How to overcome weaknesses in Medicaid postpartum coverage

Main challenges: Care disparities and ineffective communication

The researchers found that communication between states and their managed care organizations (MCOs) was not clear or comprehensive. In some states, stakeholders were not trained on the postpartum extension as they were on the Medicaid unwinding. Moreover, communications about the postpartum coverage extension were sometimes overshadowed by the volume of communications related to the Medicaid unwinding.

Some states failed to effectively communicate that beneficiaries are eligible for 12-month postpartum coverage after any pregnancy ends, not solely after a live delivery. Also, beneficiaries were not always aware that Medicaid postpartum coverage extends beyond postpartum care to benefits like behavioral healthcare.

In addition to communication challenges, some states found that beneficiaries had trouble accessing extended postpartum benefits due to health equity gaps. The rollout of extended coverage sometimes contributed to or exacerbated care disparities. Due to the way that postpartum and post-pregnancy coverage extensions were integrated into larger maternal health initiatives, experts find it hard to track the health equity impact of these initiatives.

Care coordination for perinatal care could provide an answer to these challenges and often boosts health equity in other healthcare sectors. However, for the Medicaid maternal patient population, care coordination interventions were insufficient due to a variety of challenges. For example, not all beneficiaries were offered perinatal case management and many beneficiaries do not attend first trimester care visits even after multiple communications from their MCOs. These challenges leave many low-income, underserved patients at higher risk during their pregnancies.

Additionally, the researchers found that access to maternal behavioral healthcare is difficult, especially due to maternal mental healthcare provider shortages and inaccurate MCO provider directories.

The states found MCOs lacking in certain areas, and interviewees called for greater accountability. For example, MCOs might offer limited provider networks that lack the broad range of care pregnant people need. Community health workers, midwives, doulas, ob-gyns and other provider and community supports are important facets of high-quality postpartum care.

Some MCO efforts to improve quality of care, while well-intended, were not well executed. For example, many MCOs that offered supplemental benefits, such as gym memberships and incentives, did not ensure that members were aware of these options or did not make the benefits available to pregnant and postpartum individuals.

As previously stated, MCOs' lack of care coordination impacted health equity for patients, but it also reduced the overall quality of care for pregnant members across the health plans. Disconnects between community-based or public health organizations and their MCO partners can affect the quality of patient handoffs between health plans and community representatives and impede community health workers' ability to connect beneficiaries with MCO resources. Beyond the lack of transparency around benefits, MCOs are not always transparent about the results of their efforts.

Recommendations: Improve equity, communication with beneficiaries, MCO accountability

To enhance communication strategies and address care disparities in postpartum coverage extensions, the researchers highlighted a couple of action items for states.

Medicaid and MCOs can expand the number of languages that they offer and target messaging with greater specificity. For example, they might identify individuals who have chronic diseases or who are in demographics with a higher risk of poor patient outcomes to ensure they receive strong care coordination. In addition to educating patients, they should guarantee that providers, advocates, patient education champions in the community and other stakeholders who intersect with patients throughout their pregnancy and post-pregnancy journeys know about postpartum coverage through webinars and other resources.

To address misunderstandings about the extent of postpartum coverage, one state started using the term "post-pregnancy" instead of "postpartum" to describe Medicaid coverage after pregnancy. State officials hoped that this language shift would help beneficiaries and stakeholders recognize that this coverage is also for beneficiaries who did not carry a baby to term due to a miscarriage or other reasons.

Additionally, to improve health equity for pregnant people and reduce the workforce shortage, Medicaid and MCOs can take steps such as increasing payment rates for certain specialties. Doula programs that continue to support new parents in postpartum can prevent life-threatening conditions among underserved populations. States can target areas that have high rates of maternal mortality with more resources. They can lean on multistakeholder coalitions to help create a statewide strategy for combatting maternal mortality and improving maternal outcomes across all demographics.

The Urban Institute's interviewees also identified issues that presented barriers to care in relation to prenatal care access, postpartum visits, dyadic care of both the pregnant individual and the child, and patient trust.

Prenatal care visits are an ideal time to inform pregnant individuals that their postpartum checkups are important to their health and covered under Medicaid. However, much of this education is lacking in current prenatal visit content.

Postpartum visits should be more frequent than enforced in the present standard of care. These visits are hard for individuals to secure post-pregnancy because the baby's needs often take priority for patients. As a result, dyadic care -- which centers both the baby and the mother -- is critically important in the postpartum period. States can encourage key providers to touch base with new parents, for example, by screening them for depression during pediatric visits. Some MCOs offer social determinants of health (SDOH) benefits to help relieve parents' burden and encourage postpartum care, but the process of accessing them introduces additional challenges for new parents.

To address quality of care with MCOs, the Urban Institute researchers recommended instituting better member education requirements, specifically around the postpartum coverage extension. Quality measures for MCOs that are tied to reimbursement should include postpartum metrics. Medicaid programs can do more to crack down on common issues like excessive prior authorizations and inaccurate provider directories. Medicaid programs can also require MCOs to cover supplemental benefits to address SDOH that get in the way of delivering high-quality care.

States can improve MCO transparency around quality of care by demanding public reporting on certain quality measures. Additionally, states can support MCO contracting and data-sharing with community-based organizations.

Stakeholders can also consider boosting the number of recommended postpartum checkups and initiating them closer to the end of the pregnancy. Offering more telehealth postpartum options or incentivizing pregnancy providers to work outside of traditional office hours when mothers might be working could help achieve this goal while working around provider shortages. The researchers recommended payment strategies like separating postpartum care from maternity fee bundles in order to generate more focus on postpartum care and reshaping the infant and maternal payment codes to reinforce dyadic, simultaneous care.

Additionally, the report emphasized creating avenues for reporting on discrimination against and mistreatment of patients. This effort could reduce care disparities, protect beneficiaries, rebuild minority patients' trust in the health system and improve health outcomes and quality of care.

Although monitoring and tracking these changes will be challenging as states seek to improve postpartum beneficiaries' access to and quality of care, especially since postpartum coverage was not centered in Medicaid's pregnancy coverage design systemically, states have options for re-centering their programs appropriately and assessing the impacts.

The researchers suggested implementing new postpartum care quality measures in the Healthcare Effectiveness Data and Information Set (HEDIS) and other existing accountability tools. States can also track outcomes by population, like race, zip code or provider race. Sharing the results of different strategies with other stakeholders and Medicaid programs could lead to establishing best practices. Plus, gathering feedback from the stakeholders on the ground can help supplement gaps in data when results are hard to assess.

Kelsey Waddill is a managing editor of Healthcare Payers and multimedia manager at Xtelligent Healthcare. She has covered health insurance news since 2019.