The Latest HEDIS Maternal Mental Health Screening Rates

Background

Screening to detect maternal mental health (MMH) disorders has been recommended by expert bodies, including the American College of Obstetrics and Gynecology (ACOG) and the US Preventive Services Task Force (since 2015 and 2016, respectively).^1,2 Despite clear guidelines and rising awareness, routine screening has not been widely adopted in the U.S. An estimated 50-70% of MMH disorders go undiagnosed, and 75% of those diagnosed go untreated.³  Yet, before 2019, there was no systematic way to measure provider screening rates through medical data sets. 

What are the HEDIS PND-E and PDS-E screening measures? 

In 2019, two standardized measures were created by the National Committee for Quality Assurance (NCQA) to track MMH disorder screening rates: (1) Prenatal Depression Screening and Follow-Up (PND-E)⁴ and (2) Postpartum Depression Screening and Follow-Up (PDS-E).⁵
In 2021, these measures were included in the NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) – a set of performance measures that Medicaid and commercial insurers report for accreditation purposes. However, the PND-E and PDS-E are currently included as voluntary measures, and are not yet required to be reported for accreditation by NCQA.⁶ Among Medicaid health plans, the Centers for Medicaid and Medicare Services (CMS) has also flagged these measures as voluntary to report within the CMS Adult Core Set.⁷

What are the HEDIS PND-E and PDS-E measure specifications?⁸

The PND-E and PDS-E measures include two parts: 1) the % of those who are pregnant or postpartum who have been screened using a standardized instrument, and 2) among those who screen positive, the % who received follow-up care within 30 days. The specifications for each measure can be found below:

• Prenatal Depression Screening and Follow-Up (PND-E) specifications:
  • 1) Depression screening: Of those pregnant in the past year, “deliveries in which persons had a documented result for depression screening, using an age-appropriate standardized screening instrument performed during pregnancy (on or between pregnancy start date and the delivery date)”
  • 2) Follow-up on positive screen: Of those who screened positive, “deliveries in which persons received follow-up care on or up to 30 days after the date of the first positive screen (31 total days). Any of the following on or up to 30 days after the first positive screen:
    • An outpatient, telephone, e-visit or virtual check-in follow-up visit (Follow Up Visit Value Set)⁹ with a diagnosis of depression or other behavioral health condition (Depression or Other Behavioral Health Condition Value Set).
    • A depression case management encounter (Depression Case Management Encounter Value Set) that documents assessment for symptoms of depression (Symptoms of Depression Value Set) or a diagnosis of depression or other behavioral health condition (Depression or Other Behavioral Health Condition Value Set).
    • A behavioral health encounter, including assessment, therapy, collaborative care or medication management (Behavioral Health Encounter Value Set).
    • A diagnosis of encounter for exercise counseling (ICD-10-CM code Z71.82*). 
    • A dispensed antidepressant medication (Antidepressant Medications List). OR
    • Documentation of additional depression screening on a full-length instrument indicating either no depression or no symptoms that require follow-up (i.e., a negative screen) on the same day as a positive screen on a brief screening instrument.”
• Postpartum Depression Screening and Follow-Up (PDS-E) specifications:¹⁰
  • Depression screening: Among those who have given birth in the past year, “deliveries in which persons had a documented result for depression screening, using an age-appropriate standardized instrument, performed during the 7–84 days following the delivery date.”
  • Follow-up on positive screen:  Among those screening positive for depression, “deliveries in which persons received follow-up care on or up to 30 days after the date of the first positive screen (31 total days). Any of the following on or up to 30 days after the first positive screen:
    • An outpatient, telephone, e-visit or virtual check-in follow-up visit (Follow Up Visit Value Set)¹¹ with a diagnosis of depression or other behavioral health condition (Depression or Other Behavioral Health Condition Value Set).
    • A depression case management encounter (Depression Case Management Encounter Value Set) that documents assessment for symptoms of depression (Symptoms of Depression Value Set) or a diagnosis of depression or other behavioral health condition (Depression or Other Behavioral Health Condition Value Set).
    • A behavioral health encounter, including assessment, therapy, collaborative care or medication management (Behavioral Health Encounter Value Set).
    • A diagnosis of encounter for exercise counseling (ICD-10-CM code Z71.82*). 
    • A dispensed antidepressant medication (Antidepressant Medications List). OR
    • Documentation of additional depression screening on a full-length instrument indicating either no depression or no symptoms that require follow-up (i.e., a negative screen) on the same day as a positive screen on a brief screening instrument.”

