Medicaid Managed Care, Maternal Mortality Review Committees, and Maternal Health: A 12-State Scan by Andy Schneider, Tanesha Mondestin, Ella Mathews, and Eni Akinniyi Executive Summary In This Study Each year, more than 40% of all births in the United States Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 are financed by Medicaid, making it the single largest source Key Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 of coverage for maternity care.1 Looking more closely, more I. Maternal Health Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . 3 than 60% of births to all Black women and American Indian/ II. Medicaid and Maternal Health . . . . . . . . . . . . . . . . . . . . . 4 Alaska Native women are financed by Medicaid.2 These III. Maternal Mortality Review Committees . . . . . . . . . . . . . . . . 6 are the same groups of women who are at greatest risk IV. How We Did This Study . . . . . . . . . . . . . . . . . . . . . . . . . 7 V. What We Found About Medicaid MCO Performance . . . . . . . . . 12 of maternal mortality and morbidity: data show that Black VI. What We Found in the MMRC Reports . . . . . . . . . . . . . . . .17 women, who are disproportionately poor, are nearly three VII. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 times more likely to die during or just following a pregnancy VIII. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . .23 than White women and Hispanic women, and rates are IX. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 worsening for all groups.3, 4, 5 Medicaid's foundational role Appendix A: Methodology . . . . . . . . . . . . . . . . . . . . . . . .27 in financing maternity care for low-income women makes it Appendix B: MCO Performance Metrics . . . . . . . . . . . . . . . . .28 an essential part of addressing this maternal health crisis. Appendix C: Consumer-Facing Tools . . . . . . . . . . . . . . . . . . 29 Of the approximately 1.5 million pregnant women enrolled in Medicaid annually, a large majority are enrolled through Our study aimed to answer the question: what information about Medicaid managed care organizations (MCOs), which the performance of individual Medicaid MCOs on maternal health is organize networks of providers to deliver covered services.6,7 publicly available? In our scan of Medicaid websites in 12 states, we For all intents and purposes, these MCOs are the Medicaid found that none of the state Medicaid agency websites contained program for pregnant women enrolled. MCOs determine information sufficient to draw firm conclusions as to how well whether their pregnant enrollees have timely access to individual MCOs are performing on maternal health generally, or on prenatal care; the quality of the hospitals or birthing centers maternal mortality in particular. The same was true for the MMRC at which the enrollees deliver; whether enrollees have timely reports we reviewed. access to postpartum services; and, for high-risk enrollees, the availability of effective care management. Given the ongoing maternal mortality crisis and the central role of Medicaid MCOs as a source of coverage and service delivery States are systematically reviewing the causes of maternal for low-income pregnant women in most states, more attention deaths through their maternal mortality review committees needs to be focused on the performance of those MCOs. Medicaid (MMRCs), which operate in every state except Idaho and payments to MCOs represent a major public investment in the health involve thorough reviews of deaths of pregnant women and of pregnant enrollees. Without greater transparency, it will not be women who die within one year of the end of pregnancy.8,9 possible for beneficiaries or the public to hold MCOs (and the state These committees have helped policymakers understand the Medicaid agencies that contract with them) accountable for maternal scale and urgency of the maternal mortality crisis and have health outcomes among enrollees generally, or for racial and ethnic made recommendations to prevent maternal deaths. disparities in particular. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 1 Introduction Key Findings The United States is in the midst of an ongoing maternal mortality crisis and Medicaid, the health insurer for low-income Americans, zz Only three states posted the number of has an important role to play in addressing it. Medicaid is the pregnant enrollees in each MCO, and only two nation's single largest maternity care insurer, paying for more than of those disaggregated MCO enrollment by 40% of all births on average across all states, and over half in race and ethnicity. some. Medicaid is particularly important for low-income women zz Only Kansas provided the total amount it paid of color, covering the majority of births to Black women and to its MCOs overall for enrolling pregnant women. American Indian and Alaska Native women. None of the states posted the total amount of capitation payments they made on behalf of Most pregnant women covered by Medicaid are enrolled in pregnant enrollees to individual MCOs. managed care organizations (MCOs), which contract with zz All of the states posted MCO-specific state Medicaid agencies for the delivery of covered services to performance on two of the six CMS Maternity enrollees through provider networks that the MCOs assemble and Core Set metrics for which we searched: oversee. How an MCO performs plays an important role in the Timeliness of Prenatal Care, and Timeliness of maternal health outcomes for its enrollees, yet there is little public Postpartum Care. None of the states posted transparency into that performance. MCO-specific performance results on two of As of September 2023, the large majority of states have the other metrics, Live Births < 2,500 Grams or implemented or plan to implement the option to extend Low-Risk Cesarean Deliveries. postpartum coverage for pregnant women from 60 days to 12 zz Nine of the 12 states required their MCOs to months. Because of the medical and mental health risks of the conduct Performance Improvement Projects postpartum period, this extended coverage creates another (PIPs) on a topic relating to maternal health important opportunity for states and the MCOs with which they in 2022. The most common PIP topic was contract to reduce mortality and morbidity among the mothers Timeliness of Prenatal Care. that Medicaid serves. zz Eight of the 12 state Medicaid agencies posted We examined 12 states that contract with MCOs to deliver consumer-facing tools on their websites to covered services to Medicaid beneficiaries: Georgia, Illinois, help enrollees make informed choices among Iowa, Kansas, Kentucky, Michigan, Mississippi, Nevada, New MCOs. All of these tools rated individual MCOs Jersey, New Mexico, Tennessee, and Washington. These states based on maternal health performance, but the varied considerably in the amount and type of information they metrics varied considerably in usefulness. make publicly available regarding the performance of individual zz All 12 states operate Maternal Mortality Review MCOs on maternal health. We searched for data describing MCO Committees that review the causes and performance during calendar years 2021-2022. contributing factors of death among pregnant women and new mothers and issue reports on their findings. None of the MMRC reports we scanned examined the role of individual Medicaid MCOs in managing pregnant or postpartum enrollees. zz Seven states included the state Medicaid agency on their maternal mortality review committee and five did not. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 2 I. Maternal Health Crisis The United States is experiencing an ongoing maternal mortality crisis. The nation's maternal mortality rate has 1 12 Months of Postpartum Medicaid continued to worsen over the last 20 years, even while Coverage other peer nations have generally reduced their rates In response to the alarming increases in maternal mortality in recent of maternal mortality.10, 11 Between 1999 and 2019, years, documented in many cases by state maternal mortality review the number of women in the U.S. who died during committees, state and federal policymakers have turned to Medicaid pregnancy or within in a year after delivery doubled; for policy solutions. Black women died at the highest rates and American Indian/Alaska Native women had the steepest rate Under federal law, Medicaid coverage is available to income-eligible increase in maternal deaths in this period. The stress pregnant women from the date of confirmed pregnancy through 60 and increased risk of severe illness and death for days postpartum. But the data and the lived experiences of moms pregnant women during the COVID-19 pandemic only showed that the 60-day postpartum coverage cliff cut off access worsened outcomes: between 2018 and 2021, the U.S. to prescriptions, therapies, and doctor visits, just when they need it maternal mortality rate nearly doubled for all women.12,13 most.19, 20 About 30% of pregnancy-related deaths from 2017-2019 The Supreme Court decision in Dobbs v. Jackson occurred between 43 days and one year postpartum.21 Women's Health Organization will put pregnant women Congress took action in the American Rescue Plan Act of 2021 in states that restrict or ban abortion care at greater risk to create a Medicaid state plan option for states to lengthen the of maternal mortality and morbidity.14 postpartum Medicaid and CHIP coverage period from 60 days to 12 These trends are not inevitable, and advocates, months, and to receive federal payments at their regular matching policymakers, and parents are working toward rate for the additional 10 months of coverage.22 The state option solutions. In 2021, Congress created an option for to lengthen postpartum coverage was made permanent by the states to receive federal matching funds to extend Consolidated Appropriations Act of 2023. 23,24 Medicaid postpartum coverage from 60 days to one Almost all states have taken up the option. As of September full year. As of September 2023, 38 states have taken 2023, 38 states and the District of Columbia are implementing the up the policy option, and eight more are planning to 12-month extension, and another eight states are planning to do do so (see Text Box 1).15 Federal lawmakers are also so.25 Three states have not taken any action to extend postpartum considering the "Black Maternal Health Momnibus," Medicaid coverage: Arkansas, Idaho, and Iowa. Wisconsin has a package of bills that would, among other policy submitted a Section 1115 waiver proposal to extend postpartum changes, diversify the perinatal workforce, increase coverage from 60 to 90 days.26 funding for research and data systems to reduce racial bias in maternal health care, and support moms with Medicaid coverage for a full 12 months of postpartum care presents maternal mental health conditions and substance use an opportunity for MCOs and their provider networks to reduce disorders.16,17 preventable maternal mortality, severe maternal morbidity, and health disparities. CMS has developed a postpartum care toolkit for The policy changes have the potential to improve state Medicaid and CHIP agencies that includes strategies for outcomes for the 1.5 million pregnant or postpartum contracting with MCOs to increase access to postpartum care, women covered by Medicaid each year.18 As maternal improve the quality of postpartum care, and reduce race and ethnic mortality rates continue to rise, and the rate for Black disparities.27, 28 women rises even faster, changes to the Medicaid program have the potential to spur sorely-needed Unfortunately, transparency of individual MCO performance on system improvements that advance health equity and postpartum care is not among the "CMS strategies;" nonetheless, reduce racial disparities by more effectively serving maternal health advocates should work with their state Medicaid young families of color. agencies to use transparency to hold MCOs accountable for results. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 3 II. Medicaid and Maternal Health Medicaid is the primary pathway to coverage for low-income States have discretion to define the scope of pregnancy- pregnant women. Nationally, Medicaid financed nearly half of related services. Coverage continues through the end of the all births (41%) in 2021, ranging from 21% of births in Utah month in which the 60-day period following the end of the to 61% of births in Louisiana.29 Federal law requires that all pregnancy falls, although states have the option of extending states cover pregnant women with incomes below a specified this postpartum coverage for 12 months, and most have done percentage of the Federal Poverty Level (FPL). The lowest so or are planning to do so (see Text Box 1).32 eligibility level a state is allowed to set is 138% FPL ($20,120 In 40 states and the District of Columbia, the large majority for an individual, $34,307 for a family of three in 2023). But of pregnant women are enrolled in Medicaid managed almost all states have higher thresholds for pregnant women care organizations (MCOs).33 For a fixed monthly capitation in 2023-the median is 200% FPL ($29,160 for an individual, payment for each enrollee, MCOs, operating under the $49,720 for a family of three).30 terms of contracts with the state Medicaid agency, organize People who qualify for Medicaid coverage on the basis of networks of providers and pay them to deliver covered pregnancy are entitled to pregnancy-related services and services, ensure access to quality care, and coordinate care services for other conditions that might complicate the for clinical and social needs (see Text Box 2).34 pregnancy.31 2 What is a Medicaid MCO? A Medicaid managed care organization (MCO) is an entity 2022, 40 states and the District of Columbia contracted that contracts with the state Medicaid agency to manage with a total of 283 MCOs.35 In 2020, five national the provision of covered services to enrollees. The publicly-traded companies owned 50% of all MCOs; the contract operates on a risk basis: that is, the agency pays remaining MCOs are nonprofit, public or other for-profit the MCO a fixed amount each month on behalf of each entities that are not subsidiaries of the "Big Five."36 beneficiary enrolled with the MCO, regardless of whether In general, each MCO determines the hospitals, the enrollee uses services in that month. In exchange physicians, and other providers with which it will for this capitation, or per member per month, payment, subcontract to furnish covered services to its Medicaid the MCO agrees to make services available under the enrollees. If Medicaid enrollees want Medicaid to pay contract accessible to its enrollees through a network of for their care, they will usually be limited to receiving hospitals, physicians, and other providers with which it covered services from providers that participate in their subcontracts. MCO's provider network, except in emergency situations. In contrast to fee-for-service arrangements, under which Within their provider networks, MCOs manage the use the financial incentive for providers is to furnish more of services by their enrollees through care managers services in order to generate more revenues, under a and requirements for prior authorization of services as risk contract, the incentive for the MCO is to reduce the "medically necessary" before providers will be paid. If volume of services that it pays for in order to retain more an MCO's provider networks are too narrow, its prior of the capitation payments it receives. authorization requirements are too restrictive, or