Pregnancy Medical Home Transitioned to Pregnancy Management Program Clinical Coverage Policy 1E-6, Transitioned to Pregnancy Management Program Effective July 1, 2021
Effective June 30, 2021, the Pregnancy Medical Home Program (PMH) terminated and was transitioned to the new Pregnancy Management Program (PMP) effective July 1, 2021.
The PMP offers comprehensive coordinated maternity care services with a focus on preventing preterm births and will be similar in structure to PMH. NC Medicaid Clinical Coverage Policy 1E-6, Pregnancy Medical Home is currently in the update process to reflect the new PMP program guidelines and will be changed to NC Medicaid, Clinical Coverage Policy 1E-6, Pregnancy Management Program.
In the PMP, there is no longer an enrollment requirement or process to “opt in” for participation in the program. All providers are considered participating Pregnancy Management Program providers and will receive at a minimum, the same rate for vaginal deliveries as they do for cesarean sections.
Many of the guidelines remain the same, including the continued use of the pregnancy risk screening tool and referral of high-risk pregnant women for pregnancy care management. Providers will continue to be exempt from prior approval on ultrasounds and will continue to receive pregnancy risk screen and postpartum visit incentives for completion of those services.
Providers who bill for and receive incentives should adhere to the following program requirements that will be set forth in the updated 1E-6, Pregnancy Management Program policy.
- Allow NC Medicaid or NC Medicaid’s designated vendor access to medical records for auditing purposes to measure performance on specific quality indicators;
- Commit to maintaining or lowering the rate of elective deliveries prior to 39 weeks gestation;
- Offer and provide 17 alpha-hydroxyprogesterone caproate (17p) for the prevention of preterm birth to women with a history of spontaneous preterm birth who are currently pregnant with a singleton gestation. 17p is prescribed when the beneficiary is deemed an appropriate candidate at the physician's discretion for 17p intramuscular injection and consents to participate after being informed by the provider of the benefits and risks;
- Complete the standardized risk screening tool at each initial visit on each pregnant Medicaid beneficiary and integrate the plan of care with local pregnancy care management;
- Commit to decreasing the cesarean section rate among nulliparous women;
- Decrease the primary cesarean delivery rate if the rate is over NC Medicaid’s designated cesarean rate.; Note: NC Medicaid sets the rate annually, which is at or below 20 percent;
- Ensure comprehensive postpartum visits occur within 56 days of delivery; and
- Send all screening information and applicable medical record information for members with high-risk pregnancies to contracted local pregnancy care management entities within one business day.
A future bulletin will post for providers once the 1E-6, Pregnancy Management Program policy is finalized.
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