Both the PND-E and PDS-E measures are “Electronic Clinical Data Systems (ECDS)” measures and require providers to report the prenatal or postpartum depression screening tool that they used electronically.¹² (See Figure 1 below.) Specifically, providers must report the “LOINC” code associated with the screening tool that they used. LOINC codes are universal, six-part codes that identify laboratory and clinical observations.

Figure 1: LOINC codes required for reporting the PND-E and PDS-E measures

More about maternal mental health disorders

One in five mothers in the United States experience a maternal mental health (MMH) disorder such as prenatal or postpartum depression and anxiety.¹³ The harms of undiagnosed and untreated MMH disorders are well-documented: these disorders are a leading cause of preterm birth and maternal mortality, with suicide accounting for nearly 20% of maternal deaths.¹⁴

Study Goals

This report aims to provide an in-depth analysis of the prenatal and postpartum depression screening measures at the national, state, and insurer level among both Medicaid and commercial insurers. 

Methods

To conduct this analysis, we first obtained an extract of the NCQA’s Quality Compass® data files for the most recently reported data: Measurement Year (MY) 2022 and 2023. (Quality Compass MY2022 and MY2023 data were collected in 2022 and 2023, and then reported out in 2023 and 2024.)  

This extract included the national, state, and insurer-level rates for the PND-E and PDS-E measures, grouped by Medicaid and commercial insurers. Insurers included health maintenance organizations (HMO), preferred provider organizations (PPO), and HMO-PPO combined insurers.

Our team analyzed the data provided in the Quality Compass extract to identify:

1) The total number of insurers reporting the PND-E and PDS-E measures in MY2022-2023

2) The national rates of screening and follow-up among Medicaid and commercial insurers in MY2022-2023, as calculated by NCQA

3) The state-level screening rates among Medicaid and commercial insurers in MY2023, including the “top 10” states with the highest reported rates of screening 

4)The insurer-level screening rates for MY2023, including the “top 10” Medicaid and commercial insurers with the highest rates of screening

Note: The 2022 PND-E and PDS-E data is a new baseline. 2021 totals cannot be compared to the 2022 and 2023 totals. 2021 data only includes those insurers reporting >0% on the PND-E and PDS-E measures. 2022 and 2023 data includes all insurers reporting the PND-E and PDS-E measures, including those reporting 0%. 

Findings

Our findings below are sorted into four categories:

• I. The total number of insurers reporting the prenatal and postpartum depression screening measures
• II. The national rates for prenatal and postpartum depression screening among Medicaid and commercial insurers
• III. The state-level screening rates, including the “top 10” states with the highest rates of screening within Medicaid and commercial insurance
• IV. The “top 10” insurers with the highest rates of screening for both Medicaid and commercial insurance

I. Insurers Reporting the Prenatal and Postpartum Depression Screening Measures

As of 2023, 235 Medicaid insurers and 389 commercial insurers were reporting HEDIS measures to NQCA. Among these 624 insurers reporting HEDIS measures, 73% of all Medicaid insurers and 92-93% of commercial insurers reported the prenatal and postpartum depression screening measures to NCQA. (See Table 1.) 

This suggests that even though the PND-E and PDS-E are not required for HEDIS accreditation or by CMS (ie; are voluntary to report), nearly all commercial insurers and nearly three-quarters of Medicaid insurers are choosing to report these measures. According to a contact at the NCQA, there are two possible reasons that insurers are reporting these measures, despite their voluntary nature. First, when rating health plans,¹⁵ NCQA gives a special “flag” to insurers that report voluntary measures. Second, HEDIS measures can only be run by “certified vendors”.¹⁶ These vendors generally include all measures in their pricing, so insurers may not be opting out of voluntary measures. 

The number of Medicaid and commercial insurers that chose to report the PND-E and PDS-E measures has been steadily increasing since the Quality Compass data for these measures was first released in 2021. 

Table 1: Total Insurers Reporting the Prenatal and Postpartum Depression Screening (PND-E and PDS-E) Measures 

II. National Screening Rates

As of 2023, the prenatal depression screening (PND-E) rate for Medicaid insurers was 13.2%, and 5.1% for commercial insurers. Postpartum depression screening (PDS-E) rates were lower than the prenatal screening rates at 8.7% among Medicaid insurers and 4.4% among commercial insurers.  However, rates have steadily risen, and are currently higher in Medicaid than in commercial insurance. (See Table 2.) 

