For the last 10-15 years, the global maternity care bundle payment, a single comprehensive payment to an OB/GYN or midwife to cover prenatal visits, labor and delivery, and a brief postpartum window, has governed how we reimburse maternal health care in the United States. 

As I have previously written, this is not a traditional “value-based” bundle arrangement, which aims to align clear measures of success with increased (or reduced) payment on a provider-to-insurer, contract-by-contract basis. Rather, this nearly universal payment mechanism has come with a lack of data, including claims to monitor the type of care provided. That is a travesty, particularly as childbearing-aged women have more complex health conditions, with over 30% having a heart-related condition, mental health disorder, obesity, or diabetes, for example, and as pregnancy-related health complications and maternal deaths have been rising. 

And the bundle payment’s artificial 6-week cut-off has meant women have been neglected in the postpartum period, aside from one postpartum visit to run a few checks, discuss birth control, and then say goodbye (ACOG recommended a minimum of two postpartum check-ins in 2018; there is no evidence this was implemented by OBs).

The American College of Obstetricians and Gynecologists (ACOG), and now the American Medical Association (AMA) CPT Editorial Panel have officially recognized that the bundle is not serving providers (and we argue patients) well. Effective January 2027, the global payment codes are being sunsetted and replaced with individual, itemized Evaluation and Management (E/M) procedure CPT codes (fee-for-service codes).  

Prenatal Care Focus 

The focus of ACOG has primarily been on implementing the 2025 prenatal care guidelines, which adopt a risk-based approach to the number of encounters, providing a minimum of 4 visits rather than the standard 12-14. The number of visits are based on the patient’s risk of complications and can include telehealth (phone or video and even text check-ins), in mobile clinics, in the home, via remote patient monitoring, and group prenatal care. 

A Call to Action for ACOG to Publish New Postpartum Care Guidelines and to Expand OB Care Teams

However, we are urging ACOG to also update the postpartum care guidelines now that the artificial 6-week OB care cut-off fades, and all women have postpartum coverage (including Medicaid enrollees, thanks to the 12-month postpartum care extension). 

Patients and providers alike have acknowledged that our postpartum care in America is abysmal and it matters. There is universal agreement that women deserve better, not only because maternal mortality and morbidity (death and complications) are highest in the postpartum period, but also because it’s a critical time to heal, be nurtured, and bring a new life into this world with support. It’s time to increase the number of postpartum visits/encounters women receive. We are working with groups which include ACOG to develop these recommendations as soon as possible.

Further implementation of unbundling also provides a critical opportunity to reenvision maternity care by creating comprehensive maternity care clinic (cMCC) teams (with staff or contractors being directed by a lead OB provider).  Teams can be inclusive of a combination of women’s health and psychiatric nurse practitioners, midwives, CHWs/care navigators, lactation, mental health therapists, doulas, and more. Women deserve to have coordinated and non-fragmented care, a critical intervention, to improve the health and wellbeing of women, babies and families (impacting two generations). 

Critical Implementation Implications for Payers 

Moving from a single global payment to an itemized framework carries complex operational and financial ripple effects. State Medicaid programs, which cover over 40% of all U.S. births (and over 50% in some states, like Mississippi), and commercial insurers, face a massive structural overhaul.

The following are key implementation considerations the Policy Center presented to 300+ payers during invite-only “Beyond the Bundle” technical assistance webinars. 

Account for OB Providers’ Sudden Administrative Overhead

The new payment model introduces a sudden increase in provider (and payer) administrative overhead, as clinical practices must pivot from dropping a single billing code to tracking and submitting dozens of itemized encounter claims. This will be a bear for all OB clinics and is especially concerning for independent clinics and rural health providers already operating on razor-thin margins. Payers must account for this increased administrative burden when updating fee schedules and contracts. 

On the provider side, independent clinics, non-profit health systems, and organizations should consider arrangements that provide necessary back-office billing and coding support.

Consider Disincentivizing C-Sections: Different Operational Levers

The initial efforts looking at maternity care payment involved providing a single case-rate to OB/Gyns and hospitals for c-sections to disincentivize non-medically necessary c-sections, given the link to higher rates of maternal complications and rising C-section rates in the U.S.  Payers can also consider member benefits, and exclusion of early elective c-sections (in no circumstance should a member be held financially responsible retrospectively for a c-section and denied payment to the OB or hospital.) 

