Coverage Explanation
Provider Type
- Physicians and Practitioners
- 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.
Refer to Doula section of the provider operations manual for additional information.
Billing
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 and Quality Improvement
Compliance with Health Net's perinatal standards of care is monitored by the Health Net State Health Programs Quality Improvement Department.
Comprehensive Risk Assessment and Individualized Care Plan
All perinatal care providers should complete a comprehensive risk assessment and individualized care plan (ICP), even if the obstetric care provider is not providing the full scope of CPSP support services.
The comprehensive risk assessment tool must be comparable to ACOG and the CPSP standards. Individualized care plans must be developed to include obstetrical, nutrition, psychosocial and health education interventions when indicated by identified risk factors. The assessment is designed to evaluate the member's health behaviors, knowledge base, medical conditions, and psychosocial situation. 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. This assessment must be administered at the initial prenatal visit, once each trimester thereafter, and at the postpartum visit.
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, 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:
Educating Providers on Perinatal Services
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.
Member Rights
Prior to the administration of any assessment, medication, procedure, or treatment, the member must be informed of potential risks that may affect them or their unborn child during pregnancy, labor, birth, or postpartum, and the alternative therapies available to them. 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 their privacy and confidentiality maintained
- Review their medical treatment record with their physician
- Be provided explanations about tests, and clinic and office procedures
- Have their questions answered about procedures and care
- Participate in planning and decisions about their management during pregnancy, labor and delivery, and the postpartum period
Notification and Early Entry into Care
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, CalViva Health, Community Health Plan of Imperial Valley) for the pregnant member and fax it to the number at the top of the form.
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 .
Pregnancy Care Management
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 and Post partum Care (PDF) recommends the following examination schedule for a woman with an uncomplicated pregnancy:
- Tailor visit frequency based on individual needs, traditionally every four weeks for the first 28 weeks.
- Tailor visit frequency based on individual needs, traditionally every two to three weeks until 36 weeks gestation.
- Tailor visit frequency based on individual needs, traditionally weekly from 36 weeks gestation until delivery.
- Postpartum, individualized and woman centered. All women should ideally have contact with a maternal care provider within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.
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 based on ACOG prenatal care services guidelines:
- Initial visit (as early as possible):
- Complete Blood Count (CBC).
- Urinalysis and urine culture.
- Blood type, Rh(D) Type, antibody screening.
- Hemoglobinopathy testing as appropriate based on ACOG recommendations.
- Rubella antibody titer measurement.
- Syphilis screening (Venereal Disease Research Laboratory (VDRL) test and Rapid Plasma Reagin (RPR) test).
- HBSAg, anti-HBs Ab, anti-HBc Ab, HepC Ab.
- HIV education, counseling and voluntary testing according to the California Perinatal HIV Testing Project guidelines.
- Tuberculosis testing (PPD/QuantiFERON).
- Varicella immunity testing (VZV IgG antibodies).
- Chlamydia testing.
- Gonorrhea testing.
- Cervical cytology ± HPV testing.
- Early diabetes screen.
- Carrier counseling and screening as appropriate based on ACOG recommendations.
- Blood pressure.
- Complete medical and obstetrical history, including genetic risk assessment and review of systems.
- Complete physical examination components as indicated based on gestational age and individual risk-factors.
- Orientation to Comprehensive Perinatal Services Program (CPSP).
- Prescription and dispensing of 300-day supply of vitamin and mineral supplements as needed.
- Counseling (anticipatory guidance) related to:
- Pregnancy options
- Expected prenatal care
- Weight gain
- Nutrition, dietary precautions
- Exercise
- Exposures ((e.g., Toxoplasmosis, Zika/COVID, heat, work)
- Use of medications
- Sexual activity
- Dental care/referral
- Seat belt use
- Preparation for birth
- Breastfeeding
- 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 (mental health conditions, substance use/abuse, intimate partner violence/ trauma, social drivers of health), 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 12 weeks:
- Ultrasound (if indicated).
- 10 to 21 weeks (15 weeks 0 days to 21 weeks 0 days):
- Aneuploidy screening, cell-free fetal 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), to screen for fetal autosomal trisomies (trisomy 21, trisomy 18, and trisomy 13) and sex chromosome aneuploidy (X, XXY, XYY, XXX).
- 15 to 21 weeks (15 weeks 0 days to 21 weeks 0 days):
- Maternal serum alpha-fetoprotein (MSAFP).
- 18 to 21 weeks:
- Ultrasound assessment.
- 14 to 27 weeks:
- Repeat psychosocial screening (mental health conditions, substance use/abuse, intimate partner violence).
- Repeat anticipatory guidance (Signs and symptoms of preterm labor, Selecting a newborn care clinician, reproductive life planning & contraception, postpartum care planning).
- Reassessment of nutrition.