Table 2: National Rates – Prenatal and Postpartum Depression Screening, 2022-2023

Follow-Up on Positive Screens

The second part of the PND-E and PDS-E measures captures if a patient received follow-up after they screened positive for a MMH disorder. The “follow-up” portion of the measure is only collected among those who have a positive screen. (See Table 3.)

Among individuals who had a positive prenatal depression (PND-E) screen, 50.4% of those in Medicaid and 58.5% in commercial insurance received follow-up. Among those with a positive postpartum depression screening, 62.1% of those in Medicaid and 66.3% of those in commercial insurance received follow-up. 

Table 3: National Rates – Follow-Up on Positive Screening 2022-2023

III. State Rates

Prenatal and postpartum depression screening vary widely between states. Screening rates also vary widely within states by insurance type (ie; Medicaid vs commercial insurance). 

Table 4 and 5 below summarize the “top 10” states with the highest rates of screening, first within Medicaid (Table 4), and then within commercial insurance (Table 5). Three states appeared in both the “top 10 Medicaid” states and “top 10 commercial states” including CA, PA, and WI. 

All states’ screening rates can be found in the Appendix. Please note that if a state displays no data, it means that fewer than five insurers were reporting on the measure, and the data were suppressed in the NCQA data file.

State Medicaid Rates

Table 4 lists the “top 10” states with the highest rates of Medicaid screening in 2023. Pennsylvania’s Medicaid insurers reported the highest rates of prenatal and postpartum depression screening among all states (24.6% and 24.1%, respectively), followed by CA, IN, WI, MI, LA, NY, WA, FL, and IL. 

Table 4: States with Top Medicaid Prenatal and Postpartum Screening Rates 

State Commercial Rates

Table 5 lists the “top 10” states with the highest rates of screening in commercial insurance in 2023. Wisconsin’s commercial insurers reported the highest rates of prenatal and postpartum depression screening among all states (14.2% and 14.4% respectively), followed by IA, CA, NM, CO, WA, GA, PA, UT, and TN.

Table 5: States with Top Commercial Prenatal and Postpartum Screening Rates

III. Top Insurers’ Rates

Tables 6 and 7 below summarize the “top 10” insurers with the highest screening rates, first within Medicaid (Table 6) and then within commercial insurance (Table 7). Four insurers appear in both the “top 10” Medicaid insurers and “top 10” commercial insurers, including Kaiser Foundation Health Plan of CO, MercyCare HMO of WI, Dean Health Plan of WI, and Geisinger Health Plan of PA.

Medicaid Plan Rates

Table 6 lists the “top 10” Medicaid insurers with the highest rates of screening in 2023. Kaiser Foundation Health Plan of CO topped this list, reporting that 75-76% of all prenatal and postpartum persons received depression screening. Among the remaining “top 10” Medicaid insurers, all remaining plans appear to be regional insurers within WI, CA, DC, MI, UT, MA, IN, and PA. 

Table 6: Medicaid Insurers’ HEDIS Rates – Top 10

Commercial Plan Rates

Table 7 lists the “top 10” commercial insurers with the highest rates of screening in 2023. Kaiser Foundation Health Plan of Southern CA is the top performer on this list, reporting that 96-97% of all prenatal and postpartum persons received depression screening. Kaiser plans made up five of the “top 10” performing commercial insurers, including Kaiser of Southern CA, Kaiser of Northern CA, Kaiser of GA, Kaiser of CO, and Kaiser of WA. The remaining five commercial insurers in the “top 10” are local insurers in WI, PA, NM, IL, and CA. 

Table 7: Commercial Insurers’ HEDIS Rates – Top 10

Discussion

Our analysis yielded several key findings:

Overall screening rates are low. Screening rates are higher among Medicaid insurers, as compared to commercial insurers. In 2023, insurers reported MMH screening rates of less than 15% among their perinatal patients. Compared to commercial insurers, Medicaid insurers reported higher prenatal screening rates (13% vs 5%) and higher postpartum depression screening rates (9% vs 4%). 

