By Sarah Johanek, MPH and Joy Burkhard, MBA

On July 24th, 2022, the Center for Medicare and Medicaid Services (CMS) released the Maternity Care Action Plan to support the implementation of the Biden-Harris Administration’s Blueprint for Addressing the Maternal Mental Health Crisis. Read our analysis of this White House’s Blueprint here. The Maternity Care Action Plan aims to decrease inequities among pregnant people and improve health outcomes. This plan includes technical assistance for states to extend postpartum coverage and policies to develop a diverse provider workforce.

CMS Administrator Chiquita Brooks-LaSure stated, “The United States is facing a worsening maternal health crisis. Enough is enough. We can – and will – do better. CMS will use every available lever to support people during pregnancy, childbirth, and the postpartum period, and advance health equity across the country. Our action plan is built on promising approaches, like extending postpartum coverage in Medicaid, which already covers more than 40 percent of births nationwide, to advance equitable, high-quality maternity care and reduce unnecessary maternal illnesses and deaths.”

CMS outlined five major gaps in maternity care related to CMS initiatives and highlighted them in the White House Blueprint. These five priorities are:

Coverage and Access to Care
Data Collection and Measurement
Quality of Care
Workforce Development and Expansion
Social Supports

Is Maternal Mental Health (MMH) addressed in this plan?

Mental or behavioral health is not directly mentioned in the plan; however, the actions that impact MMH are outlined below, along with our recommendations for how CMS could further its goal to improve health outcomes and reduce disparities.

CMS Priority: Coverage and Access to Care

CMS Action: “Guaranteed access to Medicaid for a year after pregnancy.

Thanks to the American Rescue Plan Act of 2021 (ARP), states can provide continuous Medicaid and Children’s Health Insurance Program (CHIP) coverage for a full year after pregnancy, up from 60 days prior to the ARP. When states use this option, Medicaid and CHIP enrollees have 12 months of postpartum coverage regardless of the changes in circumstances the person may experience, such as an increase in income. This extended coverage option offers states an opportunity to provide care that can reduce pregnancy related deaths and severe maternal morbidity, and improve continuity of care for chronic conditions. CMS has already approved 19 proposals to extend life saving Medicaid and CHIP coverage, and 9 additional states have submitted similar proposals to CMS for approval.”

Our Thoughts:

2020 Mom applauds the efforts of CMS to extend Medicaid coverage to one year postpartum. Before Medicaid extension became an option in March of 2021, about 45% of women covered by Medicaid and CHIP during pregnancy became uninsured after 60 days postpartum. The Public Health Emergency declaration prevented states from terminating Medicaid coverage, and data shows that this decreased the Medicaid to uninsured rate by 64% from 2019 to 2021. Because we know that maternal mental health disorders (MMHDs) affect one in five birthing people before, during, and after pregnancy, this coverage is vital. Additionally, ⅓ of pregnancy-related deaths happen between one week to one a year after pregnancy. Further, suicide accounts for up to 20% of deaths in the postpartum period. We encourage all states to extend postpartum Medicaid and raise awareness about the available coverage.

However, it’s critical to note that coverage is just the start. It’s critical that obstetric providers are incentivized, supported, and held accountable for actually providing recommended services. This includes screening for maternal mental health disorders, including suicidal ideation and risk for suicide. Though screening is recommended by the U.S. Preventive Services Task Force and insurers must cover screening, screening is still not being provided routinely in the U.S. In addition to screening, recommended treatment must also be provided. 2020 Mom urges CMS to prioritize engaging in monitoring of the HEDIS screening rates, developing of future HEDIS treatment measures and prioritizing value based payment structures, like pay for performance, to incentivize outcomes through Medicaid agencies and health plans.

CMS Priority: Coverage and Access to Care

CMS Action: “Reducing gaps in coverage during and after pregnancy.

CMS will identify ways that policy, technology, and operations can work better together to help people understand their coverage options if they lose eligibility for Medicaid coverage after pregnancy, including helping them transition from Medicaid to Health Insurance Marketplace® coverage. CMS is currently building data system capacity to identify people losing Medicaid coverage and provide targeted outreach to ensure that they are able to transition successfully into Health Insurance Marketplace® coverage, for which they may be eligible for subsidies. When individuals’ eligibility for Medicaid coverage changes after the [COVID-19] public health emergency (PHE) ends, CMS will report on a periodic basis the rate at which individuals losing Medicaid coverage successfully transition to coverage through the Marketplace.”

Our Thoughts:

2020 Mom recognizes the importance of providing all Americans with access to high-quality, standardized and affordable health care, starting with those in the perinatal period. We applaud the CMS’s efforts to assist the postpartum population who doesn’t have access to extended postpartum Medicaid with finding health insurance coverage on the Health Insurance Marketplace created by the Affordable Care Act (ACA). Ensuring postpartum health coverage by supporting coverage/insurance transitions is innovative and vital to improving maternal health outcomes. We encourage CMS to call on Medicaid Agencies to disclose this transition service through health plan coverage documents.

CMS Priority: Data Collection and Measurement

CMS Action: Quality Measurement

“CMS’ Hospital Inpatient Quality Reporting Program is a pay-for-reporting quality program that reduces payment to hospitals that fail to meet program requirements, including the submission of quality data.

