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Health Education Programs

Members can receive rewards for their participation in health education and disease management programs through the Alliance’s Health and Wellness Rewards Program. Only Alliance Medi-Cal members who do not have other health insurance are eligible to participate in the rewards program.

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Programa Mamás Saludables y Niños Saludables (Healthy Moms and Healthy Babies Program)

The Alliance’s Healthy Moms and Healthy Babies (HMHB) program provides education to support a healthy pregnancy and encourages pregnant women to seek early prenatal and postpartum care. Members enrolled in the Early Prenatal Care program are contacted by Alliance health educators who provide educational materials on a variety of topics, including prenatal and postpartum health, labor and delivery, breastfeeding, pediatric care and parenting. Members also receive referrals to free or low-cost local community resources, like Women, Infants and Children (WIC).

HMHB Program Health and Wellness Rewards
Early Prenatal Care	Pregnant members who attend an initial prenatal visit within their first trimester (13 weeks of pregnancy) or within 42 days of enrollment with the Alliance will be entered into a monthly raffle to receive a $50 gift card for initiating timely pregnancy care. The member will be entered into the raffle once the PCP has billed the Alliance for the visit. No form is required.
Postpartum Care	New moms can receive a $25 gift card for their postpartum visit (postpartum care) if they see their PCP within 7-84 days of the birth of their child. Members will receive this incentive once the PCP has billed the Alliance for the visit. No form is required.

Apoyo para la Lactancia Materna y Beneficio de Extractor de Leche

The Alliance provides access to breastfeeding education, support and referrals for new mothers.

The Alliance covers up to two visits with a home health agency nurse and two hours with an International Board Certified Lactation Consultant (IBCLC) outside of the hospital stay (inpatient lactation education is included in the hospital per-diem). For a current list of approved providers, please refer to the International Board Certified Lactation Consultant and Breast Pump Provider Vendor List.

Members are eligible for a free breast pump if either:

Mother or baby has medical issues that prevent nursing at the breast.
Mother is returning to work or school and wants to continue breastfeeding.

The table below shares information on benefits, authorization and billing codes for Alliance member breastfeeding support. You can also view printable versions of the Breastfeeding Support and Breast Pump Benefit Description and the International Board Certified Lactation Consultants and Breast Pump Vendor List.