At least two factors are likely contributing to the low screening rates:

1. The PND-E and PDS-E measure specifications require using LOINC codes. The use of LOINC codes by providers is primarily driven by three factors: 1) mandated public health reporting, 2) integrated health information exchanges (HIE), and 3) large health systems that are more likely to be driving computer and software systems in exchanging and making use of information (interoperability). No state is known to be the leader in LOINC adoption across all healthcare providers. However, states with strong public health reporting requirements and mature HIE networks likely have higher rates of LOINC adoption. States like California, Texas, and Washington, which have active public health agencies and collaborate with organizations that drive LOINC usage, probably have higher rates of adoption. 

2. It is currently voluntary for insurers to report the PND-E and PDS-E measures into HEDIS. Insurers may be making little effort to prioritize data collection.  Although it is voluntary to report the PND-E and PDS-E into HEDIS, a high number of insurers are reporting these measures, with approximately 73% of HEDIS-accredited Medicaid insurers and approximately 93% of HEDIS-accredited commercial insurers reporting the measures to NCQA. However, the voluntary nature of the measures may result in inaccurately reported and artificially low screening rates. Low MMH screening rates suggest that insurers may be de-prioritizing efforts to collect high-quality PND-E and PDS-E data – resulting in artificially low rates that may not reflect the real rates of MMH screening among in-network providers. 

Some state Medicaid agencies have begun requiring their plans to report these measures. State Medicaid agencies can require their Medicaid managed care organizations (MCOs) to report specific performance measures back to the state. Indeed, nine Medicaid agencies have started requiring their Medicaid MCOs to report the PDS-E or PND-E: CA, IN, MI, NH, NV, PA, WA, and WI.¹⁷  Six of these states are among the “10 top” states with the highest Medicaid screening rates: CA, PA, IN, WI, MI, WA. Four of these states also provide separate Medicaid reimbursement for MMH screening (PA, CA ,WI, WA), suggesting that these states’ Medicaid agencies are prioritizing and incentivizing MMH screening among Medicaid patients.

The measures still remain voluntary within the Centers for Medicare and Medicaid (CMS) Adult and Child “Core Set”. 

Although nine states have taken individual action to require Medicaid insurers to report the PDS-E and PND-E, these measures are still voluntary in most states. The CMS Adult and Child Core Sets do not currently require Medicaid reporting of the PND-E and PDS-E measures, but the 2026 Core Sets have included the postpartum depression screening and follow-up measure as a “provisional” measure.¹⁸

Most of the “top 10” insurers also provide their own health services (integrated care models)

Among the “top 10” Medicaid and commercial insurers identified in this study are several Kaiser health plans. Kaiser plans are “staff models” in which the plans employ their own providers and have their own hospitals and facilities. Staff model plans can therefore require their employed providers to deliver services in accordance with their systems and protocols. Most of the other plans in the “top 10” are integrated health plans/insurers and health systems, for which plans have more influence over, and generally would have greater interoperability and ease of collecting data.  Their systems may also be either more advanced in having providers adopt LOINC codes or have a process in screening data can be converted by the plan into LOINC codes for HEDIS reporting purposes. 

The organizational structure of the “top 10” Medicaid and commercial insurers is a significant factor in their data capabilities, as most utilize integrated care models. For instance, several of the top plans include Kaiser plans which operate under a “staff model” where they directly employ providers and own their facilities. This structure enables them to establish and mandate specific systems and protocols for internal service delivery. The majority of the remaining plans are integrated with health systems, giving the insurer significant influence over providers and resulting in greater interoperability and ease of data collection. Structurally, this advantage positions their systems to either be more advanced in mandating provider adoption of LOINC codes or to have streamlined processes for converting clinical data into the necessary LOINC codes for HEDIS reporting purposes.

Measure Recommendations

Reported rates of prenatal and postpartum depression screening by Medicaid and commercial insurers have been growing, but remain extremely low. The U.S. needs reliable screening data. To encourage accurate collection and reporting of these measures, we recommend NCQA do the following:  

1. Expand the allowable data sources for Electronic Clinical Data Systems (ECDS) measures to include claims data.
2. Require that PND-E and the PDS-E measure reporting be required for  NCQA accreditation (and therefore no longer be voluntary).
3. Modify PND-E and PDS-E measure specifications to include follow-up by insurer staff.

Recommendation #1: Expand the allowable data sources for the Electronic Clinical Data Systems (ECDS) measures to include claims data.

