1. (1) Covered services.

   1. (a) General.

      1. 1. Prenatal care coordination services covered by MA are services described in this section that are provided by an agency certified under s. DHS 105.52 or by a qualified person under contract with an agency certified under s. DHS 105.52 to help a member and, when appropriate, the member’s family gain access to medical, social, educational and other services needed for a successful pregnancy outcome. Nutrition counseling and health education are covered services when medically necessary to ameliorate identified high-risk factors for the pregnancy. In this subdivision, “successful pregnancy outcome” means the birth of a healthy infant to a healthy member.
      2. 2. Prenatal care coordination services are available as an MA benefit to members who are pregnant, from the beginning of the pregnancy up to the duration allowed under s. 49.46 (1) (a) 1m., Stats., and who are at risk for adverse pregnancy outcomes. In this subdivision, “risk for adverse pregnancy outcome” means that a pregnant member requires additional prenatal care services and follow-up because of medical or nonmedical factors, such as psychosocial, behavioral, environmental, educational or nutritional factors that significantly increase their probability of having a low birth weight baby, a preterm birth or other negative birth outcome. “Low birth weight” means a birth weight less than 2500 grams or 5.5 pounds and “preterm birth” means a birth before the gestational age of 37 weeks. The determination of a member’s strengths and needs to mitigate adverse pregnancy outcomes shall be made by use of the assessment tool under par. (c).
   2. (b) Outreach. Outreach is a covered prenatal care coordination service. Outreach is activity which involves implementing strategies for identifying and informing low-income pregnant persons who otherwise might not be aware of or have access to prenatal care and other pregnancy-related services.
   3. (c) Assessment. An assessment of a member’s pregnancy-related strengths and needs to mitigate an adverse birth outcome is a covered prenatal care coordination service. The assessment shall be performed by an employee of the prenatal care coordination agency. The assessment shall be completed in writing and shall be reviewed and finalized in a face-to-face contact with the member. The employee and member must sign the finalized assessment. All assessments performed shall be reviewed and signed by a qualified professional under s. DHS 105.52 (2) (a). The assessment shall be performed with the assessment criteria developed and approved by the department.

   4. (d) Care planning. Development of an individualized plan of care for a member is a covered prenatal care coordination service when performed by a qualified professional as defined in s. DHS 105.52 (2) (a), whether that person is an employee of the agency or under contract with the provider under s. DHS 105.52 (2). The member’s individualized written plan of care shall be developed with the member. The plan shall identify the member’s strengths and needs and possible services which will reduce the probability of the member having a preterm birth, low birth weight baby or other adverse birth outcome. The plan of care shall include all possible needed services regardless of funding source. Services in the plan shall be related to the factors identified in the assessment and necessary to mitigate an adverse birth outcome. To the maximum extent possible, the development of a plan of care shall be done in collaboration with the family or other supportive persons. The plan shall be signed by the member and the qualified professional responsible for the development of the plan and shall be reviewed and updated by the employee in consultation with the member at least every 60 days. Any updating of the plan of care shall be in writing and shall be signed by the member. The plan of care shall include all of the following:

      1. 1. Identification and prioritization of all needs found during the assessment, with an attached copy of the assessment under par. (c).
      2. 2. Identification and prioritization of all services to be arranged for the member by the care coordinator under par. (e) 2. and the names of the service providers including medical providers.
      3. 3. Description of the member’s informal support system, including collaterals as defined in par. (e) 1., and any activities to strengthen it.
      4. 4. Identification of individuals who participated in the development of the plan of care.
      5. 5. Arrangements made for and frequency of the various services to be made available to the member and the expected outcome for each service.
      6. 6. Documentation of unmet needs and gaps in service.
      7. 7. Responsibilities of the member.

   5. (e) Ongoing care coordination.

      1. 1. In this paragraph, “collaterals” means anyone who is in direct supportive contact with the member during the pregnancy such as a service provider, a family member, the prospective other parent or any person acting as a parent, a guardian, a medical professional, a housemate, a school representative or a friend.

      2. 2. Ongoing coordination is a covered prenatal care coordination service when performed by an employee of the agency or person under contract to the agency who serves as care coordinator under s. DHS 105.52 (2m) and who is supervised by the qualified professional required under s. DHS 105.52 (2) (b) 2. The care coordinator shall follow-up the provision of services to ensure that quality service is being provided and shall evaluate whether a particular service is effectively meeting the member’s needs as well as the goals and objectives of the care plan. The amount of service provided shall be commensurate with the specific factors addressed in the plan of care and the overall level of need. Ongoing care coordination services include any of the following:

         1. a. Face-to-face and phone contacts with members for the purpose of determining if arranged services have been received and are effective. This shall include reassessing needs and revising the written plan of care. Face-to-face and phone contact with collaterals are included for the purposes of mobilizing services and support, advocating on behalf of a specific eligible member, informing collateral of member needs and the goals and services specified in the care plan and coordinating services specified in the care plan. Covered contacts also include case-specific coordination and collaboration between qualified professionals and care coordinators regarding the needs of a specific member. All billed contacts with a member, collateral, and staff collaboration related to the member shall be documented in the member’s prenatal care coordination file.
         2. am. Information and referral provided to members and their families to connect with needed services and supports identified in the assessment and care plan. This may include providing verbal, electronic, or written information and resources to the member for the purposes of fundamental education on the referral resource and how it supports goals from the care plan, and ensuring they have the necessary support, resources, and understanding to access and navigate the resources being provided.
         3. b. Recordkeeping documentation necessary and sufficient to maintain adequate records of services provided to the member. This may include verification of the pregnancy, updating care plans, making notes about the member’s compliance with program activities in relation to the care plan, maintaining copies of written correspondence to and for the member, noting of all contacts with the member and collaterals, ascertaining and recording pregnancy outcome including the infant’s birth weight and health status and preparation of required reports. All plan of care management activities shall be documented in the member’s record including the date of service, the person contacted, the purpose and result of the contact and the amount of time spent, and must be signed and dated by the care coordinator. A care coordination provider shall not bill for recordkeeping activities if there was no member contact during the billable month.