Breastfeeding Support and Breast Pump Benefits Information
Benefit	Description	Authorization	Billing Codes
Lactation consultant visit	Restricted to Alliance-approved providers (see Alliance-Approved Lactation Consultant Providers table below for list). Provided by an International Board Certified Lactation Consultant (IBCLC). Addresses complex problems, such as mastitis, suppressed lactation, etc. IBCLC does not need a Medi-Cal provider number to bill. Invoice or bill on CMS1500 or UB04 claim form (available at office supply stores).	No RAF or TAR required for 4 units per 12-month period for a total of two (2) hours. Referred by doctor, mid-level professional, certified nurse midwife, Alliance staff or self-referral.	CPT: Z5023* with a qualifying ICD-10 diagnoses code from categories O91, O92, P92, Z39 or Dx Code R63.3 Reimbursed at $45.74 per 30-minute unit. Limited to two (2) 30-minute units per visit.
Initial nurse home visit, postpartum	Restricted to home health agencies only with a Medi-Cal billing number. For all births covered by the Alliance, mother may receive an initial nurse home visit after delivery. Addresses common problems. Provided by a trained home visit nurse. Direct skilled nursing services by a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes. Follow-up of early OB discharge. For OB service, not a typical home health service.	A TAR is required, one (1) visit per day, except when services are in conjunction with the initial or six-month case evaluation. Includes supplies used as part of the treatment visit. No limit on the number of daily visits. No TAR is required, one (1) service day limit.	National HCPCS code G0300 must be billed with revenue code 0551, skilled nursing/visit. Standard reimbursement at $74.86. National CPT-4 code 99501, home visit for postnatal assessment and follow-up care or 99502, home visit for newborn care and assessment must be billed with revenue code 0580. Standard reimbursement at $74.86.
Follow-up nurse home visit for identified breastfeeding problems	Restricted to home health agencies only with a Medi-Cal billing number. For mothers who have never breastfed and mothers who want to breastfeed but were previously unable to nurse longer than one month. Addresses common problems. Provided by a trained home visit nurse.	No RAF or TAR required for one (1) visit per 12-month period. Home visit nurse will order at initial home visit, if needed.	CPT: Z5021* with a qualifying ICD-10. Dx Code Z39.1. Reimbursed at $80.
Personal use of breast pump, purchase	For mothers separated from baby, certain medical conditions of baby, or if mother is returning to work or school. Nota: Claims follow “by report” requirements. Attach pricing/catalog page. The Alliance will cover any type of breast pump, not just the lowest cost item. IBCLCs do not need a Medi-Cal provider number to bill for the Alliance breastfeeding support benefits.	No referral or authorization request required.* Ordered by physician, mid-level professional, certified nurse midwife or IBCLC. Reimbursement to contracted pharmacies, contracted medical supply vendors or approved lactation consultants only.	CPT: E0603 with a qualifying ICD-10 Dx code Z39.1. Modifier: NU. Reimbursement at 80% of MSRP or up to $250, whichever is less.
Hospital grade electric breast pump, daily rental	Per Alliance Policy 405-2214 - Breastfeeding Support Benefits, Standards and Promotion Program, daily rental of a hospital grade breast pump will be covered when medically necessary. These conditions include, but are not limited to: Mother continues to be treated for postpartum complications that preclude direct nursing at the breast. Mother has a medical condition that requires treatment of her breast milk before infant feeding. Mother is receiving chemotherapy or other therapy with pharmaceutical agents that render her breast milk unsuitable for infant feeding. Infant continues in hospital after mother is discharged. Infant has congenital dysfunction or neonatal condition that precludes effective direct nursing at the breast (physician should refer infant to California Children’s Services).	Authorization request required only if rental is to continue beyond 60 days. Authorization request must include documentation of medical need, infant’s date of birth and requested duration of rental. Approved authorization requests will specify a time limit based on medical condition. Ordered by physician, mid-level professional, certified nurse midwife or IBCLC.	CPT: E0604 with a qualifying ICD-10 Dx Code Z39.1. Modifier: RR. Reimbursed at $2.72 per day (incl. tax). May be billed in conjunction with E0602 (see below). When previously paid rental charges equal the documented retail purchase price of the rented item, the item is considered to have been purchased and no further reimbursement to the provider will be made [per Title 22. Section 51321(C)].
Kit for hospital grade pump or manual breast pump, purchase	Personal kit for use with rented hospital grade pump, per requirements above. May also be ordered for use with a multi-user pump borrowed from WIC.	No referral or authorization request required. Ordered by physician, mid-level professional, midwife or IBCLC.	CPT: E0602** with a qualifying ICD-10 Dx Code Z39.1. Modifier: NU. Reimbursed at retail rate plus tax if pricing attached, or at estimated amount if no pricing sent. Kit may be billed in conjunction with E0604.
Miscellaneous medical supplies for lactation management and support, purchase	Includes nipple shields and creams. Does not include furniture, pillows or bedding.	Prescribed by doctor, mid-level professional or midwife. No referral or authorization request required for these supplies.	CPT: A9900 with a qualifying ICD-10 Dx code Z39.1. Modifier: NU. Reimbursed at retail plus tax if pricing attached, or at estimated amount if no pricing sent.
Replacement breast pump supplies for lactation management and support, purchase	Includes: Tubing for breast pump. Adapter for breast pump. Breast pump bottle and cap. Breast shield, splash protector and locking ring for use with breast pump. Polycarbonate bottle for use with breast pump.	A TAR must be submitted, justifying the need for any breast pump supply that needs to be replaced and may not be reimbursed when provided within the same month of service as breast pump codes E0602 and E0603.	CPT: A4281, A4282, A4283, A4284, A4285 and A4286 with a qualifying ICD-10 Dx code Z39.1. Modifier: NU. Reimbursed at retail plus tax if pricing attached, or at estimated amount if no pricing sent.
Alliance members are eligible for one personal use breast pump every three years. If there is a need for a second breast pump during the three-year period, an authorization request must be submitted with documentation stating the reason that the original pump cannot be used. *Per Medi-Cal manual, E0602 may be used to bill either a manual breast pump or a breast pump kit.