In 2021, CMS finalized a rule requiring hospitals to report to CMS whether they have participated in a maternity care quality collaborative, and if so, whether they have implemented best practices to improve maternity care quality, such as initiatives to reduce maternal hemorrhage or sepsis. Hospitals are already beginning to collect and report these data.
In April 2022, CMS proposed to add two additional maternal health quality measures to the Hospital Inpatient Quality Reporting Program, both of which are electronic clinical quality measures.
- A measure of severe obstetric complications , which describes the number of inpatient hospitalizations for patients with severe complications occurring during the delivery hospitalization, such as hemorrhage.
- A measure of low-risk Cesarean section rates, which describes the share of patients with low-risk pregnancies who give birth via a Cesarean section. Hospitals may report supplemental data for these measures, including patient race, ethnicity, and several other demographic variables.”

Our Thoughts:

2020 Mom covered this preliminary rule-making effort by CMS and applauds the Agency’s development of hospital maternal health quality measures as women deserve a standard of care regardless of where they deliver and by whom. Further, traumatic birth/severe obstetric complications as well as having had a c-section are correlated with an increased risk of maternal mental health disorders.

CMS Priority: Data Collection and Measurement

CMS Action: Medicaid quality measures

“CMS encourages state Medicaid agencies to report a broad range of quality measures describing the quality of care that Medicaid and CHIP beneficiaries receive. Included in these quality measure sets are nine measures of maternal and perinatal health, known as the maternity care core set. Beginning in 2024, CMS will require states to report a set of quality measures related to children’s health, which includes six measures in the maternity care core set, as well as all adult behavioral health measures.”

Our Thoughts:

2020 Mom supports the state requirement to report on quality measures, but advocates for the inclusion of maternal depression measures. We published a blog on U.S. Screening Measurement: HEDIS Perinatal Depression Screening Measures & Medicaid Adoption. Here we explain that according to the 2021 Child and Adult Core Set Review Workgroup Final Report (“Workgroup final report”), the workgroup recommended CMS adopt the Postpartum Depression Screening and Follow-Up measure as part of the Adult Core Measure Set. This was a significant win for maternal mental health. Unfortunately, this measure was not reported on in 2021, and CMS informed 2020 Mom that their leaders are still working with NCQA, the measure steward, to assess the feasibility of inclusion of the postpartum depression screening measure in the annual update. In addition to reporting on postpartum depression screening, 2020 Mom advocates for the inclusion of prenatal depression screening measures in the Child and Adult Core Set.

CMS Priority: Data Collection and Measurement

CMS Action: Medicaid Postpartum Care Equity Assessment

“CMS is conducting an equity assessment on the quality of postpartum care in Medicaid and CHIP. CMS is looking at Medicaid and CHIP data to identify disparities and opportunities to address inequities in postpartum care.”

Our Thoughts:

2020 Mom will analyze this program and assessment effort once additional information becomes available. Further, 2020 Mom deeply supports the CMS “Birthing Friendly” standards, health equity-focused measures, and increases in payment in the Hospital Inpatient Quality Reporting (IQR) Program finalized last month (Aug. 2022). These programs provide financial incentives for hospitals to participate in Perinatal Quality Collaboratives (PQC) and adopt recommended PQC guidelines. The programs also address hospitals establishing a culture of equity and framework for delivering more equitable health care by capturing concrete activities across five key domains, including: strategic planning, data collection, data analysis, quality improvement, and leadership engagement.

CMS Priority: Workforce Development and Expansion

CMS Action: Community-based pregnancy and childbirth care

“State Medicaid programs can cover community-based maternity services, such as those furnished by doulas and community health workers. In addition, Medicaid requires states to cover services provided through freestanding birth centers and those provided by midwives within the scope of their state licensure. However, few states have robust networks of birth centers, midwives, doulas, or community health workers. CMS released guidance in December 2021 encouraging states to expand access to doula care and will continue to work with states to expand access to these important services.”

Our Thoughts:

2020 Mom recognizes the importance of expanding the obstetric workforce to include more midwives, community-based health workers, and the need to cover birth centers through Medicaid. We are very interested in learning what type of national reporting CMS may require/provide on coverage of these critical provider types. Further, we acknowledge the critical role doulas play in supporting a mother through the maternal period, and also wish to call out the important role mental health Certified Peer Support Specialists (CPSSs) can provide. Like doulas, CPSSs can also be employed in community-based settings as well as obstetric settings. Doulas with lived maternal mental health experience may also become certified peers and be reimbursed as peers through state Medicaid agencies that do not yet reimburse doulas. Peer support is a proven model for addressing mental health, as noted in our issue brief titled A Significant Solution for Maternal Mental Health: Certified Peer Specialists.

CMS Priority: Social Supports

CMS Action: Medicaid linkages to social supports

“CMS is identifying promising approaches for state Medicaid agencies to provide directly, or to link Medicaid beneficiaries to, appropriate social supports, such as tenancy-related services, housing vouchers, nutrition services, and others. For example, CMS is working with the U.S. Department of Agriculture (USDA) to identify gaps in coverage between people who are enrolled in nutrition assistance programs and Medicaid to improve outreach and enrollment of eligible individuals who are eligible to enroll in both programs. These social supports will benefit people during and after pregnancy, when people are particularly vulnerable to adverse health and pregnancy outcomes without needed support.”

Our Thoughts:

Directly providing or creating the infrastructure to link those enrolled in Medicaid with practical supports such as housing and food assistance simply makes sense. We applaud this effort and look forward to learning more and sharing more about the maternal mental health field.