, appropriate intervention and counseling are provided, including referring the member for behavioral health services as indicated for Substance Use Disorder (SUD) assessment and treatment

  • through brief verbal screening and intervention for substance use utilizing an evidence-based screening tool with appropriate referrals as needed;

• Screening pregnant members for Sexually Transmitted Infections (STI)s, including syphilis, at the first prenatal visit, during the third trimester, and at the time of delivery;

• Educating the member through discussion and materials about the:

  • physical changes to be expected during pregnancy;

  • healthy behaviors during the perinatal period;

  • importance of complying with the care plan;

  • importance of proper nutrition;

  • dangers of lead exposure to people who are pregnant and their developing child;

  • tobacco cessation;

  • avoidance of alcohol and other harmful substances, including illegal drugs;

  • screening for STIs;

  • process of labor and delivery;

  • breastfeeding and other infant care information;

  • prescription opioid use;

  • postpartum follow up;

  • family planning options, including Immediate Postpartum Long Acting Reversible Contraception (IPLARC) options;

  • Interconception health and spacing;

  • Warning signs of complications of pregnancy and postpartum, including when to contact the provider.

• Conducting perinatal and postpartum depression and anxiety screenings at least once during pregnancy and at the postpartum visit using a validated screening tool, with appropriate counseling and referrals if a positive screen is obtained. All DCS CHP members are enrolled in behavioral health services. The maternity care provider is expected to coordinate care with the member’s behavioral health team and/or the member’s Primary Care Provider (PCP) as appropriate;

• Maintaining a complete medical record and documenting of all aspects of maternity care provided;

• Referring members to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Early Head Start or Healthy Families Arizona home visiting programs and to other community-based resources as appropriate;

• Notifying members that they may contact the Arizona Department of Health Services (ADHS) hotline for referrals to low cost or no-cost services in the event that they lose eligibility for services;

• Scheduling and conducting timely postpartum care visit that includes screening for postpartum depression;

• Submitting all claim forms with the first and last prenatal care dates of service, as well as the number of obstetrical visits the member had with the provider, independent of payment; and

• Encouraged to use the Arizona Perinatal Psychiatry Access Line (A-PAL) when questions arise surrounding mental health or substance use abuse, including medication management.

DCS CHP and its contracted MCO monitor health care providers to ensure that ACOG recommendations are followed for pregnant and postpartum members who have experienced a health issue during the pregnancy, such as hypertension, gestational diabetes, obesity, or other health issues, have been counseled about the importance of obtaining follow up care, including any medication adjustments that might be needed, and have been referred for appropriate specialty care follow up after delivery.

DCS CHP and its contracted MCO monitor health care providers to ensure that the ACOG guidelines are followed for pregnant and postpartum members who have a substance use disorder with additional attention to provider documentation that includes:

• Consents for coordination of care with the member’s SUD treatment provider;

• Naloxone prescription;

• Pain treatment plan for delivery and post-partum;

• Medication dosage adjustment needs;

• Evidence based breast feeding recommendations and precautions;

• Screening for HIV, STI and hepatitis, psychiatric disorders, Intimate Partner Violence, Barriers to care;

• Providers have a plan of safe care including Behavioral health services, alternative infant care, alternative nutritional supplementation plans for the breastfeeding mother.

Maternity Education and Outreach

DCS CHP provides educational information to the member and/or custodial agency regarding the following types of community, referral and support resources, including but not limited to:

• Women, Infants, and Children (WIC) Program;

• Childbirth education classes as appropriate;

• Parenting classes as appropriate;

• Smoking cessation Arizona Smokers Helpline (ASH Line) information;

• Healthy Families Arizona home visitation programs;

• ADHS Breastfeeding Hotline;

• Early Head Start/Head Start;

• Birth to 5 Helpline;

• Vaccines for Children (VFC) program.

Maternity education is integrated into the care of all pregnant and postpartum members and is provided through mailed materials and information provided by care managers and health care professionals, including information about:

• Risks associated with elective inductions and cesarean sections prior to 39 weeks gestation.

• Healthy pregnancy and postpartum actions (addressing nutrition, sexually transmitted infections, HIV testing, alcohol, opioids, substance use, and other risky behaviors, measures to reduce risks for low /very low infant birth weight, recognizing active labor, urgent pregnancy and postpartum warning signs that require intervention, breastfeeding, safe sleep and ways to reduce Sudden Infant Death Syndrome (SIDS)/Sudden Unexpected Infant Death (SUID) risk prevention. etc.).

• Dangers of lead exposure to people who are pregnant and their developing babies, and how to prevent exposure.

• Perinatal mood and anxiety disorders.

• Importance of timely prenatal and postpartum care, including postpartum services that are available.

• Components of pregnancy care needed (prenatal, fetal development, labor and delivery).

• Prenatal and childbirth classes.

• Special educational topics for complex pregnancy (e.g., diabetes).

• Pregnant and postpartum members receive written and verbal notification of Family Planning services and supplies, including information on LARC and Immediate Postpartum Long Acting Reversible Contraception (IPLARC) by the end of the second trimester.

