Model MMH Screening, UM and CM Legislation
Published February 2021
Updated August 2024:
Removed screening timeframes and instead reference guidelines issued by bodies such as ACOG, and add sections 3 and 4 respectively to address state Department of Insurance oversight and HEDIS reporting
Updated February 2024:
Added requirement to cover FDA-approved treatments specific to treating maternal mental health disorders including a prohibition against requiring step-therapy as well as require insurers / plans to develop quality improvement plans
Model Legislation:
Maternal Mental Health Screening, Utilization Management, and Case Management
This bill would require a licensed health care practitioner who provides prenatal or postpartum obstetric or primary care for a patient to screen those who are pregnant or within two years postpartum for maternal mental health conditions according to recommendations published by clinical bodies.
This bill would also require health insurers / managed care plans, to develop, consistent with sound clinical principles and processes, a maternal mental health utilization management and a case management program to facilitate referrals and timely access to treatment.
SECTION 1.
By x a licensed health care practitioner who provides obstetric or primary care to patients who are pregnant or within two years postpartum shall screen patients beginning in pregnancy and through the postpartum period for maternal mental health conditions in accordance with clinical recommendations and/or clinical practice guidelines issued by bodies such as the American College of Obstetricians and Gynecologists. Emergency Room practitioners shall also screen pregnant or postpartum patients for these disorders including maternal suicide, in accordance with protocols developed by the Federal Government’s National Strategy for Suicide Prevention, including adopting the screening protocol developed by the Zero Suicide Initiative.
(a) This section shall apply to licensed health care practitioners who provide obstetric or maternity care, as defined in Section xx.
(b) This section does not preclude any licensed or certified provider acting within his or her scope of practice from screening for maternal mental health conditions.
(c) For purposes of this section, the following definitions apply:
(1) “Maternal mental health condition” means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.
(2) “Health care practitioner” means xxx pursuant to Division x of the xx Code.
SEC. 2. Utilization Management and Coverage of FDA Approved Treatments
By xxx health insurers / managed care plans shall develop, consistent with sound clinical principles and processes, utilization management and a case management program for maternal mental health case management program to facilitate access to evidence-based care. If performed, utilization management review shall be performed consistently with recommendations from external clinical bodies such as the Marce Society of North America, The American College of Obstetrics and Gynecologists, and The Center for Women’s Mental Health at Harvard Medical School. Further, health insurers / Medicaid shall cover at least one FDA-approved drug and digital therapeutic specific for the treatment of a maternal mental health disorder, in each drug class, without step-therapy requirements. A case management program shall be offered to patients and contracted providers to facilitate referrals and timely access to treatment.
The utilization management program guidelines and case management program shall be promoted to contracting obstetric, primary care, and psychiatric providers and to enrollees.
(a) For the purposes of this section, the following terms have the following meanings:
(1) “Contracting provider” means an individual who is certified or licensed pursuant to Division x of the x Code and who is contracted with the enrollee’s health care service plan to provide services under the enrollee’s plan contract.
(2) “Maternal mental health” means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.
(c) This section shall not apply to specialized health care service plans, except specialized behavioral health-only plans offering professional mental health services.
SEC. 3. Provider Network Adequacy
Insurers and health plans shall monitor the network adequacy of perinatal mental health certified (PMH-C) providers in mental health provider networks.
Insurers and plans shall also be required to develop a plan for promoting, covering, and monitoring the usage of mental health provider-to-provider mental health psychiatry consultation.
Insurers and plans shall also contract with and monitor for network adequacy of certified peer support specialists. As these specialists are not licensed and overseen by a state board, peers shall be contracted through a licensed medical or mental health provider and reported in provider directories as adjunct providers of the contracted licensed provider. Network adequacy of peers shall be monitored using standards for licensed mental health providers, such as LCSWs.
SEC. 4. Measurement and Quality Improvement
By xxx health insurers / managed care plans shall collect and report the Healthcare Effectiveness Data and Information Set (HEDIS) Prenatal Depression Screening and Follow-up measure rates, and the Postpartum Depression Screening and Follow-up measure rates and/or any modifications, or additional maternal mental health measures recommended by the Federal Government, such as the Centers for Medicaid and Medicare Services (CMS) Core Set working group or the Agency for Health Care Quality and Research (AHRQ). Additionally, Insurers / managed care plans shall create a quality improvement program to monitor screening, follow-up, and treatment rates, as well as patient-reported outcomes.
SEC. 5. Oversight
The Department of Insurance shall assess compliance with these sections through regulatory oversight reporting and audits. Findings, including any corrective action requirements, shall be made public on the Department’s website and the applicable insurer and health plan’s websites within 90 days of the assessment.
Sample Regulatory Network Adequacy Standards
Typical network adequacy standards include both ratios of providers to insureds/members (the average number of women who give birth) and the geographic distance of providers relative to insurers/members.
Proposed Interim Network Adequacy Standard
Because there are currently limited numbers of each of these providers* in the state, it is recommended that a standard of 80% or more of such providers be included in the insurer’s/plan’s network until standard ratio and geo distance network adequacy standards are met.