When the Policy Center asked payers if they plan to address the high morbidity rates and costs associated with C-sections, the two payer groups favored completely different structural mechanisms:

  • Medicaid Favors Payment Restructuring: Multiple Medicaid agencies noted they are actively considering modifying OB provider payment for C-sections to financially disincentivize medically unnecessary procedures.
  • Commercial Favors Utilization Management: Commercial plans are leaning heavily toward benefit design, noting strategies like excluding coverage of elective C-sections from member benefits or implementing stricter prior authorizations to account for extenuating circumstances.

Communicating OB Maternal Mental Health Billing Codes and Reimbursement Rates 

Medicaid agencies and commercial payers should ensure they have published positions on maternal mental health screening by OB providers (Ob/Gyns, Midwives and Family Practice MDs providing maternity care) throughout pregnancy (upon confirmation of pregnancy, and at least once more during pregnancy) and the postpartum period (at least three times, including late in pregnancy).  Several Medicaid agencies have already published screening reimbursement levels and codes for OBs, many more have yet to.  Detecting these disorders in obstetrics, so the mother’s own provider can help her develop a treatment plan and to mitigate preterm birth, is critical.  And in the postpartum period, OB providers can now provide this same critical and seamless/non-fragmented screening, treatment plan development, and treatment/referral through the full 12 months postpartum. 

Pregnancy Notification Form

Payers should consider using and appropriately reimbursing OB providers for completing a pregnancy notification form. Several state Medicaid agencies require their managed care organizations (MCO) health plans to incentivize contracted OB providers in submitting these forms. Examples of forms include OH, WV and Anthem. In addition to helping the plan and Medicaid agency identify who is pregnant (which can help with new HR 1 ex parte work requirement exemptions for pregnant and parenting women), they can also identify patients with high-risk pregnancies, or track whether a pregnancy screening or visit has occurred to receive credit for these two HEDIS measures (PCC and PND). It’s highly recommended that commercial payers adopt the same form as the state Medicaid agency in each state, so providers have a single form to use for all patients.

Expanding High-Risk Pregnancy Case Management Programs 

While health plans and commercial insurers have high-risk pregnancy case management programs, not all have expanded these programs to the postpartum, nor opened them to women with a maternal mental health disorder like prenatal or postpartum depression.  Unbundling of maternity care provides payers with an important opportunity to expand these programs to women who have complications post birth as well, because it’s the right thing to do, and because the postpartum period carries the highest risk for maternal morbidity and mortality. 

Waiving Cost Share for Commercially Enrolled Patients

Those enrolled in Medicaid coverage are not charged for maternal health care. However, those enrolled in commercial coverage maternity care can be extremely high-cost and derail recommended care.  The U.S. Preventive Services Task Force (USPSTF) and Women’s (WPSI) guidelines already requires cost share be waived for prenatal care and preventive screenings, however, payers will need to ensure that claim systems are set up so claims that are submitted with the TH modifier waive all cost share (and have protocol in place with member services and provider services to urgently address problems raised by members so in no circumstances cost share is applied).  Unbundling provides a critical opportunity for commercial payers to voluntarily waive cost share for postpartum obstetric care and all prenatal tests and medically necessary ultrasounds ordered by the OB provider. 

Next Steps for the Policy Center and Maternal Health Field: 

It’s Time to Develop a New Maternity Care Measure Set

For the first time in over ten years, we will have a new source of data at hand: claims. There is an overwhelming appetite across the healthcare ecosystem for a new, comprehensive, claims-based maternity care measure set to monitor whether care is being provided in accordance with guidelines and evidence. A new measure set will allow the field, through payers, to identify systemic gaps, implement interventions, and also identify providers and health systems who are not providing recommended care. The Policy Center is holding critical conversations with measure developers, interested parties, and philanthropy to create this new system.

Unbundling maternity care must not result in a simple fee-for-service billing system to only allow payment to the right provider for prenatal care; rather, it is a necessary demolition that allows us to build a more rational, accountable system. To ensure this shift improves clinical outcomes rather than just changing administrative paperwork, payors and policymakers must use this transition to anchor a true pay-for-performance hybrid model.

Closing

We have a narrow window between now and January 2027 to reconstruct maternity reimbursement and develop a new national maternity care measure set. Operational readiness requires payors, large employers, and clinical networks to treat this as a fundamental redesign of care delivery, one that finally prioritizes the comprehensive, multi-disciplinary needs of families through pregnancy and the postpartum period.

Learn more about unbundling on the AMA’s website or ACOG’s website.

If you are a payer and are looking for a thought partner to support your maternity care QI and payment strategy, reach out for support at [email protected]

If you are a philanthropic partner looking to support this critical implementation, please email [email protected]