CurrentFidelis CarePolicy N/A

New York State Perinatal Care Standards (Medicaid)

Defines New York State Medicaid perinatal care standards for prenatal, intrapartum, and postpartum services and applies to Medicaid FFS and Managed Care providers delivering pregnancy-related care in NYS.

Policy Summary

PayerFidelis Care

PolicyNew York State Perinatal Care Standards (Medicaid)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2022

Next Review DateN/A

Key ActionOffer and arrange one initial postpartum home visit for all postpartum persons and document scheduling and summary communication to the principal maternal care provider and health plan case manager.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Aug 1, 2022effective date for NYS Medicaid FFS

Oct 1, 2022effective date for Medicaid Managed Care

12 wkspostpartum period (principal provider)

36–72 hrsinitial postpartum visit timing

24/7after-hours coverage

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Coverage Criteria for Prenatal and Postpartum Services

Prenatal Home Visit — Medical Necessity Criteria

Prenatal home visits must be provided when ordered and medically necessary. Covered when ANY of the following are met:

Prenatal home visit medical necessity: High medical risk pregnancy as defined by ACOG/AAP.

Per ACOG/AAP definitions; document rationale.

Prenatal home visit medical necessity: Need for home monitoring or assessment by a nurse for a medical condition complicating the pregnancy.

Number and frequency guided by medical necessity and the pregnant person's unique profile.

Prenatal home visit medical necessity: Pregnant person otherwise unengaged in prenatal care (no consistent visits).

Visits intended to re-engage and connect to prenatal services.

Prenatal home visit medical necessity: Need for home assessment for suspected environmental or psychosocial risk (e.g., intimate partner violence, substance use, unsafe housing, nutritional risk, unstable mental health, inadequate resources or parenting skills).

Assessments must be transmitted to the principal maternal care provider for follow-up.

Postpartum Home Visit — Eligibility and Timing

Postpartum home visits — covered stance and timing

Initial postpartum home visit: All postpartum persons are eligible for one initial postpartum home visit; birthing hospitals must offer and arrange this visit prior to discharge; if accepted, the visit should occur 36 to 72 hours after discharge.36-72 hours

Document that the visit was offered, scheduled, and send the visit summary to the principal maternal care provider and health plan case manager.

Access to Care — Visit and Referral Timeframes

Minimum access standards — initial visit timing and specialist referral urgency

Access standards: Initial prenatal visit timing: first trimester within 3 weeks of request; second trimester within 2 weeks of request; third trimester within 1 week of request. Initial family planning visit within 2 weeks of request.

These are minimum required time frames; providers should see patients sooner when clinically indicated.

Referral and urgent access standards: Urgent specialist referrals: seen as soon as clinically indicated, not to exceed 72 hours. Non-urgent specialist referrals: within 2–4 weeks. Non-emergent urgent matters: seen within 24 hours. Practices must provide 24/7 coverage with after-hours contact that returns calls within one hour.72 hours; 2–4 weeks; 24 hours; 1 hour callback

Apply clinical judgment to shorten these timeframes when necessary.

Comprehensive Prenatal Risk Assessment

Risk assessment requirements

Comprehensive prenatal care risk assessment: Conduct a comprehensive prenatal care risk assessment at the first prenatal visit including all components of the ACOG Antepartum Record and Postpartum Form; assess medical, dental, mental health, substance use, nutritional, and psychosocial risk factors; review at each routine visit and repeat early in the third trimester; document clearly in the medical record and act on identified risks with treatment, counseling, or referral.

USPSTF recommends screening adults 18+ for unhealthy drug use by questioning; positive screens should prompt diagnostic assessment or referral.

Postpartum visit coverage criteria

Covered when the following requirements/timings are met:

Initial postpartum home visit: All postpartum persons are eligible and must be offered one initial postpartum home visit arranged by the birthing hospital; if accepted the visit should occur 36 to 72 hours after discharge.36-72 hours after discharge

Visit summary and findings must be sent to the principal maternal care provider and health plan case manager.

