2.0 DESCRIPTION
Maternity care is the medical
services related to conception, delivery and pregnancy loss, including
prenatal and postpartum care (generally through the sixth post-delivery
week), and treatment of complications of pregnancy.
3.0 POLICY
3.1 Services
and supplies associated with antepartum care (including well-being
of the fetus), childbirth, postpartum care, and complications of
pregnancy may be covered.
3.2 The maternity
care benefit includes, but is not limited to, the following prenatal
screening tests:3.2.1 Anemia Screening:
3.2.2 Asymptomatic
Bacteriuria, Urinary Tract, or Other Infection Screening. Screen
with urine culture for women 12-16 weeks gestation, or at first
prenatal visit, if later.
3.2.3 Gestational Diabetes
Mellitus Screening. Screen women 24-28 weeks pregnant and those at
high risk of developing gestational diabetes.
3.2.4 Hepatitis B Screening.
Screen pregnant women for HBsAG during the prenatal period.
3.2.5 Human Immunodeficiency
Virus (HIV) Infection Screening.
3.2.6 Rh Incompatibility
Screening. Screen all pregnant women and provide follow-up testing
for pregnant women at high risk.
3.2.7 Syphilis Infection
Screening.
3.2.8 Other screening
tests as recommended by the United States Preventive Services Task
Force.
3.3 Genetic testing is considered
preventive rather than active medical treatment. However, under the
family planning benefit, genetic testing, including testing done
as part of routine prenatal care, is covered when performed in certain
high risk situations. For the purpose of the TRICARE benefit, genetic testing
may include specific tests to detect developmental abnormalities
as well as tests for specific genetic defects.
3.4 The mother and child hospital
Length-of-Stay (LOS) benefit may not be restricted to less than 48
hours following a normal vaginal delivery and 96 hours following
a cesarean section. The decision to discharge prior to those minimum
LOSs must be made by the attending physician in consultation with the
mother.
3.5 Maternity care for pregnancy
resulting from noncoital reproductive procedures may be cost-shared.
Where the contractual arrangements do not specify an amount for
reimbursement for medical expenses, the full amount of all undesignated
payments shall be deemed to be for medical expenses incurred by
the surrogate mother. TRICARE will cost-share on the remaining balance
of otherwise covered benefits related to the surrogate mother’s
medical expenses after the contractually agreed upon arrangement
has been exhausted.
3.6 For pregnancies in which the
TRICARE beneficiary is a surrogate mother, services and supplies associated
with antepartum care, childbirth, postpartum
care, and complications of pregnancy may be cost-shared.
3.8 Progesterone therapy for the
prevention of preterm birth is covered only for weekly injections of
17 alpha-hydroxyprogesterone caproate between 16 and 36 weeks of
gestation for pregnant women with a documented history of a previous
spontaneous birth at less than 37 weeks of gestation.
4.0 EXCLUSIONS
4.1 Oral progesterone
therapy or injections of 17 alpha-hydroxyprogesterone caproate are NOT covered
for other high risk factors for preterm birth, including, but not
limited to multiple gestations, short cervical length, or positive
fetal tests for cervicovaginal fetal fibronectin.
4.2 Services and supplies related
to noncoital reproductive procedures.
4.3 Home Uterine
Activity Monitoring (HUAM), telephonic transmission of HUAM data,
or HUAM-related telephonic nurse or physician consultation for the
purpose of monitoring suspected or confirmed pre-term labor is unproven.
4.4 Subcutaneous terbutaline pump
and home use of maintenance subcutaneous terbutaline to suppress
labor is unproven.
4.5 Lymphoctye
or paternal leukocyte immunotherapy in the treatment of recurrent
spontaneous fetal loss is unproven.
4.6 Salivary
estriol test for preterm labor is unproven (CPT procedure code 82677).