States are missing opportunities to require Medicaid managed care organizations (MCOs) to improve maternal health access, a new report from the Department of Health and Human Services Office of Inspector General (HHS OIG) shows.
The report (PDF), shared exclusively with Fierce Healthcare, finds there are many states where MCOs are not required to provide insurance coverage for various types of maternal health providers and professionals.
All 41 states analyzed in the report mandate MCOs cover access to OB-GYN physicians and hospital births, but this access does not necessarily extend to other types of care administers like midwives, maternal-fetal medicine specialists, doulas and community health workers.
One in 5 states does not extend coverage to midwives, and over half do not cover maternal-fetal medicine specialists. Coverage is even less common for lactation consultants, doulas and community health workers.
Federal regulations force states to cover certain services for the maternal health population, but states have the ability to determine which providers they cover. This is important, because needs may differ from one state to another.
“It’s true that states have flexibility in how they design their programs,” said Regional Inspector General Laura Kordish in an interview. “Having said that, we're saying is that some states have missed opportunities to use all available tools.”
Kordish said states could tell MCOs to cover more provider types and could give technical assistance to states about access to care. Some individuals may require more or less provider visits based on the stage of the pregnancy or level of risk an individual faces.
This can have significant consequences on the Medicaid population, which is the country’s predominant payer for pregnant beneficiaries and accounts for 40% of all births.
The U.S. has the highest rate of maternal deaths among all high-income nations, according to the Commonwealth Fund. Infants who don't receive prenatal care are five times more likely to die, and women who do not have access to postpartum care are more likely to endure postpartum depression (PDF).
Data from the Centers for Disease Control and Prevention and the National Institutes of Health show that the country’s maternal health problems are even worse for Black, American Indian, Alaska natives and women in rural areas, all populations that could benefit greatly from other types of maternal health professionals.
HHS is calling on the Centers for Medicare & Medicaid Services to make sure states cover required services from maternal care providers and give additional guidance on OB-GYN network adequacy standards.
MCOs contract with providers to build networks for maternal care services. When these services are not offered, MCOs must cover services out-of-network, though prior authorization is often required.
As defined by the department, network adequacy standards are supposed to make sure there are enough providers in MCO networks. These standards include time and distance requirements, which limit the distance enrollees should have to travel to visit providers; appointment wait time, to reduce how long patients wait for a visit; and provider-enrollee ratio standards, dictating the number of providers that networks must have in proportion to number of enrollees.
Most states enforce time and distance standards, but 14 states have only have one type of quantitative network adequacy standard that is directly attributed to maternal care.
Problematically, 36 states reported they had not observed or measured changes in access to maternal healthcare after implementing network adequacy standards.
Minnesota is the only state that requires MCOs to cover all maternal health provider and professional types reviewed in the report. This improves the probability of individuals finding the care the need, HHS said, whereas three states only require coverage for OB-GYN physician and hospital births.
Eight states require MCOs to cover five or more types of providers or professionals in maternal health, and seven states set separate network adequacy standards for maternal health. In theory, these states should have better maternal health outcomes than others.
Kordish said this report did not look at state health outcomes, instead focusing just on health access. She noted, however, that better access often leads to better outcomes.
CMS has responded to the report and agrees with HHS OIG’s recommendations. The agency is expected to respond with a plan of action within six months.
CMS said it will do outreach to states to make sure managed care enrollees have access to all required maternal health services. It will also help states adjust network adequacy standards to meet the needs of residents in their states.
Editor's Note: The story has been updated to reflect Kordish's correct title and the correct number of states requiring MCOs cover various types of maternal health professionals.