Additional postpartum home visits (medical necessity): Additional postpartum home visits are covered if ONE of the following is met: history of a high medical risk pregnancy (ACOG/AAP); need for home nursing monitoring for a postpartum medical condition; postpartum person otherwise unengaged in postpartum care; or need for home assessment for suspected environmental or psychosocial risk (e.g., intimate partner violence, substance use, unsafe housing, nutritional risk).N/A

Meeting any one criterion qualifies the person for additional visits.

Initial and comprehensive postpartum clinical visits:

Some home visit programs may not be a Medicaid-covered benefit unless provided by agencies licensed or certified under Article 36 of the Public Health Law. Medicaid-reimbursable home visits are skilled nursing visits provided by a Certified Home Health Agency (CHHA) or a Licensed Home Care Service Agency (LHCSA); other programs (for example, Nurse‑Family Partnership, local health department visits, or community health worker programs) may or may not be covered depending on agency certification and Medicaid rules.

Provide routine education and counseling about infant feeding and lactation to all pregnant and postpartum persons, but note that breastfeeding/chestfeeding or feeding expressed milk is not recommended for HIV-positive persons and may be medically contraindicated in other circumstances. Counselors should document individualized guidance and arrange referrals to lactation specialists or community supports as appropriate.

Provider Responsibilities, Documentation, and Billing Notes

Prior Authorization

Home visit medical necessity and reimbursement

Prenatal and postpartum skilled nursing home visits are Medicaid-reimbursable when provided by agencies certified or licensed under Article 36 (Certified Home Health Agency or Licensed Home Care Service Agency) and when ordered by the principal maternal care provider for medical necessity; providers must order visits and document medical necessity.

Medicaid reimbursable visit = skilled nursing home visit provided by CHHA or LHCSA.
Visits must be ordered by the principal maternal care provider and be medically necessary; document the order and justification.

Prior Authorization

Coverage for additional postpartum home visits

Additional postpartum home visits may be covered when the postpartum person's situation meets any one of four medical necessity criteria; evaluate and document which qualifying criterion applies.

History of a high medical risk pregnancy per ACOG/AAP; OR
Need for home nursing monitoring/assessment for a postpartum medical condition; OR

Key Definitions

Principal maternal care provider — main obstetric provider responsible throughout pregnancy and 12-week postpartum period

DefinitionThe principal maternal care provider is the pregnant/postpartum person's main obstetric provider responsible for leading and coordinating obstetric care throughout pregnancy and the 12-week postpartum period.

Eligible provider typesNYS-licensed physician (MD/DO) Board Certified/Eligible in Family Medicine or Obstetrics & Gynecology or completed accredited residency; NYS-licensed midwife within scope; NYS-licensed nurse practitioner within scope.

RoleServes as the principal obstetric provider for management, referrals, and coordination of care during pregnancy and the 12 weeks immediately following delivery.

Interaction with primary careThe designated primary care provider remains the PCP during pregnancy/postpartum and may also serve as the principal maternal care provider when appropriate.

Prenatal/Postpartum home visit — skilled nursing home visit reimbursable when provided by CHHA or LHCSA or other ordered home visit services

Background and Rationale

Perinatal care standards require an early, comprehensive biopsychosocial risk assessment at the first prenatal visit to identify maternal–fetal risk factors and guide timely management, referrals, and care planning. The assessment must cover medical, mental health, substance use, nutritional, dental, and social determinants of health and be reviewed at each routine visit and again in the early third trimester so that identified risks are addressed with treatment, counseling, home visits, or referrals as indicated.

Policy Summary

PayerFidelis Care

PolicyNew York State Perinatal Care Standards (Medicaid)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2022

Next Review DateN/A

SourceLink

On This Page

Initial assessment by the principal maternal care provider within the first 3 weeks postpartum (in-person or via Telehealth); for complicated gestation or cesarean delivery, schedule initial visit as early as possible or within 7 days of delivery. Comprehensive in-person postpartum visit must occur between 4 and 12 weeks after birth.

Initial: within 3 weeks (or within 7 days for complicated/cesarean); Comprehensive: 4–12 weeks

Comprehensive visit must include full assessment of maternal and infant physical, behavioral, and psychosocial well-being and referrals as needed.

Postpartum person unengaged in postpartum care; OR

Need for home assessment for suspected environmental or psychosocial risk (e.g., IPV, substance use, unsafe housing, nutritional risk).

