MMRC Behavioral Health Policy Recommendations

MMRCs identified SUD and mental health conditions as drivers of pregnancy-related deaths. Based on a review of publicly available MMRC recommendation reports as of February 2021, improving SUD and mental health services for pregnant women in the prenatal and postpartum periods is a common policy recommendation for states. Access to behavioral services is an important component in improving maternal health outcomes. Because state MMRCs review each pregnancy-related death that occurs, they can identify policy changes that can improve overall maternal health outcomes. Nearly every state that reviews pregnancy-related deaths has recommendations focusing on:

• Ensuring adequate insurance coverage and payment,
• Increasing early identification and referrals,
• Ensuring referrals and follow-up care, and/or
• Increasing access to specific services.

Ensuring Adequate Medicaid Coverage and Payment for SUD and Mental Health Related Services 

Medicaid covers more than 40 percent of births in the United States and covers approximately 65.9 percent of Black non-Hispanic births.[8] Inadequate coverage of services remains a barrier for many women seeking treatment and maintenance of care for behavioral health conditions. Many state MMRCs identify policy recommendations related to Medicaid coverage and reimbursement of substance use and mental health treatment during pregnancy.

To ensure Medicaid coverage and adequate reimbursement, many MMRCs commonly recommend three strategies as outlined below. (For specific state recommendations see Table 1). Providing coverage for SUD and mental health related services can help pregnant women to overcome barriers to receiving care.

• Offer provider incentives to complete maternal behavioral health screenings. States can use financial incentives to encourage providers to make screening, brief intervention, and referral to treatment for behavioral health conditions part of routine perinatal care and promote the use of evidence-based screening methods or tools in care settings.[9] In 2021, Louisiana began allowing separate Medicaid reimbursement for perinatal depression screenings of an enrolled caregiver during a well-child visit from birth to 1 year of age.[10]
• Increase reimbursement for behavioral health related services. Adequate reimbursement rates for behavioral health services can ensure that pregnant and postpartum women have access to the services. Washington state recommends increasing funding to the state Medicaid program to adequately reimburse hospitals for inpatient perinatal SUD care at the time of delivery and increasing reimbursement for caregiver depression screening by pediatric and family care providers.[11]
• Expand Medicaid coverage for postpartum women. States can extend Medicaid coverage beyond the standard 60 days postpartum for women and can also expand coverage to include inpatient and outpatient treatment. Illinois recently received approval for a Medicaid Section 1115 demonstration to extend postpartum coverage from 60 days after delivery up to one year postpartum, with the goal of reducing maternal morbidity and pregnancy-related mortality.[12] Illinois’ 1115 demonstration allows for full Medicaid benefit coverage and includes continuous eligibility to address individuals losing coverage and help reduce racial disparities in maternal health outcomes. Similarly, California has extended Medicaid eligibility to a period of one year following the last day of pregnancy for a pregnant individual who is receiving health care coverage under the Medi-Cal program, and who has been diagnosed with a maternal mental health condition.[13] This postpartum coverage extension is supported through state dollars and may expire at the end of 2021. California, like other states, is considering the state plan amendment option offered under the Biden American Rescue Plan to extend postpartum coverage from 60 days to 12 months.[14] States electing this option must provide full Medicaid benefits during and throughout the 12-month period.

Increasing Early Identification of SUD and Mental Health Conditions

Identifying behavioral health conditions as soon as possible during and after pregnancy is critical to providing the necessary treatment and services to ensure healthy outcomes for mothers and their babies. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends screening pregnant women for SUD in multiple settings, including the emergency department, OB/GYN visits, primary care visits, and well-child visits.[15] States are also encouraging screening for mental health conditions in a variety of settings including well-child, prenatal, postpartum, and emergency department visits. Maternal mental health conditions are the most common complications of pregnancy and childbirth.[16] Additionally, postpartum depression is common and has been shown to negatively impact maternal and infant health outcomes.[17] Currently, Medicaid programs in 43 states and Washington, DC recommend, require, or allow maternal depression screening as part of a well-child visit.[18] However, depression in pregnant and non-pregnant women of reproductive age often goes undiagnosed.[19]

To increase early identification, MMRCs commonly recommend three strategies (For specific state recommendations see Table 2.)