• Interconception spacing recommendations and family planning options.

• Ways to limit labor and birth interventions.

• How to obtain pregnancy related services and assistance with scheduling appointments.

• A statement that there is no copayment or other charge for pregnancy-related services.

All DCS CHP members who are pregnant receive Maternity Care Coordination. This includes assistance with navigating the health system, addressing missed visits, transportation issues or other perceived barriers.

Maternity care coordination includes but it not limited to:

• Identifying risk factors to decrease the incidence of infants born with low/very low birth weight;

• Educating on health promotion and the need for medical monitoring;

• Educating regarding the importance of routine dental visits to maintain optimal oral health;

• Educating regarding the importance of prenatal and postpartum visits;

• Monitor planning for maternity delivery services that follow ACOG guidelines;

• Ensuring medical and/or behavioral health referral appointments are kept;

• Referring the member to behavioral health providers when indicated through a positive depression screening or other methods;

• Searching pregnant members’ controlled substance dispensing information each trimester in the Controlled Substances Prescription Monitoring Program (CSPMP);

• Contacting pregnant members at least once per trimester as long as the youth and guardian consent. Topics for discussion include, but are not limited to, pregnancy concerns, community resources, assessing support systems, providing education regarding the use of opioids, illegal substances and alcohol during pregnancy, prenatal and postpartum appointment adherence, family planning, and STD prevention.

Monitoring Maternity Indicators and Postpartum Care

DCS CHP and its contracted MCO monitors and evaluates the types of delivery (number of cesarean sections and elective inductions) and newborn outcomes, including birth weight, looking for low/very low birth weight, and gestational age. In addition, pregnancy indicators such as entry into prenatal care and timely postpartum visits are monitored.

Maternity care outcomes are reviewed, trended and analyzed by quarter at the Medical Management and Quality Management/Performance Improvement Committee Meetings.

Family Planning Services and Supplies

Family planning services and supplies provided by physicians or practitioners are covered for all members who voluntarily choose to delay or prevent pregnancy. Family planning counseling for male and female youth focuses on the early detection and management of risk factors to avoid pregnancy.

Family Planning services include covered medical, surgical, pharmacological, and laboratory services as well as contraceptive devices (including Intrauterine Devices (IUDs) and subdermal implantable contraceptives). Covered services also include the provision of accurate information and counseling to allow members to make informed decisions about specific family planning methods available.

Family Planning services include but are not limited to:

• Contraceptive counseling, medication, and/or supplies, including but not limited to: oral and injectable contraceptives, subdermal implantable contraceptives, intrauterine devices, long acting reversible contraceptives (LARC)(including placement of Immediate Postpartum Long-Acting Reversible Contraceptives (IPLARC)), diaphragms, condoms, foams, and suppositories;

• Associated medical and laboratory examinations and radiological procedures, including pregnancy screening, ultrasound studies;

• Medications associated with medical conditions related to family planning or other medical conditions;

• Treatment of complications resulting from contraceptive use, including emergency treatment;

• Natural family planning education or referral to qualified health professionals; and

• Post-coital emergency oral contraception within 72 hours after unprotected sexual intercourse (mifepristone aka Mifeprex or RU-486, is not post-coital emergency oral contraception).

Pregnancy screenings and Sexually Transmitted Infections (STI) screenings and treatment are covered services for members.

For the purposes of family planning, the following services are not covered:

• Infertility services, including diagnostic testing, treatment services and reversal of surgically induced infertility;

• Pregnancy termination counseling;

• Pregnancy termination except as outlined in DCS CHP Policy HS-CH-05, Pregnancy Termination; and

• Hysterectomies for the purpose of sterilization.

Medically-Necessary Sterilizations

DCS CHP members are all minors. Any sterilization procedure requires Prior Authorization. DCS CHP monitors its contracted MCO for compliance with medical necessity requirements for sterilization procedures.

In general, and in accordance with AHCCCS guidelines, DCS CHP does not cover sterilization procedures if:

• Procedures are performed solely to render the individual permanently incapable of reproducing, or

• There was more than one purpose to the procedure and it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing.

Coverage of hysterectomy and sterilization services is limited to those cases in which medical necessity has been established by careful diagnosis and, prior to hysterectomy, there has been a trial of medical or surgical therapy, which has not been effective in treating the member’s condition. Even in the case of Medically Necessary Sterilizations, as DCS CHP members are children at risk, the process for authorization of the procedure require:

• Authorizations by the appropriate legal entities; the judicial system, consent of the custodial agency representative, the Guardian Ad Litem (if there is one), the biological parents (if they still have rights);

• Documentation from the physician of the medical necessity of the procedure;

• Documentation of alternate therapies attempted. If none have been attempted, the contraindications;

• Recommendation by the ethics board of the proposed facility for the procedure; and

• Review by the DCS CHP Chief Medical Officer.

This process is followed in all cases, allowing for timeliness of the procedure unless there is a life-threatening emergency.