An Open Letter to CMS Regarding Ob Reimbursement for MMH Services

By the Policy Center for Maternal Mental Health Policy Team

Our work shaping and reporting on national mental health policy is made possible through a 2020-2023 capacity grant from the Perigee Fund.

Given the Policy Center’s focus on improving maternal mental health (MMH) detection and treatment rates, we believe it’s critical that obstetric care providers (Ob/Gyns, midwives, and family practice doctors) are reimbursed for their time providing maternal mental health care. Currently, most obstetric care providers are not reimbursed for their time as many are when paid through a global maternity care bundled rate. This letter calls on CMS to provide guidance to state Medicaid agencies on the need to address reimbursement starting in pregnancy and through 12 months postpartum.  

December 8, 2023 

The Honorable Chiquita Brooks-LaSure 
Administrator, Centers for Medicare & Medicaid Services (CMS)
7500 Security Boulevard 
Baltimore, MD 21244

RE: Request for Information Bulletin Addressing Maternal Mental Health

Dear Administrator Brooks-LaSure,

We, the undersigned organizations, are focused on advancing the detection and treatment of maternal mental health (MMH) disorders in the U.S. We are writing to urge the Centers for Medicare & Medicaid Services (CMS) to issue an Informational Bulletin (IB) to state Medicaid agencies to address the critical role of obstetric providers (Ob/Gyns, Midwives and Family Physicians) in providing care for maternal mental health and substance use disorders – similar to the IB CMS issued regarding the role of pediatricians.

In May 2016, CMS released an IB to Medicaid agencies highlighting the critical role of Medicaid in supporting state policy to promote young children’s healthy development through maternal depression screening at pediatric well-child visits. This bulletin catalyzed change in the states. As of February 2020, 43 states, including Washington DC, allow, recommend, or require pediatricians to conduct maternal depression screening in the postpartum period covered by Medicaid.1

It is equally vital for maternity care physicians/QHPs to screen for these disorders and to do so beginning in pregnancy and through the full twelve months postpartum. Increasingly, women are entering pregnancy suffering from untreated depression, anxiety, or having significant risk factors. Young people (ages 18-24) report symptoms of depression/anxiety at rates as high as 50%.2 Females are about twice as likely to be diagnosed with depression as males, with depression being the leading cause of disease burden among females.3 Additionally, new onset of depression and anxiety occurs during pregnancy nearly as often as in the postpartum period; untreated depression/anxiety is the leading cause of preterm and low birth weight deliveries, and when untreated, these disorders persist into the postpartum period.4 It is critical for obstetric providers to screen and detect these disorders as early as possible.

Further, the American College of Obstetricians and Gynecologists (ACOG) has released clinical practice guidelines that recommend every well-woman, pre-pregnancy, prenatal, and postpartum patient be screened for depression and anxiety.5,6 Additionally, ACOG, in collaboration with the Health Resource and Services Administration (HRSA) through the Alliance for Innovation on Maternal Health (AIM), developed a patient safety bundle for perinatal mental health disorders.7 The AIM best practices include:

Screen for perinatal mental health conditions consistently throughout the perinatal period, including but not limited to:

  • Obtain individual and family mental health history at intake, with review and update as needed. 
  • Screen for depression and anxiety at the initial prenatal visit, later in pregnancy, and at postpartum visits, ideally including pediatric well-child visits. 
  • Screen for bipolar disorder before initiating pharmacotherapy for anxiety and depression. 
  • Screen for structural and social drivers of health that may impact clinical recommendations for treatment plans and provide linkage to resources.

Finally, all but three states have or plan to extend pregnancy Medicaid coverage through twelve months postpartum (two states are planning to do so with limited coverage).8 Obstetric care providers, as the woman’s/birthing person’s primary provider during the perinatal period, are best positioned to provide this critical perinatal care.

Given the significance of MMH, updates in guidance by ACOG and HRSA, and postpartum Medicaid extension, we request that CMS provide support and guidance to state Medicaid agencies similar to the actions taken in the 2016 IB to enhance ongoing efforts to increase screening and documentation of screening for MMH by: 

  1. Allowing the screening for MMH to be billed separately from any office visit or global payment, similar to vaccine administration and ultrasounds
  2. Posting information about MMH screening and billing on provider websites and publishing information in provider newsletters.
  3. Delivering provider training to promote the use of maternal depression screening tools, proper billing codes, and referral strategies.
  4. Providing training to clinical staff on how to implement screenings and modify patient flow in the clinic.
  5. Offering maternity care physicians and QHPs continuing medical education /continuing education credits for participation in state training efforts.
  6. Ensuring that the service is appropriately reflected in the managed care plans’ contract and includes performance standards (such as the HEDIS prenatal and postpartum depression screening measures) to ensure the service is widely performed.

Allowing separate billing for MMH will provide CMS and state Medicaid agencies with data from claims that will help improve the understanding of the prevalence and timing of the onset of MMH disorders in pregnancy. Medicaid agencies in some states have addressed screening and billing/reimbursement protocols for maternity care physicians and QHPs. Examples of states that have implemented screening and reimbursement protocols include: 

  • California: Medicaid reimburses up to four maternal mental health screenings starting during pregnancy 
  • Colorado: Medicaid reimburses for three maternal depression screenings starting in pregnancy and up to 12 months postpartum
  • Tennessee: Medicaid offers obstetric providers enhanced reimbursement for maternal mental health screening and provides support for conducting follow-ups for women with positive screening results

It is critical that states receive this direction from CMS as soon as possible to improve outcomes throughout the perinatal period and so Medicaid extension care is delivered to prevent maternal mental health morbidity and mortality in the postpartum period. We appreciate your immediate consideration of this recommendation and request a written response by January 30, 2024. 

Please do not hesitate to contact Joy Burkhard with questions or clarifications at [email protected].

Sincerely,

American College of Nurse-Midwives
American College of Obstetricians and Gynecologists
Association of State And Territorial Health Officials
Families USA 
Maternal Mental Health Leadership Alliance
Mental Health America 
National Association of Certified Professional Midwives 
Policy Center for Maternal Mental Health
Postpartum Support International