Step Therapy

Step therapy

No step therapy requirements are specified in this excerpt; there is no guidance requiring sequential trials prior to coverage of home visits.

Step Therapy

Step therapy not applicable to additional visits

Coverage for additional postpartum home visits is determined by specific medical necessity criteria rather than a step-therapy sequence; no step-wise treatment prerequisites are described.

Documentation Required

Risk assessment and mandated test documentation

Document a comprehensive prenatal risk assessment at the first prenatal visit (include all components of the ACOG Antepartum Record and Postpartum Form), review it at each routine visit and repeat in the early third trimester, and record required public health test results.

Include medical, dental, mental health, substance use, nutritional, and psychosocial risk factors.
Document mandated test results (e.g., HBsAg, syphilis testing) in the prenatal record.

Documentation Required

Home visit documentation and notification

Document prenatal and postpartum home visit assessment findings and transmit the visit summary to the postpartum/pregnant person's principal maternal care provider and the health plan case manager for follow-up.

Send prenatal home visit assessment findings to the principal maternal care provider for next steps (referrals, management).
Send postpartum home visit summary and findings to the principal maternal care provider and health plan case manager.

Documentation Required

Home visit scheduling and summary communication

Document that the initial postpartum home visit was offered to the postpartum person, whether it was accepted, that it was scheduled (if accepted, scheduled for 36–72 hours after discharge), and that a summary of the visit and findings was sent to the principal maternal care provider and health plan case manager.

Birthing hospitals must have a system to arrange and schedule the initial postpartum home visit prior to discharge.
If accepted, the visit should occur 36 to 72 hours after discharge; document offer, scheduling, and summary transmission.

Denial Risk

Presumptive Eligibility responsibilities

Perform Presumptive Eligibility determinations during visits and assist pregnant members in completing and submitting the Medicaid application (DOH-4220) to the local department of social services; failure to do so may affect access to covered prenatal services for presumptively eligible persons.

Medicaid-enrolled licensed Article 28 prenatal providers must perform Presumptive Eligibility determinations and assist with application submission.
All prenatal care providers must provide care to persons determined presumptively eligible even if not yet enrolled.

Denial Risk

Initial home visit arrangement and communication

Offer and arrange the initial postpartum home visit for all postpartum persons and send the visit summary and findings to the principal maternal care provider and health plan case manager; failing to provide or arrange this visit and summary could result in noncompliance with the standard.

All principal maternal care providers and/or birthing hospitals must offer and arrange the initial postpartum home visit.
Birthing hospitals must schedule the visit prior to discharge and ensure summary transmission after the visit.

DefinitionA skilled nursing home visit ordered by the principal maternal care provider and provided when medically necessary to manage prenatal or postpartum needs; postpartum persons are eligible for one initial visit.

Reimbursable providersMedicaid-reimbursable skilled nursing home visits are provided by agencies certified or licensed under applicable NYS requirements (e.g., CHHA or LHCSA).

Documentation and communicationAssessment findings from prenatal and postpartum home visits must be sent to the person's principal maternal care provider (and health plan case manager for postpartum visits) for follow-up actions.

Initial postpartum offerBirthing hospitals must offer and arrange the initial postpartum home visit; if accepted it should occur 36–72 hours after discharge.

Medical necessity for additional home visits — one of specified criteria (history of high-risk pregnancy, need for home monitoring, etc.)

Qualification — high-risk pregnancyHistory of a high medical risk pregnancy as defined by ACOG and AAP Guidelines for Perinatal Health qualifies for additional home visits.

Qualification — need for nursing monitoringNeed for home monitoring or assessment by a nurse for a medical condition complicating pregnancy or postpartum care qualifies for additional visits.

Qualification — unengaged in carePregnant or postpartum person who is otherwise unengaged in prenatal or postpartum care (no consistent visits) qualifies for additional home visits.

Qualification — environmental/psychosocial riskNeed for home assessment for suspected environmental or psychosocial risk (e.g., intimate partner violence, substance use, unsafe housing, nutritional risk, unstable mental health, inadequate resources or parenting skills) qualifies for additional visits.