The PND-E and PDS-E measures require providers to report the LOINC codes associated with the screening tool that they used.  LOINC codes are more commonly used among states with strong public health reporting requirements and mature health information exchanges (HIE); however, LOINC codes are not widely adopted among all healthcare providers. Therefore, we recommend that NCQA not limit PND-E and PDS-E reporting requirements to LOINC codes and allow insurers to use claims data to report the measures, as well. 

Recommendation #2: NCQA should require that the PND-E and the PDS-E measures contribute to accreditation (and therefore no longer be voluntary).

The PND-E and PDS-E measures are not yet mandatory for insurers to report to maintain/attain NCQA accreditation. There are several compelling reasons to make these measures mandatory for all NCQA-accredited insurers.

First, if reporting were mandatory, insurers would be compelled to put sufficient resources into data collection and would prioritize quality improvement interventions to increase screening rates. Although numerous insurers voluntarily report the PND-E and PDS-E measures, the screening rates of these insurers are extremely low. It is suspected that screening rates are this low because these organizations are making little effort to prioritize data collection, given the voluntary reporting status.

Second, the measures meet the criteria for NCQA mandatory reporting. NCQA notes in the HEDIS rating methodology that measures are made mandatory for accreditation when a measure has “good differentiating properties, up-to-date evidence, and high population impact.”¹⁹ The PND-E and PDS-E measures fit these criteria:

• Good differentiating properties: The PND-E and PDS-E are the first of their kind to capture rates of maternal mental health screening and follow-up.
• Up-to-date evidence: The evidence is clear – mental health disorders are the leading cause of maternal mortality in the US.²⁰ For nearly a decade, maternal depression screening has been recommended in clinical guidelines created by expert entities such as the American College of OB-GYNs (ACOG) and the US Preventive Services Task Force (USPSTF). Yet, research has shown that screening is not occurring: research estimates that 50-70% of maternal mental health disorders go undiagnosed, and 75% of those diagnosed go untreated.²¹
• High population impact: There are approximately 4 million women who become pregnant in the U.S. every year. Requiring insurers to measure/report maternal mental health screening will have a significant impact on the health and well-being of the U.S. perinatal population and their children.²²

Therefore, we strongly urge NCQA to move these measures to be required for accreditation and therefore mandatory, so insurers are incentivized to prioritize screening and follow-up given the maternal mortality crisis in America, the mental health crisis, and because undetected and untreated maternal mental health disorders also impact infants and children.

Recommendation #3: Modify PND-E and PDS-E measure specifications to include follow-up by insurer staff. 

We believe that the PND-E and PDS-E measures should only measure whether a patient’s provider is screening. We don’t believe health insurers should perform this critical function, just as they don’t for other diagnostic tests. However, follow-up could be provided by health insurer case managers to ensure that the patient accessed in-network care and received any other interventions and treatments the treating provider and patient agreed to add to any treatment plans.

APPENDIX I – All State Rates

Table 8: All State Rates – Prenatal Depression Screening Measure, 2022-2023

Table 9: All State Rates – Postpartum Depression Screening Measure, 2022-2023

Disclaimer: The source for certain health plan measure rates and benchmark (averages and percentiles) data (“the Data”) is Quality Compass® 2023 and is used with the permission of the National Committee for Quality Assurance (“NCQA”). Any analysis, interpretation or conclusion based on the Data is solely that of the authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation or conclusion. Quality Compass is a registered trademark of NCQA. The Data comprises audited performance rates and associated benchmarks for Healthcare Effectiveness Data and Information Set measures (“HEDIS®”) and HEDIS CAHPS® survey measure results. HEDIS measures and specifications were developed by and are owned by NCQA. HEDIS measures and specifications are not clinical guidelines and do not establish standards of medical care. NCQA makes no representations, warranties or endorsement about the quality of any organization or clinician that uses or reports performance measures or any data or rates calculated using HEDIS measures and specifications, and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in Quality Compass and the Data, or NCQA has obtained the necessary rights in the Data, and can rescind or alter the Data at any time. The Data may not be modified by anyone other than NCQA. Anyone desiring to use or reproduce the Data without modification for an internal, noncommercial purpose may do so without obtaining approval from NCQA. All other uses, including a commercial use and/or external reproduction, distribution or publication, must be approved by NCQA and are subject to a license at the discretion of NCQA. ©2023 National Committee for Quality Assurance, all rights reserved.

References