• Provide adequate insurance coverage for screening. Virginia’s BabyCare program provides behavioral risk screening for pregnant Medicaid enrollees. The behavioral health risks tool screens for tobacco use, alcohol and other drug use, emotional health, and intimate partner violence.[20]
• Use data systems and medical record review to monitor risk factors and track patterns. In Illinois, the MMRC notes that health care providers must, by state law, use the Illinois Prescription Monitoring Program to review patients’ past prescriptions and identify potential dependence and drug-seeking behavior. The Illinois MMRC now recommends hospital obstetric and emergency departments train providers on best practices for treating patients with SUD, including how to integrate the Illinois Prescription Monitoring Program into the electronic medical record.[21]
• Implement universal screening of pregnant women for behavioral health conditions using validated tools (e.g., SBIRT) [22] in multiple health settings, including emergency rooms and pediatric primary care. Considering its MMRC recommendations, New Jersey recently rolled out new Medicaid initiatives, including requiring providers to complete the Perinatal Risk Assessment (PRA) form during the first prenatal visit for all enrollees.[23] The PRA form identifies demographic, medical, and psychosocial factors, including impacts of COVID-19, SUD, and mental health conditions, to help determine case management plans for pregnancies.

Ensuring Appropriate Referrals and Follow Up for Women with SUD and Mental Health Related Needs

Referrals and linkage to follow up services are key components to ensuring pregnant women receive needed care. Linking pregnant women to behavioral health related services is challenging due to several issues, including stigma, lack of resources, and coverage.[24] One policy area that MMRCs identified for states to improve is working with providers to make sure pregnant women are referred to services and ensuring links to these services through appropriate follow-up coordination after the referral is made.

MMRCs commonly recommend two strategies to ensure appropriate follow-up occurs. (For specific state recommendations see Table 3.)

• Implement standard protocols in multiple settings for referrals to services after a positive screening. States can develop and share standard protocols for referral processes in hospitals, labor and delivery settings, emergency departments, well-visits, and home visits when a pregnant or postpartum woman has screened positive for a behavioral health condition. Referral processes can include protocols for pain management, consults with social workers or case managers, and connections to services like home visiting programs. These protocols can include mechanisms to ensure care coordination and connection to referred services. The Louisiana Department of Health has partnered with hospitals in implementing the Alliance for Innovation on Maternal Health (AIM) patient safety bundle on obstetric care for women with OUD.[25] These bundles are designed to improve maternal health outcomes through education, care coordination, and patient safety protocols.
• Ensure access to referred services by coordinating behavioral health services with obstetric care, working with managed care organizations to guarantee members have access to specialists and treatment, addressing social determinants of health, and providing enabling services such as child care and transportation. Implementing a warm handoff during the referral process or care transition, as Maryland and Ohio MMRCs recommend, allows pregnant women and their families to experience continuous care and engage with their entire care team. A warm handoff occurs when a transfer of care between members of the health care team is done with the patient and their family.[26] A warm handoff can be implemented between OB/GYNs, primary care providers, pediatricians, case managers, care coordinators, and behavioral health providers. States can implement a warm handoff during the postpartum period to help with care transitions.

Increasing Access to Specialized Treatment Plans and Specific Services for Perinatal Populations: Medication Assisted Treatment (MAT) for SUD and Telehealth Services for Mental Health Needs

MAT is the use of medications, along with counseling and behavioral therapies, to provide a whole patient approach to SUD treatment.[27] MAT has been shown to significantly reduce the need for inpatient detoxification and improve birth outcomes for pregnant women who have SUD.[28] Because of the effectiveness of MAT in preventing overdose and treating SUD, state MMRCs recommend these types of policy changes to ensure pregnant and postpartum women have access to this treatment. (For specific state recommendations see Table 4.).

• Link women to MAT immediately during the visit where OUD is identified.
• Expand MAT distribution and ensure coverage of MAT without prior authorization.
• Provide more MAT resources and treatment programs for women.

Telehealth services have demonstrated effectiveness in treating a range of behavioral health issues, from depression to SUD.[29] The Health Resources and Services Administration (HRSA)’s Screening and Treatment for Maternal Depression and Related Behavioral Disorders program currently funds seven states to support integrating behavioral health into maternal health care via telehealth. During the COVID-19 pandemic, there has been a rapid expansion of telehealth services to treat pregnant and postpartum women and to address their behavioral health needs.[30] Prior to the implementation of telehealth flexibilities during the public health emergency, many state MMRCs identified these policies to address the mental health needs of pregnant and postpartum women and to improve health outcomes.

• Expand telehealth services to provide SUD and mental health screening and treatment in rural areas and areas with provider shortages.
• Offer behavioral health screenings via telehealth during the postpartum period to help identify mental health needs as soon as possible.

When the public health emergency ends, states may consider keeping in place telehealth flexibilities to ensure access to mental health services for pregnant and postpartum women.