- Revise ICP as needed.
- 24 to 28 weeks:
- Diabetes screening (1-hour GTT).
- Repeat CBC.
- 28 weeks:
- Repeat antibody test for unsensitized Rh-negative members.
- Prophylactic administration of Rho (D) immune globulin (if indicated).
- 28 to 26 weeks:
- Tdap.
- 38 to 39 weeks:
- Repeat testing for sexually transmitted infections (STIs, HIV, Syphilis, Gonorrhea/Chlamydia), if indicated.
- Repeat psychosocial screening (mental health conditions, substance use/abuse, intimate partner violence).
- Repeat anticipatory guidance (fetal movement monitoring, signs and symptoms of preeclampsia, labor signs, reproductive life planning & contraception, infant feeding, newborn education, Family Medical Leave Act or disability forms, postpartum depression, post-term counseling, birth preferences [e.g., birth plan, pain management/coping, trial of labor after cesarean as indicated, induction of labor, labor support, infant medications, feeding, circumcision]).
- 32 to 36 weeks:
- RSV (seasonal).
- 36 to 37 weeks:
- GBS screen.
- 36 weeks
- Physical exam should include assessment of fetal presentation if relevant to planned mode of birth.
- 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, education and revision of the ICP and referral (if needed).
- Postpartum care visits 7 to 84 days after delivery, and additional postpartum care as needed until 365 days after delivery) based on ACOG recommendations:
- Mood and emotional well-being:
- Screen for postpartum depression and anxiety with a validated instrument.
- Provide guidance regarding local resources for mentoring and support.
- Screen for tobacco use; counsel regarding relapse risk in postpartum period.
- Screen for substance use disorder and refer as indicated.
- Follow-up on preexisting mental health disorders, refer for or confirm attendance at mental health-related appointments, and titrate medications as appropriate for the postpartum period.
- Infant care and feeding
- Assess comfort and confidence with caring for newborn, including:
- feeding method.
- child care strategy if returning to work or school.
- ensuring infant has a pediatric medical home.
- ensuring that all caregivers are immunized with Tdap.
- Assess comfort and confidence with breastfeeding, including:
- breastfeeding-associated pain.
- guidance on logistics of and legal rights to milk expression if returning to work or school.
- guidance regarding return to fertility while lactating; pregnancy is unlikely if menses have not returned, infant is less than 6 months old, and infant is fully or nearly fully breastfeeding with no interval of more than 4–6 hours between breastfeeding sessions.
- review theoretical concerns regarding hormonal contraception and breastfeeding, within the context of each woman's desire to breastfeed and her risk of unplanned pregnancy.
- Assess material needs, such as stable housing, utilities, food, and diapers, with referral to resources as needed.
- Assess comfort and confidence with caring for newborn, including:
- Sexuality, contraception, and birth spacing:
- Provide guidance regarding sexuality, management of dyspareunia, and resumption of intercourse.
- Assess desire for future pregnancies and reproductive life plan.
- Explain the rationale for avoiding an interpregnancy interval of less than 6 months and discuss the risks and benefits of repeat pregnancy sooner than 18 months.
- Review recommendations for prevention of recurrent pregnancy complications, such as 17-hydroxyprogesterone caproate to reduce risk of recurrent preterm birth, or aspirin to reduce risk of preeclampsia.
- Select a contraceptive method that reflects patient's stated needs and preferences, with same-day placement of LARC, if desired.
- Sleep and fatigue:
- Discuss coping options for fatigue and sleep disruption.
- Engage family and friends in assisting with care responsibilities.
- Physical recovery from birth:
- Assess presence of perineal or cesarean incision pain; provide guidance regarding normal versus prolonged recovery.
- Assess for presence of urinary and fecal continence, with referral to physical therapy or urogynecology as indicated.
- Provide actionable guidance regarding resumption of physical activity and attainment of healthy weight.
- Chronic disease management:
- Discuss pregnancy complications, if any, and their implications for future childbearing and long-term maternal health, including ASCVD.
- Perform glucose screening for women with GDM: a fasting plasma glucose test or 75 g, 2-hour oral glucose tolerance test.
- Review medication selection and dose outside of pregnancy, including consideration of whether the patient is breastfeeding, using a reliable resource such as LactMed.
- Refer for follow-up care with primary care or subspecialist health care providers, as indicated.
- Health maintenance:
- Review vaccination history and provide indicated immunizations, including completing series initiated antepartum or postpartum.
- Perform well-woman screening, including Pap test and pelvic examination, as indicated.
- Laboratory data as indicated (for example, CBC if anemic on discharge from hospital).
- Preventive and well-child screening exams and well-child care needs 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).
- Mood and emotional well-being:
For information on provider responsibility and pregnancy program, refer to Maternal Mental Health Screening Requirement.