Alliance-Approved Breast Pump Vendors

Any Durable Medical Equipment (DME) vendors with a Medi-Cal provider number may provide a breast pump to eligible Alliance members who are breastfeeding and meet medical necessity or who are returning to work or school. No prescription is required and only one breast pump will be dispensed every three years. Members must have a written note or letter from a physician, midlevel professional, certified nurse midwife or IBCLC. Written notes for breast pumps must include the following member information:

Alliance ID number.
Address.
Número de teléfono.
Delivery date.

Members may also call the Alliance Health Education Line at 800-700-3874, ext. 5580 for additional information on breastfeeding and how to access a breast pump. The following list of vendors routinely provides breast pumps for Alliance members.

Alliance-Approved Breast Pump Vendor List

Condado de Santa Cruz

Horsnyder Pharmacy

1226 Soquel Ave., Santa Cruz, CA 95062

Phone: 831-458-1400

Fax: 831-458-1401

Electronic Fax: 831-534-7052

Watsonville Pharmacy

1433 Freedom Blvd., Watsonville, CA 95076

Phone: 831-728-1818

Fax: 831-728-8678

Condado de Monterey

Robin Didoszak, IBCLC

Expressed Luv

Phone: 831-869-9308

*Lactation/Pump Consultations

Condado de Merced

Merced Medical Supply

1827 Canal St., Merced, CA 95340 Phone: 209-722-3832

Fax: 209-722-2779

Emily Bernard, BSPsy, IBCLC Before & After Baby

2239 Bailey Ave., Merced, CA 95341

Cell: 209-631-8511

Fax: 209-379-4218

*Lactation/Pump Consultations

DME Vendor List Serving all 3 Counties/Mail Order Only

Advance Home Medical*

Phone: 800-230-4761

Direct Line: 909-569-9013

Fax: 888-518-7568

*Upon request, may supply battery pack.

Simply Mama*

Phone: 844-470-7867

Fax: 855-552-1461

*Upon request, may supply battery pack or car adapter.

Shield Healthcare

Phone: 800-675-8842, select option 1.

Santa Cruz County Fax: 925-256-1639

Monterey and Merced counties Fax:

559-449-4257

International Board Certified Lactation Consultants

IBCLCs provide comprehensive, clinical breastfeeding management and support when medically necessary. IBCLCs do not need a Medi-Cal provider number to bill for services. A provider referral is not necessary. Members may self-refer for lactation services.

The following providers are currently approved to provide lactation consultation for Alliance members when medically necessary.

If you are an IBCLC who is interested in providing services to Alliance members, please call the Alliance Health Education Line at 800-700-3874, ext. 5580 to apply.

Alliance-Approved Lactation Consultant Providers

Condado de Santa Cruz

Willow Merchant, RN, IBCLC*

Phone: 650-862-9336

*Santa Cruz Mountains only - Boulder Creek, Ben Lomond, Felton and Bonny Doon (home visits).

Sutter Maternity Surgery Center - Lactation Center*

2900 Chanticleer Ave., Santa Cruz, CA 95065

Teléfono:
831-477-2229

Fax:
831-477-2221

*Lactation consultations and drop-in breastfeeding support groups.

Salud Para La Gente*

45 Neilson St.,
Watsonville, CA 95076

Teléfono:
831-728-0222

Fax:
831-707-2777

*Linked members only.

Watsonville Hospital Outpatient Clinic*

75 Neilson St., Watsonville, CA 95076

Teléfono:
831-768-6204

Fax:
831-625-5521

*Linked members only.

Condado de Monterey

Natividad Medical Center Outpatient Clinic

1441 Constitution Blvd., Salinas, CA 93906

Phone: 831-796-1652

Fax: 831-751-0607

Robin Didoszak, IBCLC*

Expressed Luv

Phone: 831-869-9308

*Lactation/pump consultations

Condado de Merced

Emily Bernard, BSPsy, IBCLC

Before & After Baby

2239 Bailey Ave., Merced, CA 95341

Cell: 209-631-8511

Fax: 209-379-4218

*Lactation/pump consultations

Billing

The services and equipment listed may be billed under either a mother or baby who is a current Alliance member. Billing limits apply to the mother/baby unit.