   6. (f) Health education. Health education, either individually or in a group setting, is a covered prenatal care coordination service when provided by an individual who is a qualified professional under s. DHS 105.52 (2) (a) and who by education or at least one year of work experience has the expertise to provide health education. Health education is a covered service if the medical need for it is identified in the assessment and the strategies and goals for it are part of the care plan to ameliorate a pregnant member’s member’s identified risk factors in areas including all of the following:

      1. 1. Education and assistance to stop smoking.
      2. 2. Education and assistance to stop alcohol consumption.
      3. 3. Education and assistance to stop use of illicit or street drugs.
      4. 4. Education and assistance to stop potentially dangerous sexual practices.
      5. 5. Education on environmental and occupational hazards related to pregnancy.
      6. 6. Lifestyle management consultation.
      7. 8. Reproductive health education.
      8. 9. Parenting education.
      9. 10. Childbirth education.

   7. (g) Nutrition counseling. Nutrition counseling is a covered prenatal care coordination service if provided either individually or in a group setting by an individual who is a qualified professional under s. DHS 105.52 (2) (a) with expertise in nutrition counseling based on education or at least one year of work experience. Nutrition counseling is a covered prenatal care coordination service if the medical need for it is identified in the assessment and the strategies and goals for it are part of the care plan to ameliorate a pregnant member’s identified risk factors in areas including the following:

      1. 1. Weight and weight gain.
      2. 2. A biochemical condition such as gestational diabetes.
      3. 3. Previous nutrition-related obstetrical complications.
      4. 4. Current nutrition-related obstetrical complications.
      5. 5. Psychological problems affecting nutritional status.
      6. 6. Dietary factors affecting nutritional status.
      7. 7. Reproductive history affecting nutritional status.

2. (2) Limitations.

   1. (a) Reimbursement for assessment and development of a care plan shall be limited to no more than one each for a member per pregnancy.
   2. (b) Reimbursement of a provider for ongoing prenatal care coordination and health education and nutrition counseling provided to a member shall be limited to one claim for each member per month and only if the provider has had contact with the member during the month for which services are billed.
   3. (c) Prenatal care coordination is available to a member residing in an intermediate care facility or skilled nursing facility or as an inpatient in a hospital only to the extent that it is not included in the usual reimbursement to the facility.
   4. (d) Reimbursement of a provider for prenatal care coordination services provided to a member after delivery shall only be made if that provider provided prenatal care coordination services to that member before the delivery.
   5. (e) A prenatal care coordination service provider shall not terminate provision of services to a member it has agreed to provide services for during the member’s pregnancy unless the member initiates or agrees to the termination. If services are terminated prior to delivery of the child, the termination shall be documented in writing and the member shall sign the statement to indicate agreement. If the provider cannot contact a member in order to obtain a signature for the termination of services, the provider will document the reason, as well as all attempts to contact the member.
   6. (f) Reimbursement for prenatal care coordination services shall be limited to a maximum amount per pregnancy as established by the department.

3. (3) Non-covered services. Services not covered as prenatal care coordination services are the following:

   1. (a) Diagnosis and treatment, including:

      1. 1. Diagnosis of a physical or mental illness.
      2. 2. Follow-up of clinical symptoms.
      3. 3. Administration of medications.
      4. 4. Any other professional service, except nutrition counseling or health education, which is a covered service by an MA certified or certifiable provider under this chapter.
   2. (b) Member vocational training.
   3. (c) Legal advocacy by an attorney or paralegal.
   4. (d) Care coordination and monitoring, nutrition counseling or health education not based on a plan of care.
   5. (e) Care coordination and monitoring, nutrition counseling or health education which is not reasonable and necessary to ameliorate identified prenatal risk factors.
   6. (f) Transportation.
   7. (g) Child day care.
   8. (h) Goods and supplies.
   9. (i) Personal care services.
   10. (j) Home health services.
   11. (k) Supportive home care and respite services.
   12. (L) Collateral contacts regarding non-member-specific issues or general program issues.
   13. (m) Any services that constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs.

History

History: Cr. Register, June, 1994, No. 462, eff. 7-1-94; corrections in (1) (a) 1., (c), (d) (intro.), (e) 2. (intro.), (f) (intro.) and (g) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 25-004: am. (1) (a) 1., 2., (b) to (d), (e) 1., 2. (intro.), a., cr. (1) (e) 2. am., am. (1) (e) 2. b., (f) (intro.), 1. to 9., (g) (intro.), 1. to 6., (2) (a) to (e), (3) (a) 1. to 4., (b) to (e), cr. (3) (g) to (m) Register September 2025 No. 837, eff. 10-1-25; correction in (3) (m) made under s. 35.17, Stats., Register September 2025 No. 837.