Health Agency Innovations in Financing Maternal Mental Health

October 17, 2023 | Ramya Dronamraju, Claire Rudolph

Perinatal mood and anxiety disorders are common in the United States. The societal cost of these disorders going untreated was $14.2 billion in 2017, when following the mother-child pair for five years. The high rates and cost of maternal mental health disorders coupled with near-universal Medicaid coverage during pregnancy creates enormous potential for innovations in payment and coverage structures to improve maternal mental health, including Value Based Payment and public-private partnership arrangements.

Between 10–15% of pregnant and postpartum individuals experience a mental health disorder, making it the most common complication of pregnancy and childbirth, yet just half of those diagnosed with depression in the perinatal period receive treatment. Postpartum depression and anxiety can hinder essential parent-child bonding and lead to negative mental health outcomes for children and adolescents. Poor mental health during pregnancy is also associated with increased risk for substance use disorder. However, positive maternal mental health is a protective factor for infant and child cognitive development. The 2022 White House Blueprint for Addressing the Maternal Health Crisis recognizes the importance of maternal mental health and pledges federal efforts to expand access to postpartum depression screenings and treatment.

One of the many factors that impact mental health is adequate insurance coverage. Those who are un- or underinsured can be highly stressed by medical bills and cost of care. Medicaid is an important insurance program for pregnant and postpartum individuals, covering more than four in ten births nationally. The vast majority of states provide the full Medicaid service package to all pregnant people. States determine how long pregnant people remain covered after delivery, yet just 38 states currently provide Medicaid coverage for 12 months postpartum. Forty-one states provide Medicaid coverage through managed care organizations (MCOs). The Institute for Medicaid Innovation’s 2022 Medicaid MCO survey highlights the increasing role of Value Based Payment arrangements in MCOs. Sixty eight percent of MCO respondents said they make global or capitated payments to their providers, and more than half reported making bundled or episode-based payments.

Innovative State Partnerships Related to Financing Mental Health

In November 2022, the New Mexico Department of Health (NMDOH) described mental health issues as the most frequent underlying cause of pregnancy-related deaths. To help address high rates of mental health issues in the state, NMDOH serves as a member of the New Mexico Behavioral Health Collaborative. The focus of the Collaborative is to serve as a single statewide behavioral health delivery system to manage funds effectively and efficiently. Collaborative responsibilities include contracting with a single, statewide services purchasing entity, monitoring service capacities and utilization to achieve desired performance measures and outcomes, and overseeing rate setting. By cooperating around these focus areas, the collaborative has potential to make systemic improvements to maternal mental health. The group also emphasizes regional, cultural, rural, frontier, urban, and broader issues, and seeks input from Native Americans in the state. In addition to NMDOH, 15 other state agencies and the Governor’s Office participate in this collaborative.

The North Carolina Department of Health and Human Services, in collaboration with the University of North Carolina School of Medicine and Duke University, utilizes funding from HRSA to offer the NC Maternal Mental Health MATTERS initiative. This initiative offers real-time psychiatric consultation and care discussion for women’s health providers. It also keeps comprehensive provider and family resource directories up-to-date and provides training and technical assistance on perinatal mental health for healthcare professionals. North Carolina Medicaid covers mental health counseling and support through the Baby Love Program.

Maternal Mental Health Medicaid Coverage Options

• As a primary payer of maternity care in the United States, Medicaid is a critical partner in addressing maternal mental health and states offer a variety of maternal mental health screenings and service options.
• The American Academy of Pediatrics’ Bright Futures Guidelines recommend screening for maternal depression during the infant one-, two-, four-, and six-month visits. Approximately 20 states follow these guidelines during well-child visits.
• North Dakota Medicaid covers maternal depression screening as a separate service when performed in conjunction with an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screening or any other pediatric visit and is considered a risk assessment for the child.
• After CMS released a bulletin in 2016 enabling state Medicaid agencies to cover maternal depression screening as part of well-child visits, more than 43 states allow, recommend, or require maternal depression screening during well-child visits covered by Medicaid.
• Arkansas’ 1115 Medicaid waiver demonstration allows the state to provide enhanced services for individuals with high-risk pregnancies for up to two years post-partum. These services include intensive care coordination and home visitation.
• Maine and Colorado included maternal mental health in their programming as part of their participation in the Medicaid Innovation Accelerator Program.

Recommendations for State and Territorial Health Agencies

• Collaborate with state officials and state Medicaid agencies to increase postpartum Medicaid coverage for up to 12 months postpartum, if applicable. The National Alliance on Mental Illness emphasizes that extending postpartum coverage to 12 months (or longer) can help ensure that new mothers receive regular mental healthcare and can help reduce disparities, since pregnancy-related deaths disproportionally impact communities of color. State health agency staff can also leverage existing collaboration between Title V and Medicaid programs and their established data sharing agreements to influence Medicaid coverage and policy.
• Explore Value Based Payment arrangements and alternative payment models for maternity care. Value Based Payment arrangements are playing an increasing role in Medicaid managed care. Encourage Medicaid MCOs to engage maternal mental health providers in Value Based Payment arrangements. In fact, research suggests that Value Based Payment models with shared savings could offer greater incentives for implementing interventions to prevent postpartum depression. Value Based Payment models for maternity care should be designed with health equity and decreasing disparities in mind.
• Work with Medicaid MCOs to approve postpartum depression screenings during pediatric visits, coupled with additional technical assistance and resources to pediatricians to provide appropriate referrals for positive screens.