Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-21 - Preconception Care Services › Section 5160-21-04 - Reproductive health services: pregnancy-related services

Current through all regulations passed and filed through July 1, 2024
(A) Coverage.
(1) Unless a different time period is
			 specified, services described in this rule are covered through the pregnancy
			 and the delivery.
(2) Basic
			 pregnancy-related services include but are not limited to antepartum care,
			 delivery, outpatient postpartum care, and family planning services.
(a) Antepartum care. Payment for a visit may
			 be made for either of two purposes:
(i) Basic
			 care (including the taking and subsequent updating of a medical history,
			 physical examination, the recording of vital signs, and routine chemical
			 urinalysis) provided monthly up to twenty-eight weeks' gestation, biweekly
			 thereafter up to thirty-six weeks' gestation, and weekly thereafter until
			 delivery; or
(ii) Initial
			 establishment of a relationship with a pediatrician or other primary care
			 provider who will subsequently furnish early and continuous well-child and
			 primary care for the newborn and will discuss care of the infant with the
			 individual and, as appropriate, the individual's family.
(b) Delivery. Payment may be made for
			 admission to a facility (hospital or freestanding birth center), the taking of
			 a medical history during admission, physical examinations, the management of
			 labor (intrapartum management), and either vaginal delivery (with or without
			 episiotomy and with or without forceps) or delivery by cesarean section.
(i) Separate payment may be made for
			 intrapartum management and for delivery performed as distinct procedures by
			 different providers who are not part of the same practice.
(ii) Additional payment may be made for
			 multiple-birth delivery.
(iii)
			 Additional payment may be made for evaluation and management (E&M) services
			 or medical services rendered for the diagnosis and treatment of medical
			 conditions that complicate labor and delivery management.
(iv) No additional payment will be made for
			 complex delivery nor for additional professional services (e.g., assistance by
			 a second practitioner during delivery).
(c) Outpatient postpartum care. Payment may
			 be made for hospital and office visits involving routine, uncomplicated
			 follow-up care rendered during the postpartum period specified in rule
			 5160:1-2-16
			 of the Administrative Code. Postpartum care rendered prior to discharge from
			 the facility is considered incidental to the delivery.
(d) Family planning services. Policies
			 governing payment for these services are set forth in rules
			 5160-21-02
			 and 5160-21-02.2 of the Administrative Code.
(3) Payment may be made for one report of a
			 pregnancy that is diagnosed in conjunction with an E&M service not
			 associated with a normal obstetrics/ gynecology visit, submitted on either form
			 ODM 10257, "Report of Pregnancy (ROP)" (7/2021), or its web-based equivalent.
			 This payment is separate from the payment for the E&M service (or the
			 encounter or visit of which the E&M service is part).
(4) A pregnancy risk assessment may be used
			 to screen an individual for medical and social factors that may place that
			 individual at risk for preterm birth or other poor pregnancy outcome and to
			 substantiate the individual's need for enhanced pregnancy-related services and
			 other support services. Payment may be made for one such assessment, performed
			 at the initial antepartum visit by a practitioner of obstetric services and
			 submitted on either form ODM 10207, "Pregnancy Risk Assessment" (rev. 7/2021),
			 or its web-based equivalent.
(a) If an
			 individual is determined to be at risk and the practitioner obtains the
			 individual's informed consent, then the practitioner sends to the entity
			 responsible for managing the individual's pregnancy-related care a report with
			 recommendations, in the form and format specified by the entity.
(b) If the individual needs additional
			 support services during the course of pregnancy, then (with the individual's
			 informed consent) the practitioner may relay that information to the entity
			 responsible for managing the individual's pregnancy-related care.
(5) Enhanced pregnancy-related
			 services promote general health, improve the quality of life, and produce
			 better outcomes for a pregnant individual or a fetus during pregnancy or the
			 postpartum period. Coverage of
									
									such
			 services include but are not limited to the following services:
(a) High-risk patient monitoring (the
			 additional monitoring of an individual who has been determined to be at risk
			 for a preterm birth) performed by a healthcare professional qualified to
			 identify the signs of preterm labor, which has three components:
(i) Counseling and education to assist the
			 individual in identifying and reducing the risk of preterm labor;
(ii) Regular contact with the individual,
			 either in person or by telecommunication, to identify signs of preterm labor;
			 and
(iii) Ready access to the
			 provider in the event the individual begins to show signs of preterm
			 labor;
(b) Group
			  pregnancy education
			 (the face-to-face presentation by a medical professional to a group of
			 two or more participants but no more than
			 twenty
										) in a session
			 that may consist of one or more classes. Group
			 pregnancy education provides information utilizing culturally sensitive
			 communication and facilitates family-centered collaboration and support. Group
			 pregnancy education classes will meet the following criteria:
(i)
											Cover subjects related to pregnancy, including:
(a)
			 Childbirth preparation (e.g., Lamaze);
(b) Childbirth
			 refresher;
(c)
			 Nutrition;
(d) Parenting;
			 and
(e) Infant safety;
			 or
(ii)
											Consist of an
			 evidence-based or evidence-informed curriculum that has been demonstrated to
			 result in improved health outcomes and/ or improved health equity for pregnant
			 and postpartum women and their infants.
(c) Individual counseling and education,
			 given during an antepartum visit, that entails a face-to-face encounter of at
			 least fifteen minutes in which the primary focus is the specific needs of the
			 individual;
(d) Medical nutrition
			 therapy in accordance with rule 5160-8-41 of the
			 Administrative Code;
(e)
			 Family planning-related services in accordance with
			 rule 5160-21-02 of the Administrative Code; and
(f) Tobacco cessation counseling and
			 treatment.