Coverage Explanation
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Members may see any qualified participating Health Net provider within their participating physician group (PPG), including their primary care physician (PCP), obstetrician or gynecologist (OB/GYN), or certified nurse midwife (CNM) and certified nurse practitioner (CNP) for prenatal care. PPGs or PCPs and specialists are prohibited from requiring a referral or prior authorization for basic prenatal care. If there are no CNMs or CNPs in the PPG network, access to non-contracting CNMs or CNPs is a benefit.
All pregnant members must have access to Comprehensive Perinatal Services Program (CPSP) services, which integrate health education, nutrition and psychosocial services with obstetrical care. CPSP support services providers are required to use the Department of Health Care Services (DHCS)-approved assessment tools. Health Net has developed assessment tools approved by DHCS that are included in this manual. The multidisciplinary approach to delivering perinatal care in the CPSP framework is based on the recognition that providing these services from conception through 60 days following delivery improves pregnancy outcomes.
The provision of CPSP services to pregnant members is the responsibility of all California Department of Public Health (CDPH)-certified CPSP providers who contract with Health Net, a subcontracting health plan or PPG.
Health Net-participating PPGs must maintain and reimburse a network of obstetric and community providers who are CPSP-certified in order to promote access to CPSP and improve birth outcomes for their patients. PPGs may not redirect CPSP services away from participating CPSP-certified providers who are in good standing with the state and local county CPSP program. CPSP-certified providers must be allowed to provide services to Health Net Medi-Cal members. Health Net and CDPH attempt to have all obstetricians providing care to Medi-Cal members become CPSP-certified to allow CPSP services to be provided during routine obstetric prenatal and postpartum visits.
Individual participating providers who are not certified by the California Department of Public Health (CDPH) for the Comprehensive Perinatal Services Program (CPSP) are reimbursed for maternity services with a global professional fee, which includes all professional services normally provided for routine perinatal care. CPSP providers should bill each service separately, using the DHCS designated "Z" codes.
Compliance with Health Net's perinatal standards of care is monitored by the Health Net State Health Programs Quality Improvement Department.
Comprehensive Perinatal Services Program (CPSP) providers should complete a comprehensive risk assessment and individualized care plan (ICP) if the obstetric care provider is not providing the full scope of CPSP support services.
The comprehensive risk assessment includes information from the medical-obstetric assessment combined with a health education, nutrition and psychosocial assessment. The assessment is designed to evaluate the member's health behaviors, knowledge base, medical conditions, and psychosocial situation. The assessment is conducted by the provider or trained paraprofessional (comprehensive perinatal health worker). The ICP is developed by the provider in consultation with the member. The provider is responsible for making referrals to alleviate identified risks, with priority given to the most severe.
Identified risks, interventions and referrals comprise the ICP. The ICP includes a statement of the risks identified and the interventions taken to address the risks in priority order, the identification of the persons responsible for carrying out the proposed interventions, the evaluation or outcome of the actions taken by the provider or member, and any updates. The provider must retain a copy of the ICP in the member's medical record.
For all members participating in CPSP, risk reassessment occurs during each trimester and the postpartum period. The ICP is revised as indicated.
Health Net makes available the following CPSP assessment tools and resources:
- Prenatal Combined Assessment/Reassessment Tool (PDF)
- Prenatal Assessment Protocols (county specific) - currently available for Fresno (PDF), Los Angeles (PDF) and Tulare (PDF) counties
- Postpartum Combined Assessment Tool (PDF)
- Postpartum Assessment Protocols (county specific) - currently available for Fresno (PDF), Los Angeles (PDF) and Tulare (PDF) counties
- Individualized Care Plan (PDF) and Instructions (PDF)
- Perinatal Food Frequency Questionnaire (PDF)
- HIV Information Documentation form (PDF)
- Domestic Violence Danger Assessment form (PDF)
- Perinatal Risk Screening Tool (PDF)
Information regarding perinatal services and community information sources is available from the Health Net Medi-Cal Facility Site Review (FSR) Compliance Department and the Health Net Health Education Department.