Please note that professional services, rental, supplies and durable medical equipment (DME) items cannot be billed to Medi-Cal for an amount greater than what is charged to the general public, per Title XXII.

If education is conducted as a home visit, bill only for education time. Travel time and expenses are not reimbursable.

Approved IBCLCs and DME vendors may bill for listed services and equipment under either mother or baby. Billing limits apply to the mother/baby unit.

Additional Resources Available to Alliance Members (Bilingual English/Spanish)
Service	Description	How to Access	Fees
Breastfeeding Helpline (U.S. Department of Health and Human Services)	La Leche League-trained peer counselors offer support for successful breastfeeding. Counselors can help with common breastfeeding questions on issues ranging from latching to pumping and storage.	800-994-9662	Members must call first to learn more about the programs and if there are any fees involved.
Comprehensive Perinatal Services Program (CPSP) breastfeeding services	Approved CPSP providers offer breastfeeding education, nutrition education, support and referrals for Medi-Cal members only. Services are provided in the antepartum and postpartum period. Services are billed with specific CPSP codes. Providers must be set up in the Alliance system as CPSP providers in order to be reimbursed for these codes.	County Perinatal Services Coordinators: Condado de Santa Cruz 831-454-5477 Condado de Monterey 831-755-4640 Condado de Merced 209-381-1142	No charge, but members must qualify. Services are billed under CPSP perinatal education, nutrition, psychosocial and health education billing codes. Medi-Cal members only.
Women, Infants and Children (WIC) program breastfeeding services	WIC serves pregnant or breastfeeding women, and children up to age 5. Alliance Medi-Cal members automatically qualify for WIC. Other members may qualify, depending on income. WIC provides breastfeeding classes during and after pregnancy. WIC also provides other support services including breast pump loans and counseling. Women get more WIC benefits if breastfeeding.	Mothers should call WIC directly for enrollment: Condado de Santa Cruz Santa Cruz 831-426-3911 Watsonville 831-722-7121 Condado de Monterey Seaside 831-393-3251 Salinas 831-796-2888 Soledad 831-678-5121 Condado de Merced 888-381-5261	No charge, but members must qualify.

Programa Peso Sano de por Vida (Healthy Weight for Life Program)

The Alliance’s Healthy Weight for Life (HWL) program is designed to engage with high-risk members 2-18 years of age with a body mass index (BMI) at or above the 85^th percentile. These members are contacted by Alliance health educators, who utilize motivational interviewing and trauma-informed care techniques to help members and their families identify measurable goals that support a healthier lifestyle.

The Alliance offers the HWL program through a 10-week workshop that teaches parents how to help children reach a healthy weight. The program includes new ways for parents to support their child, make lifestyle changes, eat healthy and be more active.

HWL Health and Wellness Rewards
Members who attend a 10-week HLP workshop will receive a Target Gift card of up to $100 and will also be entered into a raffle for a chance to win a bike.

Members who are moderate or low risk do not receive direct contact, but all participating members receive health education materials via mail. These materials emphasize the importance of nutrition and physical activity and provide an overview of available local low or no cost exercise and nutrition resources. Providers can also refer members who are moderate or low risk to participate in the HWL 10-week workshop.

Programa de Apoyo Para Dejar de Fumar (Tobacco Cessation Support Program)

The Tobacco Cessation Support Program (TCSP) offers many ways to help members quit smoking. The Alliance is committed to supporting members who wish to stop smoking and/or using tobacco products. To accomplish this, the Alliance provides tobacco cessation benefits and services that support prevention and cessation of tobacco use.

Tobacco dependence is a chronic condition that often requires repeated intervention, medication and multiple attempts to quit. While counseling and medication are both effective in treating tobacco use when used alone, they are more effective when used together.

The Alliance supports members by referring them to the convenient, toll-free California Smokers' Helpline at 800-NOBUTTS (800-662-8887). The helpline provides free tobacco cessation counseling over the phone for anyone in California. The Alliance also covers the cost of counseling sessions for eligible Alliance members.

