The WVCHIP provides coverage of maternity-related professional and facility services, including prenatal care, midwife services and birthing centers beginning July 1, 2019. If a member is pregnant at the time of turning 19 and aging out of WVCHIP coverage, the member needs to contact DHHR. to be evaluated for WVCHIP pregnancy coverage. Contact your DHHR County Field Officer.
Maternity services for members who require more than 20 visits in 6 months will be covered with prior authorization. Coverage includes but is not limited to 2 ultrasounds during a pregnancy without prior authorization; testing for Downs Syndrome, Associated Protein Plasma-A, etc., with prior authorization; and inpatient stays for vaginal/cesarean delivery, breast pumps and breastfeeding education. Sterilization is covered for members over 21 with prior authorization.
END OF MATERNITY BENEFIT COVERAGE:
Maternity benefit ends after the Postpartum period, 60 days from the birth of the baby (the last day of the month that the 60th day falls in). Example: 60th day after the birth of the baby falls on 9/15, the coverage would end 9/30.
- prenatal care included –
- up to 20 office visits will be paid.
- More than 20 visits in 6 months will require a PA.
- Ultrasounds -- 2 per pregnancy may be billed.
- More than 2 per pregnancy require a PA.
- Inpatient visits do not require a PA until over 48 hours for vaginal delivery;
- 96 hours for Cesarean delivery
Statement of Rights Under the
Newborns’ and Mothers’ Health Protection Act
WVCHIP is required by law to provide you with the following statement of rights.
WVCHIP’s maternity benefit meets or exceeds all the requirements of the Newborns’ and Mothers’ Health Protection Act.
Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by Cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., 26 your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.
Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification, contact your KEPRO at 1-888-571-0262.
WVCHIP is making tobacco cessation services available to members 18 and older for two 12-week cycles per lifetime.
WVCHIP will provide 100% coverage for the tobacco cessation benefit for pregnant members during their pregnancy at 18 and older. WVCHIP will cover an initial and follow-up visit to the member’s physician or nurse practitioner at no cost to the member.
Tobacco cessation products covered under CVS Caremark pharmacy plan are:
● Buproion HCL tab SR 12 hr 150 mg
● Chantix tab 0.5 mg and 1 mg
● Chantix tab 0.5 mg x 11 tabs and 1 mg x 42 pack
● Nicotine polacrilex gum 2 mg and 4 mg
● Nicotine prolacrilex lozenge 2 mg and 4 mg
● Nicotine TD patch 24 hr 21 mg, 14 mg and 7 mg/24 hr
● Nicotrol inhaler system 10 mg
● Nicotrol NS nasal spray 10 mg ml