Prior to the administration of any assessment, medication, procedure, or treatment, the member must be informed of potential risks that may affect her or her unborn child during pregnancy, labor, birth, or postpartum, and the alternative therapies available to her. The member has a right to consent to or refuse administration of any assessment, medication, procedure, test, or treatment.
The member has the right to:
- Be treated with dignity and respect
- Have her privacy and confidentiality maintained
- Review her medical treatment record with her physician
- Be provided explanations about tests, and clinic and office procedures
- Have her questions answered about procedures and care
- Participate in planning and decisions about her management during pregnancy, labor and delivery, and the postpartum period
Upon the discovery that a member is pregnant, all participating providers (including primary care physicians (PCPs), obstetric care providers, midwives, and family planning clinics) are required to notify the care manager of their affiliated participating physician group (PPG). Direct network providers must notify the Health Net Medi-Cal Health Services Department. Primary care physicians only should complete the Confirmation of Pregnancy Form (Medi-Cal or CalViva Health) for the pregnant member and fax it to the number at the top of the form.
Forms are required for documentation and tracking purposes. The Perinatal Notification and Assessment Report (Kern, San Juaquin and Stanislaus (PDF), CalViva Health (PDF), Los Angeles, Riverside, San Bernardino, San Diego (PDF), Sacramento (PDF), and Tulare (PDF)) and the Perinatal Risk Screening Tool were developed for reporting risk assessment data. The Pregnancy Outcome Notification Report provides Health Net with the information needed to meet the Department of Health Care Services (DHCS) reporting requirements. Completed forms must be faxed to the Health Net Medi-Cal Health Services Department .
The initial prenatal examination must occur within two weeks (for Medi-Cal facility site review purposes, within seven calendar days) of the initial referral or request for pregnancy-related services. The obstetric provider is expected to provide care for members using standards consistent with current American Congress of Obstetricians and Gynecologists (ACOG) recommendations and within accepted Health Net guidelines.
ACOG's guidelines for Perinatal Care (PDF) recommends the following examination schedule for a woman with an uncomplicated pregnancy:
- Every four weeks for the first 28 weeks
- Every two to three weeks until 36 weeks gestation
- Weekly from 36 weeks gestation until delivery
- Postpartum, four to eight weeks after delivery
Women with medical or obstetric problems may require closer surveillance. The interval between visits is determined by the obstetric provider according to the nature and severity of the problems.
Recommended intervals for routine tests for individual members during pregnancy are as follows:
- Initial visit (as early as possible):
- Hemoglobin or hematocrit measurement
- Urinalysis, including microscopic examination and infection screening
- Blood group and Rh type determinations
- Antibody screening
- Rubella antibody titer measurement
- Syphilis screening (Venereal Disease Research Laboratory (VDRL) test and rapid plasma reagin (RPR) test)
- Cervical cytology
- Hepatitis B virus screening
- HIV education, counseling and voluntary testing according to the California Perinatal HIV Testing Project guidelines
- Tuberculosis testing
- Chlamydia testing
- Gonorrhea culture
- Blood pressure
- Complete medical and obstetrical history, including genetic risk assessment and review of systems
- Complete physical examination
- Orientation to Comprehensive Perinatal Services Program (CPSP)
- Prescription and dispensing of 300-day supply of vitamin and mineral supplements as needed
- Counseling related to:
- Danger signs and what to do in an emergency
- Seat belt safety
- Teratogens
- Smoking, alcohol and substance use
- Breastfeeding promotion
- Referral to the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program
- Referral to Department of Health Care Services (DHCS)-certified genetic services (if needed)
- Comprehensive nutrition, psychosocial and health education risk assessment (ideally at initial visit, but within four weeks of initial visit)
- Development of an individualized care plan (ICP)
- 8 to 18 weeks:
