(1) A member is eligible for targeted case management as a high risk pregnant woman if:
(a) the person is receiving Medicaid or is presumptively eligible for Medicaid; and
(b) the member's pregnancy outcome is considered high risk.
(2) A pregnancy is of high risk if the member:
(a) is age 17 or younger;
(b) has medical factors which indicate the potential for a poor pregnancy outcome;
(c) abuses alcohol, tobacco, or drugs;
(d) has someone in the member's immediate environment who abuses alcohol, tobacco, or drugs;
(e) is currently in an abusive relationship;
(f) is homeless;
(g) has had greater than three residences during pregnancy; or
(h) demonstrates an inability to obtain necessary resources and services and the person meets three of the following criteria:
(i) has a history of physical or sexual abuse;
(ii) has no support system or involvement of a spouse or other supporting person;
(iii) has not had a dental cleaning in the last year;
(iv) is not educated beyond the 12th grade level or does not have a GED;
(v) has a physical disability or mental impairment;
(vi) has had no prenatal care before or during the first 20 weeks of gestation;
(vii) is a refugee or a migrant worker;
(viii) is age 18 or 19;
(ix) is over the age of 35; or
(x) has limited English proficiency.
(3) The member is not eligible for targeted case management services if enrolled in a Medicaid Patient Centered Medical Home (PCMH) program, Comprehensive Primary Care Plus (CPC+), or Health Improvement Program (HIP).
(4) Targeted case management services may be delivered to the member, if Medicaid eligibility continues, until the last day of the month in which occurs the 60th day following the end of the pregnancy.