Providers can refer an Alliance member to TCSP by submitting the Health Education and Disease Management Referral form. Members can also self-refer by calling the Alliance Health Education Line at 800-700-3874, ext. 5580.

Review the information below for a list of tobacco cessation benefits, support options and resources. You can also download a print-friendly copy of the Tobacco Cessation Benefit Description.

Tobacco Cessation Benefits
Tobacco Cessation Materials
Benefit	Description	Authorization	Contact Information
Alliance Health Programs	Alliance Health Education Coordinators (HECs) will respond to member inquiries by sending easy-to-read tobacco cessation health education materials with information and tips on how to quit. HECs will assist members with access and/or referrals to community tobacco cessation resources.	No RAF or TAR is required for the basic program.	Alliance Health Education Line 800-700-3874, ext. 5580
Individual Telephonic Counseling/Resources
Benefit	Description	Authorization	Contact Information
California Smokers’ Helpline	Services include: self-help materials, a referral list of other programs and one-on-one counseling over the phone. Counseling is also available via TDD/TTY for members with hearing or speech difficulties at 1-800-933-4TDD.	No RAF or TAR is required for the basic program.	English: 800-NO-BUTTS (800-662-8887) Spanish: 800-45-NO-FUME (800-456-6386) Chewing Tobacco: 800-844CHEW (800-844-2439) www.nobutts.org
Individual Online Counseling/Resources
Benefit	Description	Authorization	Contact Information
Freedom From Smoking® Online Program (FFS Online Basic)	Provides information about preparing to quit smoking and guides members through the first few weeks of being smoke-free (FFS Online Basic is free). Takes members through different modules with lessons that include valuable information about how to quit smoking.	No RAF or TAR is required for the program. Please call the Alliance Health Education Line to learn more about how to enroll.	freedomfromsmoking.org
Individual and Group Counseling
Benefit	Description	Authorization	Contact Information
The Alliance Tobacco Cessation Support Program	Members can self-refer or their PCP can also refer directly to tobacco cessation providers. HECs will help Alliance members enroll in an approved tobacco cessation class within their area. Classes are scheduled and managed by agencies outside of the Alliance; therefore, dates and locations are subject to change. Members are responsible to confirm class details prior to attending.	The Alliance will cover one counseling session of at least 10 minutes in duration per day with no yearly frequency limit. No mandatory breaks will be required between quit attempts in order for members to receive counseling sessions.	Alliance Health Education Line 800-700-3874, ext. 5580

The following tobacco cessation resources are available for Alliance-contracted providers.

Tobacco Cessation Resources for Alliance Providers
Resource	Source
Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons	United States Preventive Services Task Force (USPSTF)
Clinical Practice Guideline, Treating Tobacco Use and Dependence	Centers for Disease Control and Prevention (CDC)
Tobacco and Nicotine Cessation During Pregnancy	The American College of Obstetrics and Gynecology
Performing Preventive Services: A Bright Futures Handbook (Tobacco Use Cessation, p. 179)	Academia Americana de Pediatría
Clinical Guidelines and Recommendations – Treating Tobacco Use and Dependence: Five Major Steps to Intervention (The “5 A’s”)	Agency for Healthcare Research and Quality (AHRQ)

Tobacco Cessation Counseling

Providers can bill for tobacco cessation counseling using the following evaluation and management (E&M) codes:

CPT Code 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes.
CPT Code 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes. Not to report 99407 in conjunction with 99406.

The Alliance will reimburse providers for one counseling session of at least 10 minutes in duration per day with no yearly frequency limit. No mandatory breaks will be required between quit attempts in order for members to receive counseling sessions.

Members are not required to receive a particular form of tobacco cessation service as a condition of receiving any other form of tobacco cessation service.

Tobacco cessation therapy services are limited to two 12-week treatment periods per member per year. Tobacco cessation services must be rendered in a face-to-face setting and documented in the member’s record during the treatment period.

When providing these services on the same date as a significant, separately identifiable E&M service, append modifier 25 to the E&M service code.

For questions regarding the status of claims previously denied, please contact the Claims Department at 800-700-3874, ext. 5503.