- Ultrasound (if indicated)
- Amniocentesis (if indicated)
- Chorionic villus sampling (if indicated, between 9 and 12 weeks only)
- 10 to 21 weeks:
- Cell-free DNA (cfDNA) screening (recommended from 10 weeks 0 days though 21 weeks 0 days, but can be ordered on or after 10 weeks 0 days through term)
- 15 to 21 weeks:
- Maternal serum alpha-fetoprotein
- By 27 weeks:
- Reassessment of nutrition, psychosocial and health education needs (revise ICP as needed)
- 26 to 28 weeks:
- Diabetes screening
- Repeat hemoglobin or hematocrit (if indicated)
- 28 weeks:
- Repeat antibody test for unsensitized Rh-negative members
- Prophylactic administration of Rho (D) immune globulin (if indicated)
- 32 to 36 weeks:
- Ultrasound (if indicated)
- Repeat testing for sexually transmitted infections (STIs), including bacterial vaginosis (if indicated)
- Repeat hemoglobin or hematocrit, if indicated
- Family planning counseling and plan
- Offer HIV test again if previously refused or continued high-risk health behaviors
- By 39 weeks:
- Reassessment of nutrition, psychosocial and health education needs (revise ICP if needed)
- Inquiry related to member's plan for pediatric services. Provide information about the Child Health and Disability Prevention (CHDP) program and importance of well-baby visits
- Every prenatal visit:
- Urine check for glucose and protein
- After quickening, report of fetal movement
- Blood pressure, weight, uterine size, fetal heart rate, edema, Leopold's maneuvers
- Interval history
- Opportunity for questions
- Continual risk assessment and revision of the ICP and referral (if needed)
- Postpartum (four to eight weeks following delivery):
- Physical exam to include:
- Breast examination
- Recto-vaginal evaluation
- Bimanual examination of the uterus and adnexa
- Weight and blood pressure
- Abdominal examination
- Interval history and adaptation to newborn
- Discussion of normal symptoms and warning of postpartum depression
- Family adaptation
- Immunization status (especially rubella for non-immune women)
- Breastfeeding inquiries
- Counseling regarding future health and pregnancies (for example, gestational diabetes, vaginal birth after cesarean, genetic anomalies, and hypertension)
- Laboratory data as indicated (for example, hgb if anemic on discharge from hospital)
- Family planning counseling and prescription
- Well-child care CHDP inquiry and referral
- Reassessment of nutrition, psychosocial and health education needs (revise or close ICP as needed)
- Send copy of the ICP to the member's primary care physician (PCP)
- Physical exam to include:
For information on provider responsibility and pregnancy program, refer to Maternal Mental Health Screening Requirement.
When Health Net is notified that a Medi-Cal member is pregnant, the member is offered, with their consent, a pregnancy packet from the Health Net Health Education Department. The packet includes educational materials on various subjects, including breastfeeding, nutrition, exercise, perinatal check-ups, safety, and alcohol and substance misuse. It contains a booklet about having a healthy pregnancy, breastfeeding and caring for a newborn. It also contains information about Health Net's toll-free Breastfeeding and Nutrition Support Line (BNSL), information about postpartum care and information about how to get health insurance coverage after the baby is delivered. The packet is available in English and Spanish and provides member with additional resources on:
- Helping members find a ride to and from their doctor’s appointments, labs or the hospital
- Providing breastfeeding support and resources
- Helping members obtain a breast pump at no cost to them
- Assisting members if they are experiencing the baby blues (feeling sad, overwhelmed, “down” or thinking about harming themselves or others)
- Providing methods to help members quit smoking, alcohol or drugs
- Pregnant members may also contact the Health Education Department at 800-804-6074 to request the Infant Nutrition Benefit Guide (INBG).
Pregnant members are identified through primary care physician (PCP) or obstetric care provider submission of assessment reports, authorizations, inpatient admissions, Comprehensive Perinatal Services Program (CPSP) reports, and member contact with the Health Net Medi-Cal Member Services Department (Health Net or CalViva), the Health Net Medi-Cal Health Services Department or the Health Net Health Education Department.