its care managers don't effectively manage high-risk pregnant State Medicaid agencies are not required to purchase women, then maternal outcomes will likely not be as covered services from MCOs for any beneficiary good as they could or should be.37,38 group, but the large majority do so, most commonly for children, parents, and pregnant women. As of March October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 4 For pregnant women enrolled in MCOs, their MCO is, in disorders or untreated mental health conditions.46, 47 Other effect, the Medicaid program. Transparency about the factors include limited access to care, especially in maternity performance of each MCO in managing the care of pregnant care deserts; racial discrimination; food insecurity; housing women, especially those women at greatest risk of serious instability; and other challenges that contribute to chronic complications or death related to pregnancy, is essential to stress and lower life expectancy.48, 49 While some of these identifying the causes of maternal death and implementing factors are outside of the control of the Medicaid MCO, it can, solutions for enrollees. at minimum, ensure that it is connecting pregnant women with the services it is being paid to provide. Evidence on the effects of Medicaid managed care for pregnant women is limited. Several studies reviewed indicate Just as Medicaid MCOs cannot, by themselves, end the that women enrolled in Medicaid managed care plans have, maternal health crisis, so transparency-including for MCO at best, the same outcomes as those in fee-for-service, and performance related to maternal health outcomes-will not at worst, have experienced reductions in access to care and on its own solve the maternal health crisis. But without it, poorer birth outcomes after their states moved from fee-for- we miss a critical opportunity to find solutions and address service to managed care delivery systems.39 systemic problems in maternity care that contribute to the maternal mortality crisis. Severe obstetric complications and pregnancy-related deaths are not limited to women with low incomes and enrolled in Medicaid. Racial disparities in birth outcomes persist regardless of a woman's income, education, age, or where she lives. A landmark California study showed that even the most educated and highest income Black women were still more likely to die of pregnancy-related causes than the least educated and lowest income white women.40 Pregnancy- related deaths and severe complications among Black women celebrities and athletes have also brought significant attention to the issue of racial bias and maternal health inequities.41,42 Maternal mortality rates are highest among Black women and American Indian/Alaska Native women, who are more likely to be covered by Medicaid.43,44 As a result, it is unsurprising to see that in several cases, state maternal mortality review committee data show that women who were enrolled in Medicaid account for a larger share of pregnancy-related deaths than women covered by private insurance.45 This information alone is not enough to determine the role that coverage plays in maternal deaths. The factors driving maternal mortality are varied, and include preexisting health conditions, such as hypertension, diabetes, substance use October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 5 III. Maternal Mortality Review Committees Each maternal death is a tragedy for the families and teams that convene regularly to review deaths that occur communities left behind. The Centers for Disease Control and within a year of pregnancy.51 Most issue regular reports on the Prevention (CDC) finds that more than 80% of pregnancy- number, demographics, and other characteristics of maternal related deaths are preventable.50 To understand the causes of deaths reviewed, frequently using standardized criteria from and recommend solutions to prevent maternal deaths, state the CDC (see Text Box 3).52 and local public health agencies have established maternal mortality review committees, which are multidisciplinary 3 Maternal Mortality Review Committees As rates of maternal mortality have risen in the United Medicaid agency representatives, behavioral health States, maternal mortality review committees (MMRCs) experts, law enforcement representatives, individuals have become even more critical to reviewing the causes of with lived experience, American Indian and Alaska maternal death and making recommendations to prevent Native tribe members, advocacy groups, and them in the future. MMRCs are state-level committees community-based organizations. MMRC reports can that consist of multidisciplinary representatives typically generally be found on the websites of state public health appointed to review deaths that occur during or within agencies. a year of pregnancy.53 The scope of the MMRC review The funding sources of MMRCs may include state process differs by state and there is a great deal of funds, grants, or donations from private organizations. variation in composition and operation. The committees The CDC supports MMRCs in 44 states and two are not mandatory, but 49 states have a formal MMRC. U.S. territories under the Enhancing Reviews and Idaho is the only state that has decided to disband its Surveillance to Eliminate Maternal Mortality (ERASE MM) MMRC; it did so in 2023. program.55 The general goal of MMRCs is to review all maternal Based on their analyses, these committees often deaths, identify root causes and contributing factors to make policy recommendations, which have included these deaths, make recommendations to improve care at Medicaid expansion for all low-income adults and an individual and systemic level, and disseminate findings. extending postpartum Medicaid coverage for 12 MMRCs are provided access to clinical records and months after the end of pregnancy (i.e., Illinois, Kansas, demographic information to enable them to understand Kentucky, Michigan, Mississippi, Nevada, New Jersey, the circumstances that led to a maternal death and to New Mexico, Tennessee, Washington).56 While some help identify systemic changes that could avoid maternal committees have been operating quietly for decades, deaths in the future. There is no uniform analytic protocol, interest in the review process and committee reports has though many of the MMRCs follow guidelines created by grown in recent years as more attention has been paid the CDC.54 to widening racial disparities in maternal deaths and the Committee membership varies by state, and may consist increasing rate of maternal deaths overall. of public health professionals, OB/GYNs, maternal-fetal medicine specialists, physicians, midwives, doulas, October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 6 IV. How We Did This Study To determine what information is publicly available about women enrolled under each MCO's contract with the state; the performance of individual Medicaid MCOs on maternal (2) the amount of capitation payments made by the state to health, we scanned the websites of Medicaid agencies in each MCO for these enrollees; (3) the performance of each 12 states, as well as the websites of the contracted MCOs. MCO on Maternity Core Set metrics collected by the state Additionally, we scanned the websites of the public health (see Text Box 5); and (4) what Performance Improvement agencies in the selected states for MMRC reports. We also Projects relating to maternal health, if any, the state Medicaid searched for financial information on state budget websites agency required each MCO to conduct (see Text Box 7). (legislative and executive). Finally, we scanned the website We also checked whether the state Medicaid agency had a of the Center for Medicaid & CHIP Services at the Center publicly-accessible data dashboard that includes maternal for Medicare & Medicaid Services (CMS). We conducted health metrics for each MCO. our scan May through August 2023. (For a more detailed The federal government does not require state Medicaid discussion of our methodology, see Appendix A.) agencies to post items (1) and (2), but this information is, in The 12 states we examined are Georgia, Illinois, Iowa, our view, foundational to any understanding of the role of Kansas, Kentucky, Michigan, Mississippi, Nevada, New Medicaid managed care in improving maternal health in a Jersey, New Mexico, Tennessee, and Washington. These state. It begins to answer the basic question: what is the size states do not represent a statistically significant sample of of the population of pregnant women whose care is being the 41 Medicaid managed care states (including the District managed by each MCO, and what is the size of the state of Columbia), but they do represent a mix of population sizes, and federal government's investment in each MCO for this urban/rural composition, regions of the U.S., managed care population? penetration, and Medicaid coverage policies (i.e., expansion CMS regulations do, on the other hand, require that state vs. non-expansion). Medicaid agencies post the Annual Technical Reports As shown in Table 1, these 12 states represent about one- prepared by External Quality Review Organizations fifth (22%) of all Medicaid enrollees at the end of 2022 (EQRO) (see Text Box 4). Those reports should contain the and account for 23% of all births in 2021. Their 2018-2021 information in items (3) and (4) above, but the content varies maternal mortality rates ranged from 17 deaths per 100,000 from state to state because CMS regulations currently do not live births in Illinois to 43 deaths per 100,000 live births in require states to collect all Maternity Core Set metrics from Mississippi.57 In 2020, all 12 states had Medicaid managed MCOs or to conduct Performance Improvement Projects care penetration rates of 64% or more; these rates are likely relating specifically to maternal health. CMS regulations do, higher now.58 The Medicaid income eligibility levels in these however, require that state Medicaid agencies post their risk states for pregnant women in 2022 ranged from 165% of contracts with each MCO; the ways in which those contracts FPL ($22,423 for a single individual) (Nevada) to 380% of FPL approach maternal health have been analyzed in great detail ($51,642 for a single individual) (Iowa).59 The share of births in by researchers at George Washington University for The 2021 covered by Medicaid ranged from 29% in New Jersey Commonwealth Fund.61,62 to 59% in Mississippi.60 All of these states have MMRCs. In our scans, we looked for the following information about each MCO with which the state Medicaid agency contracted during 2022: (1) the number and demographics of pregnant October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 7 Table 1. Characteristics of States Selected Total Medicaid Number of Percentage Number Share of Maternal Medicaid Eligibility Level Contracting of Medicaid Number of of Births Births Mortality Rate State Enrollment for Pregnant MCOs in Beneficiaries Live Births Financed by Financed by (Deaths per (as of Jan. 1, Women, % of Scan Enrolled in MCOs (2021) Medicaid Medicaid 100,000 live 2023) FPL (2022) (2022) (2020) (2021) (2021) births; 2021) National 85,915,795 200% 285 72.0% 3,664,292 1,490,085 41% – Georgia 2,165,047 225% 3 69.3% 124,073 57,113 46% 33.9 Illinois* 3,463,814 213% 5 74.4% 132,189 49,868 38% 17.3 Iowa 784,989 380% 2 89.6% 36,835 13,918 38% 20.2 Kansas 434,716 171% 3 88.4% 34,705 10,509 30% 22.0 Kentucky 1,487,786 195% 6 90.8% 52,214 23,430 45% 38.4 Michigan 2,924,598 200% 9 75.0% 104,980 39,585 38% 19.4 Mississippi 698,366 199% 3 63.9% 35,156 20,721 59% 43.0 Nevada** 823,792 165% 4 77.5% 33,686 14,908 44% 21.7 New Jersey 1,957,543 194% 5 94.4% 101,497 29,575 29% 25.7 New Mexico 835,044 255% 3 82.0% 21,391 11,504 54% 30.2 Tennessee*** 1,646,542 200% 4 92.5% 81,717 37,328 46% 41.7 Washington 2,095,795 198% 5 87.9% 83,911 27,992 33% 20.4 National maternal mortality rate is not available given small sample sizes in 13 states and DC. * Illinois has a total of seven plans but Humana Health Plan (Humana), which covers dual Medicare and Medicaid enrollees, and YouthCare (Centene), the enrollment of which is limited to children and youth in foster care and [juvenile justice institutions], were not included for the purposes of this study. ** Our results differed from KFF Medicaid MCO Enrollment by Plan and Parent Firm (March 2022), which lists Nevada as having three MCO plans: Anthem BlueCross Blue Shield (Elevance), Health Plan Nevada (UnitedHealth Group), and SilverSummit Health Plan (Centene). Our survey included an additional MCO plan: Molina Healthcare of Nevada (Molina), which began providing coverage to Medicaid and Nevada Check Up members effective January 1, 2022. *** There are four MCOs parent firms operating in Tennessee, however there are a total of 10 MCO plans and results (Core Set Metrics) are reported for each of three regions in the state. Sources: Brooks et al., "Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies," KFF (March 2023), Table 2, https://www.kff.org/statedata/ collection/medicaid-and-chip-eligibility-enrollment-and-renewal-policies/. MACStats: Medicaid and CHIP Data Book 2022, Exhibit 29, https://www.macpac.gov/wp-content/uploads/2022/12/EXHIBIT-29.-Percentage-of- Medicaid-Enrollees-in-Managed-Care-by-State-July-1-2020.pdf. CDC, "State and Territorial Data: births, birth rates, deaths, and death rates by state and territory," https://www.cdc.gov/nchs/fastats/state-and- territorial-data.htm. KFF, "Births Financed by Medicaid, 2021," available at https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/?activeTab=map& currentTimeframe=0&selectedDistributions=percent-of-births-financed-by-medicaid&sortModel=%7B%22colId%22:%22Location%22,%22sort% 22:%22asc%22%7D. CDC, "Maternal deaths and mortality rates: Each state, the District of Columbia, United States, 2018-2021," available at https://www.cdc.gov/nchs/ maternal-mortality/mmr-2018-2021-state-data.pdf. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 8 4 What's an External Quality Review Organization? Under risk contracts between state Medicaid agencies EQROs are a potentially powerful source of data and and MCOs, there is a financial incentive for the MCO to analysis that could inform efforts of maternal health limit the amounts it pays out for covered services. This advocates and policymakers to understand and, where incentive is one reason that many state Medicaid agencies necessary, improve the outcomes for pregnant and contract with MCOs to contain their program spending. As postpartum women enrolled in MCOs. The information a check against these cost containment incentives, federal they collect must be made available on request to regulations require that state Medicaid agencies contract interested parties, including beneficiary advocacy with at least one External Quality Review Organization groups.64 In our study, the only standardized maternal (EQRO) to assess MCO performance and quality. The health metrics available in each state we scanned were EQRO must be independent of both the state Medicaid those presented in the ATRs prepared by the EQROs. agency and any MCO it reviews. The federal government Unfortunately, not all state Medicaid agencies have made pays 75% of the cost of the state's contract with the maternal health a priority for EQRO activities, and even EQRO. where they have, the ATRs tend to focus on process rather States have discretion as to the scope of their contract than outcomes and are often too dense to be useful to with an EQRO, but there are some minimum federal stakeholders and the public.65 There is currently interest requirements. Among other things, the state agency must at the federal level in improving EQRO oversight of MCO require the EQRO to produce each year a detailed report performance generally. The Medicaid and CHIP Payment that includes the data the EQRO has collected and its and Access Commission (MACPAC) has published a assessment of "each MCO's strengths and weaknesses background issue brief, and CMS has proposed changes for the quality, timeliness, and access to health care to the current EQRO regulations.66, 67 It is possible that services furnished to Medicaid beneficiaries."63 The report, these efforts, combined with state-level advocacy, could known as the Annual Technical Report (ATR), must be lead to greater and more effective EQRO focus on MCO posted on the state Medicaid agency's website by April performance on maternal health.68 30 of each year. The state agency may not substantively revise the content of the final ATR "without evidence of error or omission." The MCOs contracting with each state in 2022, along with subsidiaries in two states, and Humana Health Plan, McLaren their parent companies, are listed in Table 2. (This list does Health Care, and CareSource, each of which operated in one not include MCOs that enroll only children and youth in state. In addition, there were 10 plans that are not subsidiaries foster care, as is the case in Illinois).69 Of the 52 MCOs, 37 of any national, publicly traded company. We scanned the are owned by one of the "Big Five" national companies in websites of each of these MCOs as well as their parent the Medicaid managed care market: 11 by Centene, eight by companies looking for the same information for which we UnitedHealth Group, seven by Elevance Health, and six by searched on state Medicaid agency websites, above. Molina, and five by CVSHealth.70 The remaining MCO parent firms are Health Care Service Corporation, which operated October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 9 Table 2. Medicaid Managed Care Organizations by State, 2022 Parent Companies as of March 2022 Total Medicaid Pregnant Women State MCOs Parent Company for MCO Enrollment for MCO Enrolled (March 2022) (March 2022) Amerigroup Community Care Elevance 531,178 NR Georgia Care Source CareSource 405,300 NR Peach State Health Plan Centene 978,459 NR Cook CountyCare N/A 428,497 9,513 Aetna Better Health CVS Health 440,771 6,556 Illinois Meridian Health Plan Centene 893,207 15,791 Blue Cross Blue Shield of Illinois Health Care Service Corporation 706,257 15,727 Molina Healthcare of Illinois Molina 345,142 5,628 Amerigroup Elevance 413,193 NR Iowa Iowa Total Care Centene 318,532 NR Aetna Better Health of Kansas CVS Health 136,320 NR Kansas Sunflower Health Plan Centene 164,154 NR United Healthcare Community Plan UnitedHealth Group 173,628 NR Aetna Better Health of Kentucky CVS Health 248,380 NR Anthem BlueCross Blue Shield Elevance 171,031 NR Humana Healthy Horizons in Kentucky Humana Health Plan 168,042 NR Kentucky Passport Health Plan by Molina Healthcare Molina 329,846 NR United Healthcare Community Plan UnitedHealth Group 66,546 NR Wellcare of Kentucky Centene 485,633 NR Aetna Better Health of Michigan CVS Health 53,821 NR Blue Cross Complete of Michigan N/A 330,124 NR HAP Empowered N/A 30,639 NR McLaren Health Plan McLaren Health Care 257,027 NR Meridian Health Plan of Michigan, Inc. Centene 556,274 NR Michigan Molina Healthcare of Michigan Molina 390,141 NR Priority Health Choice N/A 240,404 NR UnitedHealthcare Community Plan UnitedHealth Group 300,282 NR of Michigan Upper Peninsula Health Plan N/A 52,693 NR Magnolia Health Centene 159,876 NR Mississippi Molina Healthcare Plan of Mississipi Molina 79,089 NR Anthem BlueCross Blue Shield Elevance 190,859 NR Health Plan Nevada UnitedHealth Group 208,850 NR Nevada Molina Healthcare of Nevada Molina N/A NR SilverSummit Health Plan Centene 137,904 NR Aetna Better Health of New Jersey CVS Health 128,603 NR Amerigroup New Jersey Elevance 259,640 NR Horizon NJ Health N/A 1,147,605 NR New Jersey UnitedHealthcare Community Plan of UnitedHealth Group 405,675 NR New Jersey Wellcare of New Jersey Centene 108,523 NR October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 10 Table 2. Medicaid Managed Care Organizations by State, 2022 (cont'd) Total Medicaid Pregnant Women State MCOs Parent Company for MCO Enrollment for MCO Enrolled (March 2022) (March 2022) Blue Cross Blue Shield of New Mexico Health Care Service Corporation 292,418 3,349 New Mexico Presbyterian Health Plan N/A 423,306 3,707 Western Sky Health Plan Centene 86,145 905 Amerigroup Tennessee Elevance 495,571 NR BlueCare N/A 617,379 NR Tennessee TennCare Select N/A 52,737 NR UnitedHealthcare Community Plan UnitedHealth Group 496,792 NR of Tennessee Amerigroup Washington Elevance 221,255 1,453 Community Health Plan of Washington N/A 237,208 1,671 Coordinated Care Corporation Centene 203,205 1,262 Washington Molina Healthcare Plan of Washington Molina 951,225 5,691 UnitedHealthcare Community Plan UnitedHealth Group 238,016 1,493 of Washington We also examined the most recent MMRC report issued by data to inform this study.71 CMS does not post MCO-specific each state's public health agency. We looked to see whether enrollment data, broken down by pregnancy status, or by race the analysis of maternal deaths took into account the source and ethnicity of pregnant women.72 It does post the Maternity of health insurance coverage (if any) in general and Medicaid Core Set measures that state Medicaid agencies report, but MCO enrollment in particular, and if so, what findings the the most recent report is for performance in federal fiscal year report made (see Text Box 5). 2020, and the data are presented on a statewide, aggregate basis, not on an MCO-specific basis (see Text Box 6).73 The Finally, we scanned the CMS Medicaid website for CMS Maternity Care Action Plan (December 2022) does not information about MCO-specific performance on maternal mention Medicaid MCOs.74 health. The CMS state managed care profiles did not have 5 What is a Managed Care Program Annual Report? As part of its oversight of Medicaid managed care, CMS States are required to submit MCPARs to CMS annually. requires state Medicaid agencies to submit an annual report States are also required to post the MCPARs on their on the operation of their managed care programs. This websites and provide them to their Medical Care Advisory Managed Care Program Annual Report (MCPAR) includes Committees.78 Of the 12 states we surveyed, only at least nine different elements, including the financial Mississippi posted the MCPAR for its non-specialized performance of each MCO and an evaluation of MCO MCOs.79 Michigan posted a MCPAR for its managed performance on quality measures.75 In June of 2021, CMS behavioral health program.80 Iowa posts an MCO Annual issued a reporting template for states to use in submitting Performance Report but not its MCPAR.81 As of August their MCPARs; the template at tab D2 requires states to 2023, CMS had not posted any of the MCPARs the states report measure results for each MCO in eight domains, have submitted, but in July of 2022 it indicated that they including maternal and perinatal health.76 The first round of would be publicly available on request.82 submissions, for the contract year 7/21/2021 to 6/30/22, was due in December 2022.77 October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 11 V. What We Found About Medicaid MCO Performance In the 12 states we studied, there was little transparency about a statewide basis were Timeliness of Prenatal Care and the performance of Medicaid MCOs on maternal health. Here is Postpartum Care. All 12 of the states reported statewide what we found for each piece of information searched: results for these measures.90 The other four measures were much less frequently reported on a statewide basis. 1. Number and demographic characteristics of pregnant women enrolled in each MCO. Only Illinois reported statewide results on the measure of Live Births Weighing Less than 2,500 Grams. Iowa MCO accountability for maternal health outcomes begins and Illinois were the only states to report on the measure with identifying how many pregnant women whose care the of Low-Risk Cesarean Delivery. Only Mississippi, New MCO is being paid to manage. Only three state agencies- Jersey, and New Mexico reported at least one of the Illinois, New Mexico, and Washington-posted the number measures on Contraceptive Care for Postpartum Women of pregnant enrollees in each MCO. Only two-New Mexico on a statewide basis. and Washington-disaggregated those MCO-specific enrollee numbers by race and ethnicity. States that report some Maternity Core Set measures on a statewide basis do not necessarily also report those 2. Total amount of capitation payments made by measures on an MCO-specific basis. As shown in Table the state Medicaid agency to each MCO for 3, Illinois reported statewide results for Live Births < pregnant enrollees. 2500 Grams but did not report MCO-specific results for Accountability of an MCO also starts with the size of the that measure. On the other hand, all 12 states reported state's (and federal government's) investment in each Timeliness of Prenatal Care and Timeliness of Postpartum MCO's management of the care of pregnant women. Only Care on both a statewide and MCO-specific basis. Kansas provided the total amount its paid its MCOs for Where available, the MCO-specific results were usually enrolling pregnant women. None of the states posted the included in the Annual Technical Report prepared by total amount of capitation payments to individual MCOs on the state's EQRO and posted on the state Medicaid behalf of pregnant enrollees. agency's website (see Text Box 4). Our detailed findings 3. Performance of each MCO on Maternity Core about individual MCO performance on the Maternity Core Set measures, extracted from these EQRO reports, are Set metrics collected by the state with which presented in Appendix B. it contracts. As explained in Text Box 6, the Maternity Core Set is We also searched for MCO performance on three other a group of nine standardized performance measures Healthcare Effectiveness Data and Information Set identified by CMS. State collection and reporting of these (HEDIS) metrics related to maternal health that are not metrics is currently optional. As a result, there is wide included in the CMS Maternity Core Set: (1) Prenatal variation from state to state as to which of the measures Immunization Status; (2) Prenatal Depression Screening are collected from MCOs and whether the state posts the and Follow-up; and (3) Postpartum Depression Screening measures it collects on an aggregate statewide basis or and Follow-up.91 New Mexico posted MCO-level on an MCO-specific basis. (This will change in 2024 when performance data on the Prenatal Immunization Status collection and reporting of six of these measures on a measure for two of its three MCOs. No other state posted statewide basis will become mandatory.)83 MCO-specific results for any of these measures, and only Illinois reported statewide performance data on We focused on six of the nine CMS Maternity Core Set Postpartum Depression Screening and Follow-Up. measures for performance years 2021 or 2022.89 As shown in Table 3, the two measures most frequently reported on October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 12 6 What is the Maternity Core Set? To better understand the quality of maternal and infant Child Core Set measures at the MCO level, but they do health care delivered to people enrolled in Medicaid, the give CMS the authority, after consultation with the states Centers for Medicaid and CHIP Services has developed and interested parties, to require stratification of one or the Maternity Core Set, comprised both of child and more of the measures by race and ethnicity, among other adult quality metrics that highlight several perinatal health factors, over the next five years. indicators, such as timeliness of prenatal and postpartum care and access to contraception for teens and adults.84 Reporting on these measures has been voluntary for states, but that will change in 2024 when state reporting becomes mandatory for the measures that are drawn from the Child Core Set. CMS regulations issued in August 2023 require that all states report Child Core Set measures for 2024 to CMS no later than December 31, 2024.85 The nine measures in the Maternity Core Set quality metrics for 2024 are listed in Table 7 located on page 25). State reporting on the three measures that come from the Adult Core Set will continue to be voluntary but we recommend that states report them.86 Particularly as states implement the 12-month postpartum coverage period (see Text Box 1), measuring rates of postpartum visits and contraception will be key to measuring the effectiveness of the coverage extension.87 Advocates have also recommended that these metrics be disaggregated by race, ethnicity, managed care plan, geography and other demographic factors.88 Transparency for state and MCO-level reporting on these metrics would allow pregnant women, policymakers, managed care plans and the public to see how well states and individual MCOs are performing on these metrics, and identify disparities. This level of transparency is critical to understanding the ongoing maternal health crisis and identifying where improvements in Medicaid are needed. The August 2023 CMS regulations do not require reporting of the October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 13 Table 3. State Reporting of Medicaid Maternity Core Set Measures Results from performance year 2021 or 2022 Live Births < Low-Risk Cesarean Timeliness of Timeliness of Contraceptive Care Contraceptive Care State 2500 grams Delivery Prenatal Care Postpartum Care Postpartum Ages 15-20 Postpartum Ages 21-44 GA S, MCO S, MCO IL S S S, MCO S, MCO IA S S, MCO S, MCO KS S, MCO S, MCO KY S, MCO S, MCO MI S, MCO S, MCO MS S, MCO S, MCO S, MCO NV S, MCO S, MCO NJ S, MCO S, MCO S, MCO S, MCO NM S, MCO S, MCO S TN S, MCO S, MCO WA S, MCO S, MCO S = Statewide results posted (not necessarily from ATR). MCO = MCO-specific results posted. Source: State and MCO results for Georgia, Kentucky, New Jersey, Michigan, Nevada, Washington all found in EQRO ATR. Illinois: "2022 Perinatal Report" (Springfield: Illinois Department of Healthcare and Family Services, 2022), https://www.ilga.gov/reports/ReportsSubmitted/31 11RSGAEmail5974RSGAAttachGeneral%20Assembly%20Perinatal%20Report%202022%20FINAL.pdf/. Kansas: "KanCare Dashboard," (Topeka: KanCare Medicaid for Kansas, 2022), https://www.kancare.ks.gov/docs/default-source/policies-and-reports/quality- measurement/kancare-dashboard.pdf?sfvrsn=3b4f511b_12/; and "KanCare Program Annual External Quality Review Technical Report 2022–2023 Reporting Cycle," https://www.kancare.ks.gov/docs/default-source/quality-measurement/eqro-reports/current-eqro-report/2022-2023-annual-eqr-technical-report. pdf?sfvrsn=9770521b_2/. New Mexico: "Healthcare Effectiveness Data and Information Set (HEDIS) Reports," New Mexico Human Services Department available here, and "New Mexico Medicaid Managed Care Centennial Care 2.0 Program" (Santa Fe: New Mexico Human Services Department, April 2023), https://www.hsd.state. nm.us/healthcare-effectiveness-data-and-information-set-hedis-reports/. Mississippi: "Managed Care Program Annual Report (MCPAR) for Mississippi: Mississippi Coordinated Access Network (MSCAN)," (Jackson: Mississippi Division of Medicaid, December 2022), https://api.realfile.rtsclients.com/PublicFiles/6c91aefc960e463485b3474662fd7fd2/27375da2-d30b-47e2-b327- ddd41fbdc6b8/EQRO-IPRO%20Annual%20Technical%20Report%202021; and "Mississippi External Quality Review Annual Comprehensive Technical Report For Contract Year 2021– 2022," op. cit. Tennessee: "2022 Annual HEDIS/CAHPS Report," (Nashville: Division of TennCare, November 2022), https://www.tn.gov/content/dam/tn/tenncare/ documents/hedis22.pdf. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 14 4. State requirement that MCOs conduct Performance Improvement Projects relating to maternal health. As part of their responsibility to improve the quality of their topics.92 The PIPs must be validated-that is, reviewed for managed care programs, state Medicaid agencies must accuracy, reliability, and freedom from bias-by the state's require that MCOs conduct Performance Improvement EQRO, which must include its analysis of the result in its Projects (See Text Box 7). The agencies have broad ATR. We searched the ATRs posted by each state agency latitude in determining what clinical areas their PIPs for PIPs relating to maternal health during performance address; maternal health is just one of many possible year 2022. 7 What's a Performance Improvement Project? State Medicaid agencies are required, as part of their Timeliness of Prenatal Care" again in 2021. The detailed responsibility for overseeing the quality of services study indicators varied from MCO to MCO, but the furnished by the MCOs with which they contract, to direct common objective was to increase the percentage of the MCOs to conduct Performance Improvement Projects eligible pregnant women in designated areas who received (PIP) and report the results at least annually. The PIPs a prenatal visit during the first trimester, on or before the have to be designed "to achieve significant improvement, enrollment date, or within 42 days of enrollment in the sustained over time, in health outcomes and enrollee MCO, with the goal of reducing racial disparities in these satisfaction;" there's no further federal guidance as to the percentages. The EQRO analyzed the results achieved by specific topics a state must select.93 One of the mandatory each MCO; of the 10 MCOs, six met their validation rating, activities of an EQRO (see Text Box 4) is to validate the one partially met it, and three did not.95 PIPs underway in each MCO. CMS has a detailed technical The EQRO identified timeliness of prenatal and postpartum protocol for EQROs to follow in validating PIPs.94 The care as a program-wide weakness: "Although [the Michigan Annual Technical Report prepared by the EQRO and posted Medicaid agency] mandated the [MCOs] conduct an on the state Medicaid agency's website must include a Addressing Disparities in Timeliness of Prenatal Care PIP description of the data obtained and the conclusions drawn to support improvement, many women were not always about each PIP the EQRO validated during the previous 12 having, or accessing timely, prenatal and/or postpartum months. care visits, as demonstrated through lower [Medicaid As noted, state Medicaid agencies determine the topics of managed care program] performance for the Prenatal the PIPs that MCOs must conduct. (CMS has the authority and Postpartum Care measure rates. Both measure rates to specify PIPs that states must require MCOs to conduct, ranked below the [national Medicaid] 25th percentile and but has not done so). In 2018, Michigan became one of demonstrated a statistically significant decline from the the states that requires PIPs relating to maternal health prior year. Timely and adequate prenatal and postpartum performance. All 10 of Michigan's MCOs were required to care can set the stage for the long-term health and well- conduct PIPs on the topic of "Addressing Disparities in being of new mothers and their infants."96 October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 15 As shown in Table 4, nine of the 12 states required one or more of their MCOs to conduct PIPs on a topic relating to maternal health in 2022; Kentucky, New Jersey, and Tennessee did not. The most frequent PIP topic was Timeliness of Prenatal Care- conducted by 18 MCOs in five states (Georgia, Illinois, Michigan, Nevada, New Mexico). Table 4. Performance Improvement Projects Relating to Prenatal and Postpartum Care, 2022 State PIP Topic (# of MCOs with topic out of total MCOs) GA Y Timely Prenatal Care (3 of 3) IA Y Timeliness of Postpartum Care (2 of 2) IL Y Timeliness of Prenatal Care (5 of 5) KS Y Prenatal Care (1 of 3) KY N None MI Y Addressing Disparities in Timeliness of Prenatal Care (6 of 9); Improving Timeliness of Prenatal Care (3 of 9) MS Y Reducing Preterm Births (1 of 3); Prenatal and Postpartum Care (1 of 3); Improved Pregnancy Outcomes (1 of 3) NV Y Timeliness of Prenatal Care (3 of 4) NJ N None NM Y Timeliness of Prenatal Care (1 of 3); Prenatal-Postpartum (1 of 3); Addiction in Pregnancy (1 of 3) TN N None WA Y Improving Timeliness of Postpartum Visits (1 of 5) October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 16 VI. What We Found in the MMRC Reports All 12 states we studied had an active MMRC, and all of those MMRCs issued reports on their findings. The reports we reviewed varied significantly in length and depth of analysis as well as in the time period covered. Here is a summary of our findings: 1. Timeline of the most recent MMRC report published and data reviewed. We found a wide range of years reported. Only Michigan and Nevada had data reflecting maternal deaths that occurred as recently as 2021. Illinois had the oldest data of the states we scanned: its most recent maternal mortality review committee report reflects maternal deaths that occurred in 2016-2017. Importantly, this data lag puts the MCO performance data analyzed above, and the maternal deaths reviewed, on different timelines. Table 5. Most Recent Year of Maternal Mortality Measured, as of July, 2023 Most Recent Year of Maternal Mortality State(s) Data Measured 2021 Michigan, Nevada 2020 Georgia, Tennessee, Washington 2019 Iowa, Kansas, Kentucky, Mississippi 2018 New Mexico, New Jersey 2017 Illinois 2. State Medicaid agency participation in the MMRC. Identifying the cause of, and promoting solutions to, maternal mortality includes understanding whether the mother can access timely, high-quality health care. As the payer for over 40% of all births each year, Medicaid has important insight into the opportunities and challenges new mothers face in accessing lifesaving care. Of the 12 states reviewed, seven states included the state Medicaid agency on their maternal mortality review committee and five did not. Table 6. Medicaid Agency Participating on Maternal Mortality Committee Medicaid Agency Participating on State(s) MMRC Yes (7) Georgia, Illinois, Kansas, Kentucky, Michigan, New Jersey, Washington No (5) Iowa, Mississippi, Nevada, New Mexico, Tennessee* *Tennessee indicated public and private insurers are represented. Based on AMCHP Review to Action, available at https://reviewtoaction.org/tools/networking-map. 3. MMRC analysis of insurance coverage at time of death. All but one state maternal mortality review committee (Michigan) reported the type of insurance coverage for maternity care for the mother who died of pregnancy-related causes. The reports generally separated the sources of coverage by Medicaid, private insurance, or uninsured. Where they identified Medicaid as the source of coverage, however, none of them noted whether the coverage was provided on a fee-for-service basis or through risk-based managed care. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 17 4. MMRC analysis of enrollment by Medicaid MCO. Simply looking at a pregnant woman's enrollment in the Medicaid program is not sufficient to understand how the performance of her MCO could be associated with her pregnancy-related death. In the 12 states reviewed, no state MMRC report included data related to the enrollment in a particular Medicaid MCO among women who died during pregnancy or within a year after birth. Without this level of information, states are missing an opportunity to understand which MCOs are doing well, which ones are doing poorly, and where changes are needed to protect the lives of new mothers. 5. MMRC analysis including Medicaid-specific findings or policy recommendations. Each of the 12 states had an MMRC report that included either Medicaid-specific findings, such as comparing the rate of Medicaid-covered women who died versus women who had private coverage, or a Medicaid-related policy recommendation. Michigan's MMRC report was the only one not to mention Medicaid, but it did include a recommendation to refer pregnant women to its unique Medicaid-financed home visiting program.97 Some of the most frequent Medicaid-related recommendations were extending the duration of postpartum Medicaid coverage to one year after the end of pregnancy (Georgia, Iowa, Mississippi, Nevada, New Mexico), and utilizing presumptive eligibility to enroll more women in early prenatal care (Kentucky, Mississippi). Other recommendations included better care coordination, referral to the respective state Medicaid-financed home visiting program, and improved access to Medicaid-supported transportation.98 Illinois was the only state to make recommendations for actions Medicaid MCOs should take to reduce maternal mortality (see Text Box 8). 8 The Illinois MMRC's Recommendations to MCOs In its 2021 Maternal Mortality Review Committee Report, Illinois made specific recommendations for actions that health insurance plans, including Medicaid MCOs, should take to reduce maternal mortality.99 The report emphasized that the majority of the pregnancy-associated deaths occurred more than two months after pregnancy, and that payers should increase access to all necessary medical services during the first year postpartum, including ensuring sufficient specialist networks and non-traditional services, such as doula care and services delivered via telehealth. The committee recommended that Medicaid MCOs:100 zz Allow reimbursement for multiple postpartum visits for all women; zz Cover intensive case management and outreach and non-medical support services (such as doulas) for women with complex medical and mental health conditions while pregnant and up to one year after delivery; and zz Reimburse for telehealth regardless of patient or provider location, for clinical services not widely geographically available in Illinois such as cardiology, pain management, psychiatry, substance use treatment, counseling services. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 18 VII. Discussion We undertook this research with relatively low expectations Even if the performance data that states report were stratified about the transparency of information relating to performance by race and ethnicity, the measures reported are insufficient of individual MCOs on maternal health. These expectations to judge how an individual MCO is performing on maternal had been set by two previous scans, one looking for health. Appendix B tells the tale. It presents, for each MCO performance for individual MCOs for children, and the other in each of the 12 states we scanned, the performance of the for performance of MCOs enrolling children and youth in MCO on each of nine maternal health metrics. As noted in foster care.101,102 Unfortunately, we found little improvement in Table 3, we found MCO-specific results in all states for two of transparency. the metrics-Timeliness of Prenatal Care and Timeliness of Postpartum Care. For the other seven metrics, MCO-specific In general, neither state Medicaid agencies, MCOs, nor CMS results were largely unavailable. are transparent about the performance of individual MCOs relating to maternity care. For the most part, information is What, if anything, can results on just two metrics (see Text difficult to access from state or MCO or CMS websites, and Boxes 9 and 10) tell beneficiaries and the public about an the information that is accessible is limited, fragmented, and MCO's performance on maternal health? At best, by enabling not sufficient to inform a judgment of how well or how poorly the comparison of an MCO's performance to that of other an individual MCO is performing. MCOs in the same state, these results can serve as a flag for further inquiry. The example of Centene, which has the largest In all 12 states we surveyed, the MCO-specific performance footprint in the Medicaid market and operates subsidiaries in on Maternity Core Set metrics that states reported was 11 of the 12 states we scanned, is instructive.105 not disaggregated by race or ethnicity. New Mexico and Washington posted the number of pregnant women enrolled in each MCO, disaggregated by race and ethnicity, but they did not stratify the performance metrics they reported by race or ethnicity. Medicaid pays for a disproportionate share of births to Black women and American Indian/Alaska Native women.103 Women in these groups have higher rates of maternal mortality than the national average.104 In managed care states, pregnant women in those groups who are covered by Medicaid are also likely to be enrolled in an MCO. How that MCO performs- how accessible its providers are, how effectively it identifies high-risk enrollees and manages their care-matters. Yet even the sparse MCO-specific performance data that is publicly available is not stratified by race or ethnicity. This makes it impossible, as a practical matter, for those other than the MCO, the state Medicaid agency, and (upon request) CMS, to know whether there are disparities in access to maternity care or outcomes within an MCO or how to advocate for reducing those disparities. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 19 9 Timeliness of Prenatal Care Performance Metric One of the most frequently reported measures in our scan From a clarity standpoint alone, this is challenging. There of 12 states was state and MCO-level performance on is no way to know how many women are in each category. "Timeliness of Prenatal Care." This measure provides the The potential for pregnancy complications is vastly different only available glimpse into the access to prenatal care for a woman who starts prenatal care in the first trimester, across MCOs and states. Research shows prenatal care compared to a pregnant woman whose enrollment in reduces risks of pregnancy complications for the mother Medicaid happens less than seven months before delivery and increases the likelihood that the baby will be born and who receives a prenatal visit 42 days later. This could at full gestation at a healthy birth weight.106 Because of put a pregnant woman's prenatal visit well into month the importance of prenatal care to healthy pregnancy five of pregnancy or even later. While this care would be outcomes, the measure is worth unpacking to understand counted as "timely" for purposes of the measure, it is far just what it captures–and what it does not. from the American College of Obstetrics and Gynecology's recommendation to initiate prenatal care as soon as an The metric counts prenatal visits for women in two individual thinks they may be pregnant.108 groups.107 For the first group, it counts women who were continuously enrolled in Medicaid for at least seven Most MCOs we reviewed exceeded 70% of enrolled months before delivery and 60 days postpartum, and pregnant women receiving a timely prenatal visit who had their first prenatal visit in the first trimester according to the measure specifications (see Appendix (roughly 12 weeks) of pregnancy. In the second group, B). The American College of Obstetrics and Gynecology the metric counts women who were not continuously recommends roughly 15 prenatal visits throughout enrolled in Medicaid within seven months of delivery, and pregnancy.109 who had one prenatal visit within 42 days of enrollment in Because the metric is part of the Child Core Set of Medicaid. measures, reporting the Timeliness of Prenatal Care These groups are then combined and compared to measure will be mandatory for states in 2024. Standardized the total universe of women with live births in the state and MCO-level data reporting is an essential-if measurement year, who are continuously enrolled in limited-first step in creating a standard for accountability Medicaid at least 43 days before delivery and 60 days for access to the most basic prenatal care. postpartum. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 20 10 Timeliness of Postpartum Care Performance Metric The postpartum period is a critical time for physical One postpartum visit is less than the standard recovery and bonding for the mother, infant and new of care: The American College of Obstetrics and family.110 It can also be a dangerous time: roughly 53% Gynecology recommends women receive at least two of pregnancy-related deaths happen between 7 and postpartum visits, one within the first three weeks and a 365 days postpartum.111 Along with the "Timeliness of comprehensive visit within 12 weeks of birth.114 Prenatal Care," the "Timeliness of Postpartum Care" The Timeliness of Postpartum Care measure is part of metric was the most frequently-reported metric in our the Adult Core Set, so it will remain optional for states 12-state scan, though just 39 states nationally reported it to report. However, as states implement the 12-month in federal fiscal year 2020.112 postpartum coverage option (see Text Box 1), this metric The metric counts how many pregnant women who were will be critical to track to see if the lengthened coverage enrolled in Medicaid for at least 43 days before birth period is leading to greater utilization of postpartum care. and 60 days postpartum, received one postpartum visit between 7 and 84 days after delivery.113 The rates in the states we scanned varied from 52% to 89%. In six of the 11 states where Centene operates-Georgia, in each of these states. None of these six states reported any Iowa, Kansas, Nevada, New Mexico, and Washington-the of the remaining Maternity Core Set metrics for Centene or Centene subsidiary ranked the lowest among all the MCOs any other MCO, and none posted any MCO-specific maternal on both the Timeliness of Prenatal Care and the Timeliness mortality outcomes. The websites of the Centene subsidiaries, of Postpartum Care (see Appendix B). In all selected states the parent company, and CMS were also uninformative. None other than Kansas, the Centene subsidiaries were directed of the MMRC reports in the 11 states where Centene operates to conduct a PIP related to maternal health, and the EQRO's analyzed maternal mortality or morbidity among enrollees of evaluation of that project is available in the Annual Technical individual MCOs. Report posted on the state agency website (see Text Box 2). These are useful flags for further inquiry, but there is little if any publicly available information beyond those metrics and PIPs October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 21 11 Why does transparency matter to MCO performance on maternal health? Transparency about performance is one tool for contract with the EQRO. These multiple responsibilities holding MCOs accountable for the accessibility and are technically and logistically complex, placing large quality of services for pregnant women and other demands on often under-resourced state Medicaid enrollees. It greatly enhances the primary tool for MCO agencies. Combined with the political reach of many accountability-the risk contract between the state MCOs, these constraints limit the ability of state Medicaid Medicaid agency and the MCO (see analysis at endnote agencies, by themselves, to hold MCOs accountable for 34)-at minimal cost and administrative burden to the performance.116 agency or the MCO. There are three main considerations. Finally, there is the question of behavioral incentives. If the First, pregnant women who are enrolled in a Medicaid management of an MCO knows that its performance will MCO are dependent on that MCO for access to the be available to the public, the management will likely want services they need and for which the MCO has taken to ensure that the organization's performance is strong, responsibility to deliver under its contract with the state both to maintain and expand its enrollment and to protect Medicaid agency. The agency is paying the MCO on a its wider reputation. If the leadership of a state Medicaid monthly basis to manage the care of all of its enrollees, agency knows that the performance of each of the MCOs including pregnant women. That is a complicated with which it has decided to contract and to which it is undertaking that involves, among other things, organizing making large payments will be available to the public, it a network of high-quality providers, ensuring that the will likely want to ensure that any low-performing MCOs enrollees are accessing the services the MCO has improve their performance to avoid reputational damage contracted with the state agency to provide, tracking to the agency. The same dynamic would apply at the and analyzing utilization, and reporting on metrics and federal level as well. outcomes. And because the state pays the MCO a Transparency of Medicaid MCO performance data will monthly capitation amount for each enrollee regardless of not, in and of itself, solve the maternal health crisis in whether the enrollee uses services, the financial incentive this country. It is, however, an effective mechanism for the MCO is to furnish fewer rather than more services. for holding MCOs, state Medicaid agencies, and CMS Second, because of their size and complexity and the accountable for their performance on maternal health. financial incentives inherent in capitation, holding MCOs The MCOs and the state agencies have (or should have) accountable for their performance can be challenging.115 the data on maternal health outcomes for pregnant The primary responsibility for oversight rests with the women enrolled in each MCO. Collection and analysis of state Medicaid agency, which selects the MCOs with these data, stratified by race and ethnicity, are integral which it contracts, sets the terms of those contracts, to managing care, identifying health disparities, and establishes the rates of payment to the MCO, and addressing them.117 But if these data remain hidden from monitors and enforces compliance with the contract public view, there is less incentive for both the MCOs and terms. To assist the agency in its monitoring, the federal the state Medicaid agencies to improve performance. government pays 75% of the cost of independent There is also less opportunity for MCOs and state quality review by an EQRO, giving the agency access agencies to learn from high-performing MCOs, and no to validated data about each MCO's performance on opportunity for the public to know who those MCOs are. an annual basis, but requiring the agency to select and October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 22 VIII. Recommendations We offer four sets of recommendations for improving maternal explains that its goal in creating this designation is "not simply health in Medicaid managed care. Three focus on increasing to grant hospitals a maternal health 'gold star,' but to do so in the accountability of MCOs, state Medicaid agencies, a way that is meaningful for patients and families in search of and CMS through greater transparency (see Text Box 11). facilities with a demonstrated commitment to the delivery of These recommendations can be implemented with minimal high-quality, safe, and equitable maternity care."121 administrative burden and cost to CMS, states, and MCOs. In that same August 2022 rule, CMS also adopted two The fourth set of recommendations focuses on opportunities maternal health measures that hospitals participating in for health advocates to hold individual MCOs accountable for Medicare's Inpatient Quality Reporting (IQR) program will performance. be required to report: Cesarean Birth (FY 2023) and Severe States and CMS can both do better. One example of what Obstetric Complications (FY 2024).122 Currently, performance is possible is an August 2022 CMS initiative to designate on the Maternal Morbidity Structural Measure is not based hospitals participating in Medicare as "Birthing-Friendly" if on these measures, but CMS "continues to assess" whether they meet a Maternal Morbidity Structural Measure.118,119 CMS performance on those measures should be included in the intends to post hospitals' designations on its beneficiary- "Birthing-Friendly" designation.123    facing website, Care Compare, in the fall of 2023.120 CMS Recommendations for State Medicaid Agencies zz State Medicaid agencies should maintain on their zz State Medicaid agencies should prioritize requiring websites a readily-accessible data dashboard that MCOs to conduct at least one Performance presents MCO-specific performance metrics for Improvement Project each year that is designed to maternity care, stratified by race and ethnicity.124 advance maternal health. State agencies should also These metrics should include, at a minimum, the require their EQRO contractors to present the results of number of pregnant women enrolled, the total their independent validation of each MCO's PIP in clear, amount each MCO received from the state agency non-technical language in an easy-to-find section of the to manage the care of these enrollees for the most EQRO's Annual Technical Report. The state agency's recent contract year, and the performance of each data dashboard should link directly to this section of MCO on the Maternity Core Set metrics that CMS the ATR. Results should also be shared with the state requires states to submit beginning in 2024. The Maternal Mortality Review Committee. dashboard should also include Medicaid and MCO- zz State Medicaid agencies should require each of the specific information from the state Maternal Mortality MCOs with which they contract to include at least one Review Committee. (Appendix C provides more hospital designated as "Birthing-Friendly" by Medicare detail on state data dashboards.) in their provider network and inform their enrollees as zz In addition to the data dashboards, state Medicaid to which hospitals have that designation.125 According agencies should also maintain on their websites to CMS, over 25 health insurers, including Centene, beneficiary-facing MCO maternal health scorecards/ CVSHealth/Aetna, Elevance Health, and Molina, have report cards (see Appendix C). These tools should committed to displaying "Birthing-Friendly Hospital" synthesize the performance measures on the data on their provider directories when the designation is dashboard and present the data in such a way that available this fall.126 The state agencies should also beneficiaries can understand which MCOs are high- reward the MCOs that are high-performing on maternal performing on maternal health (not just women's health measures with public recognition, financial health) and which are not. bonuses, or both. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 23 Recommendations for State Public Health Agencies zz All states should operate Maternal Mortality Review where warranted, make recommendations to the state Committees consistent with CDC guidelines. The Medicaid agency and the MCO for improvements that MMRCs should include representation from the will reduce maternal mortality and morbidity going state Medicaid agency, perhaps the agency's Chief forward. Medical Officer, as well as from MCOs. zz State Public Health agencies should post their MMRC zz MMRCs should report the source of insurance reports, including Medicaid MCO-specific findings coverage for all maternal deaths reviewed. In the and recommendations, in an easy-to-find location on case of a death of a woman with Medicaid (or their agency websites. They should make the reports separate CHIP) coverage while enrolled in an MCO, available to the state Medicaid agency and its Medical the MMRC should identify the MCO in which the Care Advisory Committee as well as the individual woman was enrolled at the time of death and, MCOs with which the state contracts. Recommendations for the Centers for Medicare & Medicaid Services zz Under current law and regulations issued by CMS, should consult with states and other stakeholders and state Medicaid agencies are required to report state- provide public notice and opportunity to comment (see level Child Core Set measures to CMS beginning Table 7). in 2024. These include six of the nine Maternity zz CMS should add the HEDIS metrics, Prenatal Core Set measures. CMS should require states with Depression Screening and Follow Up, and Postpartum managed care programs to report MCO-level data Depression Screening and Follow-Up, to the on all nine of its Maternity Core Set measures at Behavioral Core Set measures that states will be both the State and the MCO level and post these required to report beginning in 2024.128,129 measures on medicaid.gov. zz CMS should make the MCO-specific results on its zz CMS should use its regulatory authority to specify Maternity Core Set measures available as part of the PIPs that are likely to improve maternal health Managed Care Program Annual Reports that states and reduce racial disparities that state Medicaid began submitting in December of 2022 (see Text Box agencies would be required to direct MCOs to 6). As of September 2023, CMS had not posted these conduct.127 In developing these specifications, CMS reports; it should do so. Recommendations for Advocates zz Research the performance on maternal health for it can be leveraged to obtain such information from each of the Medicaid MCOs in your state. Include in the agency.130 your search the most recent Annual Technical Report zz If there are low-performing Medicaid MCOs, engage of your state's EQRO, which should be posted on directly with the state Medicaid agency, the state the state Medicaid agency website (see Text Box MMRC Committee, and the MCOs themselves to 4) and the most recent report from your state's develop and implement a strategy for improvement. Maternal Mortality Review Committee report which This strategy could include reporting of performance is often found on the public health agency's website on maternal health measures by each MCO, posting (see Text Box 5). of those measures by the state Medicaid agency, zz Engage with your state Medicaid agency's revising the contract between the state agency and stakeholder advisory committee (formally known the MCO, and incorporating performance on those as the Medical Care Advisory Committee) to measures into the evaluation of an MCO's bid during see whether it has information on MCO-specific the state's procurement process.131 performance on maternal health and if not, whether October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 24 Table 7. Maternity Core Set for 2023 and 2024 Measure Name CMS Core Set Mandatory or Optional in 2024 Live Births Weighing Less Than 2,500 Grams Child Mandatory Low-Risk Cesarean Delivery Child Mandatory Well-Child Visits in the First 30 Months of Life* Child Mandatory Timeliness of Prenatal Care** Child Mandatory Contraceptive Care – Postpartum Women Ages 15 to 20 Child Mandatory Contraceptive Care – All Women Ages 15 to 20 Child Mandatory Postpartum Care*** Adult Optional Contraceptive Care – Postpartum Women Ages 21 to 44 Adult Optional "2023 and 2024 Core Set of Maternal and Perinatal Health Measures for Medicaid and CHIP (Maternity Core Set)," Centers for Medicare and Medicaid Services, available at https://www.medicaid.gov/medicaid/quality-of-care/downloads/2023-maternity-core-set.pdf. *Measures the percentage of children who had 6 or more well-child (preventive care) visits in their first 15 months.a The American Academy of Pediatrics recommends nine well-child visits in the first 15 months of life.b **Measures the percentage of deliveries in which women had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization.c ***Measures the percentage of deliveries in which women had a postpartum visit on or between 7 and 84 days after delivery.d a "Well-Child Visits in the First 15 Months of Life" measures the percentage of children who had 6 or more well-child (preventive care) visits in their first 15 months. Information about this metric is available at https://www.medicaid.gov/state-overviews/scorecard/well-child-visits-first-15-months-of-life/index.html. b "Recommendations for Preventive Pediatric Health Care," American Academy of Pediatrics, available at https://downloads.aap.org/AAP/PDF/periodicity_ schedule.pdf. c "Prenatal and Postpartum Care (PPC)," National Committee for Quality Assurance, available at https://www.ncqa.org/hedis/measures/prenatal-and- postpartum-care-ppc/. d Ibid. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 25 IX. Conclusion The U.S. is in the midst of a maternal health crisis that, despite In this scan of 12 states, we looked for information about the increased attention, appears to be getting worse. The causes performance of individual MCOs on maternal health. We found of maternal mortality and morbidity, and the racial disparities little transparency. Without this, it is simply not possible for in maternal health outcomes, are complex, and the solutions pregnant women to make an informed decision about which need to be correspondingly sophisticated. As the nation's MCO is best for them or for the public and other stakeholders largest insurer of births, Medicaid has an important role to play to understand which MCOs are performing well and which are in addressing the crisis. And in the 40 states (and the District not. Moreover, without this information, it is not possible to of Columbia) that rely on MCOs to manage care for pregnant know which improvements in MCO care delivery are needed to and postpartum Medicaid beneficiaries, individual MCOs have reduce pregnancy-related deaths and other adverse outcomes. an important role to play. This role will only grow as states In short, greater transparency is essential to enable the public extend coverage through the full 12 months postpartum, to hold MCOs, and the state Medicaid agencies that contract giving MCOs the opportunity to ensure that their enrollees with them, more accountable for maternal health outcomes. receive the services they need during this critical period. Acknowledgments The authors would like to thank former Georgetown Center for Children and Families Program Director Maggie Clark for her significant contributions to conceptualizing and writing this report. The authors would also like to thank the following for their contributions: Joan Alker, Elisabeth Wright Burak, Hannah Green, and Cathy Hope of the Center for Children and Families and Kay Johnson, President of the Johnson Group Consulting, Inc. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America's children and families. CCF is based at the McCourt School of Public Policy. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 26 APPENDIX A: Methodology Data Sources New Mexico were included in the 13-state scan that CCF This report analyzes the performance of Medicaid managed conducted in 2021 to assess the performance of individual care organizations (MCOs) for pregnant women using data Medicaid MCOs for children and pregnant women. from state Medicaid agency websites, state Public Health The states and MCOs included in this scan are not necessarily department websites, state budget websites (legislative and representative of all 40 states that contract with MCOs or of executive), and individual MCO websites. In some cases, all MCOs contracting with those states. We include states that state agency websites referred us to external websites, such range in population size, rural and urban composition, regions as that of the National Committee for Quality Assurance of the U.S., Medicaid managed care penetration, Medicaid (NCQA). For additional information on state reporting and coverage policies (i.e., expansion vs. non-expansion), and maternal health metrics, we also used the websites of the political leadership. Center for Medicaid & CHIP Services and the Centers for Disease Control and Prevention (CDC). We conducted our The list of data elements included in our scan can be scans of these websites between May and August 2023. found in Appendix B. In our view, these elements are the minimum necessary to make an informed assessment of the We used the Kaiser Family Foundation's (KFF) Medicaid performance of an MCO for pregnant and postpartum women Managed Care Tracker to cross check our list of MCOs and enrolled in Medicaid. parent firms for the 2023 plan year.1, 2 In some cases (GA, NJ, MI) state MCO offerings had changed since the KFF Medicaid We limited our search to publicly accessible websites. We MCO Enrollment by Plan and Parent Firm was updated in did not file Public Records Act requests with state Medicaid March 2022.3 agencies or insurance departments for the performance data we were seeking, nor did we file Freedom of Information The quality measures presented in this paper reflect MCO Act requests for this information with CMS. We did use performance during calendar years (CY) 2021-2022. These online search engines (i.e., Google), though we limited were largely selected from the Maternity Core Set reported in data collection to results from the state and MCO website the most recent External Quality Review Organization (EQRO) domains. It is worth noting that this may have impacted our Annual Technical Report (ATR) posted on the state website. search results as various search algorithms learned which These rates were the most recent data available at the results we tended to select throughout the survey process. beginning of our scan in May 2023. Most of our data comes from state EQRO ATRs as well as reports from state Maternal Limitations Mortality Review Committees (MMRCs) and other Medicaid agency statistical reports. We focus on a set of performance data considered most relevant to the performance of individual MCOs in relation to We also reviewed other sources for additional information maternal health metrics. Since there is little standardization including MCO contract documents, Medicaid funding of what metrics a state Medicaid agency requires its MCOs and enrollment reports, and maternal health and enrollee to report or what a state decides to publish, there were few dashboards where available. instances when/where a metric was available across all states or MCOs for the same time period. For example, not every Data Collection state agency requires the MCOs with which it contracts to The 12 states included in this scan had ten or fewer MCOs in conduct Performance Improvement Projects (PIPs) relating to operation as of June 2023 and are states where CCF provides maternal health each year. ongoing technical assistance to health advocates as part of Because of the lack of comparable performance data, we Alliance for Early Success or the CCF Finish Line Network. frequently use data for the most recent year available, instead Additionally, all states except Michigan, New Jersey, and of a common year or metric which could have allowed October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 27 us to examine trends in MCO performance or compare As noted above, our search results may have been affected performance across MCOs in different states. The same by our specific search history and patterns over this two- applies to MMRC reports. Many states do not produce month survey. It is unclear if we would have found greater or reports annually, data is often aggregated over multiple years, less transparency around individual MCO performance for and there are no standardized requirements for a "report," so pregnant women with different online search techniques. we include the most recent document available and do not Finally, caution should be exercised in comparing statewide limit collection to a certain reporting period. metric reporting and MCO performance across states. The By limiting our search for MCO-specific metrics to CY 2020- demographic profile, health status of pregnant women 2021, we did not capture any changes that state Medicaid enrolled in MCOs, and MCO provider networks may vary agencies may have reported in MCO performance over significantly from state to state. time. Inclusion of results from prior years may have yielded additional opportunities for comparison of MCO performance, but it would not inform the basic question of this study, i.e., what current performance information is publicly available? APPENDIX B. MCO Performance Metrics A state-by-state, MCO-by-MCO table of performance on Maternity Core Set metrics is available here. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 28 APPENDIX C: MCO-Specific State Performance Data Dashboards and Scorecards/Report Cards The purpose of transparency about MCO performance on are able to access maternal health performance metrics for maternity care is to hold MCOs (and the state Medicaid each MCO on a dashboard maintained by the state Medicaid agencies that contract with them) accountable (see Text Box agency. 11). One key element of accountability is whether Medicaid We searched each of the 12 state Medicaid agency websites beneficiaries who are or expect to become pregnant are for data dashboards and report cards or scorecards that able to make an informed choice as to which MCO would contain MCO-specific performance information on maternal be the best for them. Another is whether other stakeholders, health. Our results are shown in the table below. including researchers, advocates, the press, and the public, Appendix C Table. Maternal Health Performance Dashboards and Beneficiary Scorecards Column 1: Column 2: Column 3: Column 4: Column 5: EQRO Annual Technical NCQA Health Medicaid Performance Medicaid Performance Beneficiary-Facing State Report has Maternal Plan Report Dashboard with Dashboard with Scorecard/Report Card with Health Performance Data Cards Maternal Health Data Maternal Health Data Maternal Health Measures (Statewide) (MCO-specific) (MCO-specific) Georgia Y Y Y Y N Illinois Y Y N N Y Iowa Y Y N N Y Kansas Y Y Y Y N Kentucky Y Y N N Y Michigan Y Y Y N Y Mississippi Y Y N N N Nevada Y Y N N N New Jersey Y Y Y Y N New Mexico Y Y Y Y Y Tennessee Y Y N N N Washington Y Y Y N N Y = Data found on state Medicaid agency website (columns 1, 3, 4, 5) or NCQA (column 2). N = Date not found on state Medicaid agency website. Column 1: Every state agency posted the Annual Technical specific performance required by federal regulations other Report (ATR) prepared by its External Quality Review than Managed Care Program Annual Reports (MCPARs) (see Organization (EQRO) (see Text Box 4). In every case, the below). Dashboards and scorecards or report cards, if any, are ATR contained MCO-specific results for two Maternal Core voluntarily posted by state agencies. Many stakeholders will Set metrics-Timeliness of Prenatal Care, and Timeliness of have the ability to locate the ATRs on the state website and Postpartum Care. In two states, there were also results on find the relevant metrics. Most beneficiaries may not be able to one or both of the Contraceptive Care Postpartum metrics. do so. (See Table 3.) This is the only form of transparency on MCO- October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 29 Column 2: All but one of the Medicaid MCOs in each state Column 4: Georgia, Kansas, and New Mexico are the we reviewed is accredited by the National Committee for only state Medicaid agencies among the 12 that maintain Quality Assurance (NCQA) (the one exception is TennCare dashboards with MCO-specific performance data that Select in Tennessee).4 NCQA posts "Health Plan Report includes performance on maternal health. This was surprising, Cards" that rate each of the commercial, Medicare, Medicaid, because a number of these states have MCO-specific and Marketplace plans it accredits.5 It uses a star rating data dashboards with child health metrics.6 For example, system with eight tiers (1.5 to 5.0) to provide an overall Iowa, which has an otherwise excellent MCO performance rating for each plan as well as ratings on particular metrics, dashboard that it updates on a quarterly basis, does including three for "Women's Reproductive Health:" (1) not include maternal health metrics. MCO-specific data Prenatal checkups (Did members who gave birth have a dashboards are essential for researchers, advocates, the prenatal visit in their first trimester or shortly after enrolling in press, and other stakeholders to assess the maternal health a health insurance plan?); (2) Postpartum care (Did members performance of individual MCOs, but they are likely not useful who gave birth have a postpartum visit on or between seven to most beneficiaries. and 84 days after delivery?); and (3) Prenatal immunizations Column 5: Five of the 12 state Medicaid agencies- (Did members who gave birth receive both recommended Illinois, Iowa, Kentucky, Michigan, and New Mexico-have immunizations by their delivery date?). NCQA updates its beneficiary-facing "scorecards" or "report cards" that include ratings every September. information about individual MCO performance on maternal The NCQA Report Card webpage is searchable by plan name health. (There is no uniform definition for these terms; in and by state, so stakeholders who know of the existence of our summaries we use the term designated by each state). the site and understand how to interpret the star ratings will In our view, for beneficiaries to hold MCOs accountable, be able to access information about the Medicaid MCOs in transparency requires a consumer-friendly page that which they are interested. Beneficiaries are unlikely to be beneficiaries can easily locate on the state Medicaid agency's familiar with NCQA. Mississippi and Tennessee state Medicaid website with actionable information that they can understand. agency websites provide a link to the NCQA Health Plan In the case of Illinois, Iowa, and Kentucky, this information is Report cards for the MCOs in their states. This may be helpful presented in the scorecard or report card under the heading to some stakeholders, although posting the data on a state "Women's Health," a topic that includes but goes beyond agency performance dashboard would be far more effective maternal health, so that it is not possible for the beneficiary transparency. Even in these states, however, beneficiaries are to understand the MCO's performance on maternal health. unlikely to recognize the significance of the link; to the extent For example, Kentucky's report card explains that an MCO's they do follow the link, they will have to construct their own rating on "Women's Health" (on a scale of one to five stars) side-by-side comparisons. tells you "if women receive tests that check for female Column 3: Six of the state Medicaid agency websites we cancers and infections" and "if women receive care before searched maintain a data dashboard on Medicaid managed and after their babies are born." Michigan's report card care performance at the state level and include in that uses the label "Taking Care of Women" as an indicator for an dashboard metrics on maternal health: Georgia, Kansas, MCO's performance on a number of maternal, reproductive, Michigan, New Jersey, New Mexico, and Washington. These and preventative health services. dashboards are available to stakeholders, the press, and the general public. They indicate what results Medicaid managed care is producing overall but they do not enable users to understand the performance of individual MCOs, even though the statewide results presumably reflect the combined performance of individual MCOs. Statewide performance data is of limited value to beneficiaries choosing among MCOs. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 30 Managed Care Program Annual Reports Iowa: "IA Health Link: 2021 Managed Care Organizations States are required to submit a MCPAR to CMS each year Scorecard" rates MCOs using a 5-star scale on, among (See Text Box 6). Among the data elements included in other criteria, "Women's Health," which includes "women the MCPAR reporting template are Plan-Level Quality and receive care before and after their babies are born:" Performance Measures in eight domains, one of which is Maternal and Perinatal Health (Tab D2).7 States must describe Iowa's MCO performance data dashboard, updated each measure they require MCOs to report, the performance quarterly, includes MCO-specific information on child measurement period, and the results for each MCO. If states health but not maternity care performance. complete the MCPAR reporting templates, and if they submit Iowa's Department of Health and Human Services has them to CMS and post them on their Medicaid agency also posted a detailed report, "Access to prenatal care, website as required, MCPARs could serve as an important selected behaviors and selected birth outcomes by source of transparency about individual MCO performance. Medicaid status, Iowa resident births 2017 – 2022." We did not examine the MCPARs of the 12 states we reviewed because they were not available at the time we Kansas: The "KanCare Dashboard" includes three performance conducted our study. They were not posted on the CMS measures for maternal health for 2021, statewide and website and only Mississippi's Medicaid agency posted MCO-specific: Timeliness of Prenatal Care; Postpartum its MCPAR on its website.8 (The state's MCPAR provides Care; and Well-child Visits in the Frst 30 Months of Life the measures on Elective Delivery, Postpartum Care, and ages 0-15 months, ages 15-30 months. The MCO-specific Contraceptive Care for Postpartum Women 21-44 for each results are positioned to be as inconspicuous as possible. of the three MCOs). The unavailability of the MCPARs is in part a function of CMS reporting deadlines, which vary with Kentucky: the contract year of the state's managed care program. The "Kentucky Medicaid 2021 Guide to Choosing Your Health first tranche of MCPARs, covering the contract year 7/1/21 – Plan" rates MCOs using a 5-star scale on, among other 6/30/22, was due December 27, 2022; the last, covering the criteria, "Women's Health," which includes "women contract year 4/1/22 – 3/1/23, was due September 27, 2023. receive care before and after their babies are born." State Performance Dashboards (Columns Michigan: 3-4) and Scorecards/Report Cards "A Guide to Michigan Medicaid Health Plans" rates MCOs using a 3-apple scale on, among other criteria, "Taking (Column 5) Care of Women," which includes "Moms in the plan also Georgia: get care before and after their baby is born to help keep "2023 Quality Performance Dashboard for Georgia mom and baby healthy." Families (Measurement Year 2021)" includes both statewide and MCO-specific maternal health metrics. Mississippi: The Dashboard rates MCOs using a 5-star scale on three The Medicaid agency has a page on its website titled Maternity Core Set metrics: Timeliness of Prenatal Care; "Measuring Managed Care Performance." The page Postpartum Care; Well-Child Visits in First 30 Months. includes a link to where you can "view the most recent rating of MississippiCAN's coordinated care organizations Illinois: (CCOs) published by the National Committee for Quality "HealthChoice Illinois: 2021 HealthChoice Illinois Plan Assurance." Report Card" rates MCOs using a 5-star scale on, among other criteria, "Women's Health," which includes "women Nevada: receive care before and after their babies are born." There are two Medicaid websites. One is unwieldy. The other is usable and contains a link to the NCQA website. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 31 New Jersey: Tennessee: The Medicaid agency has a performance dashboard The 2021 EQRO Annual Technical Report (March 2022), that includes both statewide and MCO-specific includes statewide maternal health metrics but not maternal health metrics (Timeliness of Prenatal Care and MCO-specific metrics; those are presented in a separate Postpartum Care), but it has not been updated since report, "2022 Annual HEDIS/CAHPS Report: Comparative 2019. Analysis of Audited Results from TennCare MCOs for Measurement Year (MY) 2021." The agency has also posted a Health Plan Brochure for beneficiaries, but only one of the MCO summaries Washington: includes a Maternal Core Set metric (Postpartum care). The state Medicaid agency maintains a Medicaid Maternal and Child Health Measures Dashboard that presents New Mexico: statewide performance on several maternal health metrics, "Departmental Performance Scorecard Goal 1 Measures: including Timeliness of Prenatal Care and Well-child Visits Medicaid Managed Care Organizations and Family & in the First 15 and 30 Months of Life, but the data are not Children" includes three Maternity Core Set metrics in the MCO-specific. aggregate and for each MCO for 2021 (the 2022 and 2023 data are aggregate, not MCO-specific). The Scorecard frames the metrics with the question: "I'm pregnant. How good is my MCO at working with providers to ensure (1) I receive the prenatal care I need, (2) I receive the postpartum care I need, and (3) my children will have at least 6 well-child visits by 15 months old?" The metrics are presented in horizontal bars for each MCO; it's not clear that most beneficiaries will be able to interpret them. 1 There were two plans in Illinois that were not included for the purposes of this study: Humana Health Plan (Humana) and YouthCare (Centene). Humana Health Plan (Humana) is specific to dually eligible Medicare and Medicaid beneficiaries with few if any pregnancies and therefore was not pertinent to this study on maternal health. We excluded the MCO plan YouthCare (Centene) because the enrollment is limited to children and youth in foster care and juvenile justice institutions. Notably, it is dissimilar to other plans in our survey that enroll foster youth (Amerigroup Community Care in Georgia, TennCare Select in Tennessee, and Coordinated Care in Washington) because those plans are available to individuals from multiple eligibility categories/are not exclusive to foster youth. 2 "Medicaid Managed Care Tracker," Kaiser Family Foundation, available at https://www.kff.org/statedata/collection/medicaid-managed- care-tracker/. 3 "Medicaid MCO Enrollment by Plan and Parent Firm, March 2022," op. cit. 4 National Committee for Quality Assurance (NCQA), available at https://www.ncqa.org/hedis/measures/. 5 "Health Plans," National Committee for Quality Assurance (2023), available at https://reportcards.ncqa.org/health-plans. 6 A. Corcoran and A. Osorio, "Take the Child Health Dashboard Tour," (Washington: Georgetown Center for Children and Families, June 8, 2022), available at https://ccf.georgetown.edu/2022/06/08/take-the-child-health-dashboard-tour/. 7 "Medicaid and CHIP Managed Care Reporting," op. cit. 8 "Managed Care Program Annual Report (MCPAR) for Mississippi: Mississippi Coordinated Access Network (MSCAN)," op. cit. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 32 Endnotes 1 Medicaid and CHIP Access and Payment Commission (MACPAC), 14 E. Declercq, R. Barnard-Mayers, L. C. Zephyrin, K. Johnson, "The U.S. "Medicaid's Role in Financing Maternity Care" (Washington: MACPAC, Maternal Health Divide: The Limited Maternal Health Services and Worse January 2020), available at https://www.macpac.gov/wp-content/ Outcomes of States Proposing New Abortion Restrictions," (Washington: uploads/2020/01/Medicaid%E2%80%99s-Role-in-Financing-Maternity- The Commonwealth Fund, December 14, 2022) available at https://www. Care.pdf. commonwealthfund.org/publications/issue-briefs/2022/dec/us-maternal- health-divide-limited-services-worse-outcomes. 2 K. Knocke et al., "Doula Care and Maternal Health: An Evidence Review" (Washington: Assistant Secretary for Planning and Evaluation, 15 "Medicaid Postpartum Coverage Extension Tracker," Kaiser Family December 13, 2022), available at https://aspe.hhs.gov/sites/default/files/ Foundation, https://www.kff.org/medicaid/issue-brief/medicaid- documents/dfcd768f1caf6fabf3d281f762e8d068/ASPE-Doula-Issue- postpartum-coverage-extension-tracker/. Brief-12-13-22.pdf. 16 M. Clark, "Maternal Mental Health Month Shines Light on Need 3 To maintain accuracy, Georgetown CCF uses the term "women" when for Policy Solutions," (Washington: Georgetown Center for Children referencing statute, regulations, research, or other data sources that use and Families, May 25, 2023), available at https://ccf.georgetown. the term "women" to define or count people who are pregnant or give edu/2023/05/25/maternal-mental-health-month-shines-light-on-need-for- birth. Where possible, we use more inclusive terms in recognition that not policy-solutions/. all individuals who become pregnant and give birth identify as women. 17 The Black Maternal Health Momnibus Act, S. 1606, 118th U.S. 4 D. Hoyert, "Maternal Mortality Rates in the United States, 2021" Congress, 1st Session (May 15, 2023), available at https://www.congress. (Hyattsville, MD: National Center for Health Statistics, March 2023), gov/bill/118th-congress/senate-bill/1606/text. available at https://www.cdc.gov/nchs/data/hestat/maternal- "Medicaid After Pregnancy: State-Level Implications of Extending 18 mortality/2021/maternal-mortality-rates-2021.pdf. Postpartum Coverage (2023 Update)," op. cit. 5 L. Fleszar et al., "Trends in State-Level Maternal Mortality by Racial and 19 Congressional Budget Office, "Reconciliation Recommendations Ethnic Group in the United States" JAMA. 330, no. 1 (July 2023): 52–61. of the House Committee on Energy and Commerce" 6 S. Gordon et al., "Medicaid After Pregnancy: State-Level Implications (Washington: Congressional Budget Office, February 14, of Extending Postpartum Coverage (2023 Update)," (Washington: Office 2021), available at https://www.cbo.gov/system/files/2021-02/ of the Assistant Secretary for Planning and Evaluation, U.S. Department EnergyandCommerceReconciliationEstimate.pdf#page=6. of Health and Human Services, April 2023), available at https://aspe.hhs. 20 L. Santhanam, "How this Medicaid extension throws postpartum gov/reports/extending-medicaid-postpartum-coverage-2023-update. parents a lifeline," PBS News Hour (April 8, 2022), available at https:// 7 E. Hinton and J. Raphael, "10 Things to Know About Medicaid Managed www.pbs.org/newshour/health/the-lifesaving-potential-of-extending- Care" (Washington: Kaiser Family Foundation, March 1, 2023), available postpartum-medicaid. at https://www.kff.org/medicaid/issue-brief/10-things-to-know-about- 21 S. Trost et al., "Pregnancy-Related Deaths: Data from Maternal medicaid-managed-care/. Mortality Review Committees in 36 US States, 2017–2019," (Atlanta: 8 As of 2023, CDC supports maternal mortality review committees Centers for Disease Control and Prevention, September 2022), available in 44 states and two U.S. territories through funding from at https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/ the Enhancing Reviews and Surveillance to Eliminate Maternal data-mmrc.html#table3. Mortality (ERASE MM) program available at https://www.cdc.gov/ 22 E. Park and S. Corlette, "American Rescue Plan Act: Health Coverage reproductivehealth/maternal-mortality/erase-mm/index.html?CDC_AA_ Provisions Explained" (Washington: Georgetown Center for Children refVal=https%3A%2F%2Fwww.cdc.gov%2Ferasemm%2Findex.html. and Families, March 11, 2021), available at https://ccf.georgetown. For the purposes of this study, our results included all states that currently edu/2021/03/11/american-rescue-plan-act-health-coverage-provisions- operate a self-identified maternal mortality committee, not limited to explained/. those receiving funding from CDC. For more information see Review to Action available at https://reviewtoaction.org/tools/networking-map. 23 M. Clark, "Permanent Medicaid Postpartum Coverage Option, Maternal Health Infrastructure Investments in 2022 Year-End Omnibus Bill" 9 N. Schachar, "Idaho Drops Panel Investigating Pregnancy-Related (Washington: Georgetown Center for Children and Families, Say Ahh! Deaths as US Maternal Mortality Surges," KFF Health News, July 7, 2023, Health Policy Blog, January 4, 2023), available at https://ccf.georgetown. available at https://kffhealthnews.org/news/article/idaho-drops-panel- edu/2023/01/04/permanent-medicaid-postpartum-coverage-option- investigating-pregnancy-related-deaths-as-us-maternal-mortality-surges/. maternal-health-infrastructure-investments-in-2022-year-end-omnibus- 10 L. Fleszar et al., op. cit. bill/. 11 M. Gunja, E. Gumas, and R. Williams, "The U.S. Maternal Mortality 24 E. Park et al., "Consolidated Appropriations Act, 2023: Medicaid and Crisis Continues to Worsen: An International Comparison" (Washington: CHIP Provisions Explained" (Washington: Georgetown Center for Children The Commonwealth Fund, December 1, 2022), available at https:// and Families, January 5, 2023), available at https://ccf.georgetown. www.commonwealthfund.org/blog/2022/us-maternal-mortality-crisis- edu/2023/01/05/consolidated-appropriations-act-2023-medicaid-and- continues-worsen-international-comparison. chip-provisions-explained/. Government Accountability Office, "Maternal Health: Outcomes 12 25 "Medicaid Postpartum Coverage Extension Tracker," op. cit. Worsened and Disparities Persisted During the Pandemic" (Washington: 26 Wisconsin Department of Health Services, "Request to Extend Government Accountability Office, October 19, 2022), available at https:// Postpartum Coverage for Eligible Medicaid Members from 60 Days www.gao.gov/products/gao-23-105871. to 90 Days Under a Section 1115 Demonstration Waiver," (Madison: 13 D. Hoyert, op. cit. Department of Health Services, Division of Medicaid, June 3, 2022), available at https://www.medicaid.gov/sites/default/files/2022-06/wi- postpartum-coverage-pa.pdf. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 33 27 Centers for Medicare and Medicaid Services, "Increasing Access, 38 HHS Office of Inspector General, "High Rates of Prior Authorization Quality, and Equity in Postpartum Care in Medicaid and CHIP: A Toolkit Denials by Some Plans and Limited State Oversight Raise Concerns for State Medicaid and CHIP Agencies," (Baltimore: Centers for Medicare About Access to Care in Medicaid Managed Care," (Washington: and Medicaid Services, August 2023), available at https://www.medicaid. Department of Health and Human Services Office of Inspector General, gov/sites/default/files/2023-08/ppc-for-state-and-medicaid-toolkit.pdf. July 2023), available at https://oig.hhs.gov/oei/reports/OEI-09-19-00350. pdf. 28 A. Dwyer and E. W. Burak, "CMS Releases Postpartum Care Toolkit to Help States Address Access, Quality, and Equity of Care in Medicaid 39 In a study of how the rollout of mandatory Medicaid managed care in and CHIP," (Washington: Georgetown Center for Children and Families, Pennsylvania affected birth outcomes between 1994-2004, researchers September 8, 2023), available at https://ccf.georgetown.edu/2023/09/08/ found that implementation was associated with deterioration in birth cms-releases-postpartum-care-toolkit-to-help-states-address-access- outcomes, worse prenatal care, and an elevated risk of inappropriate quality-and-equity-of-care-in-medicaid-and-chip/. gestational weight gain. Cost savings were achieved by reducing use of some high-tech obstetrical services and limiting access to high-quality 29 "Births Financed by Medicaid," Kaiser Family Foundation, available hospital services, the researchers found. More information see J. Yan at https://www.kff.org/medicaid/state-indicator/births-financed-by- "The Impact of Medicaid Managed Care on Obstetrical Care and Birth medicaid/. Outcomes: A Case Study," Journal of Women's Health 29, no. 2 (February 30 T. Brooks et al., "Medicaid and CHIP Eligibility, Enrollment, and 2020): 167-176, available at https://www.liebertpub.com/doi/10.1089/ Renewal Policies as States Prepare for the Unwinding of the Pandemic- jwh.2019.7792. Another study of the same managed care rollout in Era Continuous Enrollment Provision" (Washington: Georgetown Center Pennsylvania found that pregnant women enrolled in managed care, for Children and Families and Kaiser Family Foundation, March 2023), particularly those in poorer health, have fewer preventable complications available at https://files.kff.org/attachment/REPORT-Medicaid-and- than those in the fee-for-service population, but they found no evidence CHIP-Eligibility-Enrollment-and-Renewal-Policies-as-States-Prepare-for- of cost savings by rolling out the program. For more information see the-Unwinding-of-the-Pandemic-Era-Continuous-Enrollment-Provision. T. Hu, S. Chou, and M. Deily, "Pregnancy Outcomes for Medicaid pdf#page=45. Patients in Mandatory Managed Care: The Pennsylvania HealthChoices Program," Southern Economic Association 82, no. 1 (July 2015): 100- 31 Pregnancy-related services are services "necessary for the health 121, available at https://www.jstor.org/stable/44114323. A Texas study of the pregnant women and fetus, or that have become necessary as comparing access and quality of care for Black and Hispanic mothers a result of the woman having been pregnant," including prenatal care, as their counties transitioned from fee-for-service to managed care delivery, postpartum care, and family planning services. Services for found that racial disparities between these groups widened after the other conditions that might complicate the pregnancy include those change. Researchers found that Black mothers in Medicaid managed for "diagnoses, illnesses, or medical conditions which might threaten care were less likely than Hispanic mothers to begin prenatal care in the the carrying of the fetus to full term or the safe delivery of the fetus." first month, have more than eight prenatal visits, and gain the minimum See M. Clark "Medicaid and CHIP Coverage for Pregnant Women: recommended amount of weight during pregnancy. For more information Federal Requirements, State Options" (Washington: Georgetown Center see I. Kuziemko, K. Meckel, M. Rossin-Slater, "Does Managed Care for Children and Families, November 2020), available at https://ccf. Widen Infant Health Disparities? Evidence from Texas Medicaid," georgetown.edu/wp-content/uploads/2020/11/Pregnancy-primary-v6.pdf. American Economic Journal: Economic Policy 10, no. 3 (August 2018): 32 M. Clark and E. Wright Burak, "Opportunities to Support Maternal 255-283, available at https://www.jstor.org/stable/26529043. and Child Health Through Medicaid's New Postpartum Coverage 40 K. Kennedy-Moulton et al., "Maternal and Infant Health Inequality: New Extension," (Washington: Georgetown Center for Children and Families, Evidence from Linked Administrative Data," (Cambridge: National Bureau July 15, 2022), available at https://ccf.georgetown.edu/2022/07/15/ of Economic Research, November 2022), available at https://www.nber. opportunities-to-support-maternal-and-child-health-through-medicaids- org/papers/w30693. new-postpartum-coverage-extension/. 41 B. Chappell, "Tori Bowie, an elite Olympic athlete, died of complications 33 E. Hinton and J. Raphael (March), op. cit. from childbirth," NPR (June 13, 2023), available at https://www.npr. 34 S. Rosenbaum et al., "The Road to Maternal Health Runs Through org/2023/06/13/1181971448/tori-bowie-an-elite-olympic-athlete-died-of- Medicaid Managed Care," (Washington: The Commonwealth Fund, May complications-from-childbirth. 22, 2023), available at https://www.commonwealthfund.org/blog/2023/ 42 E. Howell, et al. "Black-white differences in severe maternal morbidity road-maternal-health-runs-through-medicaid-managed-care. and site of care," American Journal of Obstetrics and Gynecology, 214, 35 "Medicaid MCO Enrollment by Plan and Parent Firm, March 2022," no. 1 (August 2016): 122.e1-7, available at https://pubmed.ncbi.nlm.nih. Kaiser Family Foundation, available at https://www.kff.org/medicaid/ gov/26283457/. state-indicator/medicaid-mco-enrollment-by-plan-and-parent-firm- 43 L. Fleszar et al., op. cit. march-2021/?currentTimeframe=0&sortModel=%7B%22colId%22:%22S tate%22,%22sort%22:%22asc%22%7D. 44 K. Knocke et al., op. cit. 36 E. Hinton and J. Raphael, "A Closer Look at the Five Largest Publicly 45 Illinois Department of Public Health, "Illinois Maternal Morbidity and Traded Companies Operating Medicaid Managed Care Plans," Mortality Report 2016-2017" (Springfield: Illinois Department of Public (Washington: Kaiser Family Foundation, July 6, 2023), available at https:// Health, April 2021), available at https://dph.illinois.gov/content/dam/soi/ www.kff.org/medicaid/issue-brief/a-closer-look-at-the-five-largest- en/web/idph/files/maternalmorbiditymortalityreport0421.pdf. publicly-traded-companies-operating-medicaid-managed-care-plans/. 46 L. Zephyrin, "Changing the Narrative and Accelerating Action to 37 A. Schneider and A. Corcoran, "Standards for Provider Network Reduce Racial Inequities in Maternal Mortality," American Journal of Adequacy in Medicaid and the Marketplaces," (Washington: Georgetown Public Health 111, no. 9 (September 2021): 1575-1577, available at Center for Children and Families, May 16, 2022), available at https://ccf. https://pubmed.ncbi.nlm.nih.gov/34436918/. georgetown.edu/2022/05/16/standards-for-provider-network-adequacy- S. Trost et al., "Pregnancy-Related Deaths: Data from Maternal 47 in-medicaid-and-the-marketplaces/. Mortality Review Committees in 36 US States, 2017–2019," op. cit. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 34 48 March of Dimes, "Nowhere to Go: Maternity Care Deserts Across the 1%20Maternal%20Mortality.pdf#page=25; Tennessee Department of U.S. (2022 Report)," available at https://www.marchofdimes.org/maternity- Health, "2021 Tennessee Maternal Mortality Annual Report,"(Nashville: care-deserts-report. Tennessee Department of Health, 2021), available at https://www.tn.gov/ content/dam/tn/health/program-areas/maternal-mortality/MMR_Annual_ 49 D. Davies, "How poverty and racism 'weather' the body, accelerating Report_2021.pdf#page=8; B.S. Stein et al., "Washington State Maternal aging and disease" NPR (March 28, 2023), available at https://www.npr. Mortality Review Panel: Maternal Deaths 2017–2020," (Olympia: Office org/sections/health-shots/2023/03/28/1166404485/weathering-arline- of Family and Community Health Improvement, April 2023), available at geronimus-poverty-racism-stress-health. https://doh.wa.gov/sites/default/files/2023-02/141-070-MaternalMortality 50 "Four in 5 pregnancy-related deaths in the U.S. are preventable," ReviewPanelReport-2023.pdf?uid=640f86122eb78#page=99. Centers for Disease Control and Prevention Press Release (September 57 "Maternal deaths and mortality rates by state, 2018-2021," Centers 19, 2022), available at https://www.cdc.gov/media/releases/2022/p0919- for Disease Control and Prevention National Center for Health Statistics, pregnancy-related-deaths.html. available at https://www.cdc.gov/nchs/maternal-mortality/mmr-2018- 51 "Enhancing Reviews and Surveillance to Eliminate Maternal Mortality 2021-state-data.pdf. (ERASE MM)," Centers for Disease Control and Prevention, https://www. 58 "Medicaid Managed Care Penetration Rates by Eligibility Group," Kaiser cdc.gov/reproductivehealth/maternal-mortality/erase-mm/index.html. Family Foundation, available at https://www.kff.org/medicaid/state- 52 "Maternal Mortality Review Information Application – MMRIA," Review indicator/managed-care-penetration-rates-by-eligibility-group. to Action, https://reviewtoaction.org/tools/mmria. 59 "Medicaid and CHIP Income Eligibility Limits for Pregnant Women as a 53 "Enhancing Reviews and Surveillance to Eliminate Maternal Mortality Percent of the Federal Poverty Level, as of January 1, 2023," Kaiser Family (ERASE MM)," op. cit. Foundation, available at https://www.kff.org/health-reform/state-indicator/ medicaid-and-chip-income-eligibility-limits-for-pregnant-women-as-a- 54 "Maternal Mortality Review Committee Facilitation Guide," (Centers for percent-of-the-federal-poverty-level/. Disease Control and Prevention and Review to Action, 2021), available at https://www.reviewtoaction.org/national-resource/maternal-mortality- 60 "Births Financed by Medicaid," op. cit. review-committee-facilitation-guide. 61 42 C.F.R. § 438.602(g) (2023). 55 "Enhancing Reviews and Surveillance to Eliminate Maternal Mortality 62 S. Rosenbaum et. al., op. cit. (ERASE MM)," op. cit. 63 42 C.F.R. § 438.364(a)(3) (2023). 56 The following are examples of postpartum coverage extension recommendations from states: Illinois Department of Public Health 64 42 C.F.R. § 438.364(c)(2)(ii) (2023). "Maternal Mortality in Illinois," (Springfield: Illinois Department of Public 65 See New Jersey EQRO ATR 2022, available at https://www.state.nj.us/ Health, April 2021), available at https://dph.illinois.gov/content/dam/soi/en/ humanservices/dmahs/news/2022_Core_Medicaid-MLTSS_Annual_ web/idph/files/maternal-mortality-in-illinois.pdf; Kansas Maternal Mortality Technical_Report.pdf. For the 12 states in our scan, the average number Review Committee, "Kansas Maternal Mortality Report 2016-2018," of pages in an EQRO ATR was 308. Only two states' ATRs were under 100 (Topeka: Kansas Department of Health and Environment, December 2020), pages in length, while there were two states with ATRs over 650 pages available at https://kmmrc.org/wp-content/uploads/2022/07/KS-Maternal- long. Morbidity-Mortality-Report_Dec-2020_FINAL.pdf#page=38; Kentucky Cabinet for Health and Family Services, "Public Health Maternal Mortality 66 Medicaid and CHIP Access and Payment Commission (MACPAC), Review – Annual Report 2021" (Lexington: Kentucky Department for Public "Managed Care External Quality Review Issue Brief" (Washington: Health, 2021), available at https://www.chfs.ky.gov/agencies/dph/dmch/ MACPAC, July 2023), available at https://www.macpac.gov/wp-content/ Documents/MMRAnnualReport.pdf#page=4; Michigan Maternal Mortality uploads/2023/07/Managed-Care-External-Quality-Review-Issue-Brief.pdf. Review Committee, "Michigan Maternal Mortality Surveillance Program," 67 Georgetown Center for Children and Families, Comments on "Medicaid (Lansing: Michigan Maternal Mortality Review Committee, February 15, Program; Medicaid and Children's Health Insurance Program (CHIP) 2022), available at https://www.michigan.gov/mdhhs/-/media/Project/ Managed Care Access, Finance, and Quality; Proposed Rule - CMS- Websites/mdhhs/Folder4/Folder32/Folder3/Folder132/Folder2/Folder232/ 2439-P," Public Comment (June 30, 2023), available at https://ccf. Folder1/Folder332/Michigan_Maternal_Mortality_Surveillance_All_ georgetown.edu/wp-content/uploads/2023/07/CCF-Managed-Care- Committee_Recommendations_-External_FY21Q2.pdf?rev=c7e1249e Comment-FINAL.pdf. 7d15454cae23dc02f86cfd6d&hash=D144B63113174E2D33B9827E7 6F85FAC#page=4; Maternal Mortality Review Committee, "Mississippi 68 D. Machledt. "Medicaid External Quality Review: An Updated Overview," Maternal Mortality Report 2017-2019," (Jackson: Mississippi State (Washington: National Health Law Program, November 2020), available Department of Health, January 2023), available at https://msdh.ms.gov/ at https://healthlaw.org/resource/medicaid-external-quality-review-an- msdhsite/_static/resources/19612.pdf#page=21; Office of Analytics and updated-overview/. Maternal, Child, and Adolescent Health Section "Maternal Mortality and 69 A. Schneider, A. Corcoran, and E. Hurler, "Transparency in Medicaid Severe Maternal Morbidity Nevada, 2020-2021," (Carson City: Division of Managed Care for Children and Youth in Foster Care" (Washington: Public and Behavioral Health, December 2022), available at https://dpbh. Georgetown Center for Children and Families, October 12, 2021), available nv.gov/uploadedFiles/dpbhnvgov/content/Programs/MMRC/MMRC%20 at https://ccf.georgetown.edu/2021/10/12/transparency-in-medicaid- MM%20and%20SMM%20LCB%20Report%20December%2028%20 managed-care-for-children-and-youth-in-foster-care/. 2022%20FINALv2(2).pdf#page=45; A.K. Nantwi, R.N. Kraus, and C.B. Slutzky, "New Jersey Maternal Mortality Report 2016-2018," (Trenton: 70 H. Klukoff, M. Lehan, and A. Schneider, "Medicaid Managed New Jersey Department of Health, 2022), available at https://www.nj.gov/ Care Financial Results for 2022: Another Big Year for the Big Five," health/fhs/maternalchild/documents/New%20Jersey%20Maternal%20 (Washington: Georgetown University Center for Children and Families, Mortality%20Report%202016-2018.pdf#page=52; New Mexico SayAhh! Health Policy Blog, February 22, 2023), available at https://ccf. Department of Health, "New Mexico Maternal Mortality Review Committee georgetown.edu/2023/02/22/medicaid-managed-care-financial-results- Annual Report," (Santa Fe: New Mexico Department of Health), available for-2022-another-big-year-for-the-big-five/. at https://www.nmlegis.gov/handouts/LHHS%20103122%20Item%20 October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 35 71 "Managed Care State Profiles and State Program Features" (Centers 87 M. Clark and E. Wright Burak, op. cit. for Medicaid and CHIP Services) do not include any of the information for 88 "We Can't Change What We Don't Measure!" My Care Counts, available which we looked. The most recent data (July 1, 2021), available at https:// at https://whymycarecounts.org/quality-data/. 89 We excluded Well-Child www.medicaid.gov/medicaid/managed-care/profiles-program-features/ Visits in the First 30 Months of Life because it did not relate directly to the index.html. health of the mother, and we excluded Contraceptive Care All Women 72 For datasets pertaining to enrollment see "State Medicaid and CHIP Ages 15 to 20 and Contraceptive Care All Women Ages 21 to 44 because Applications, Eligibility Determinations, and Enrollment Data" (Data. they are not specific to pregnant women. Medicaid.Gov, Centers for Medicaid and CHIP Services), available at 90 Mississippi reports statewide average performance on Timeliness of https://data.medicaid.gov/datasets?theme%5B0%5D=Enrollment. Prenatal Care and Postpartum Care in the "Mississippi External Quality 73 "Quality of Maternal and Perinatal Health Care in Medicaid and CHIP: Review Annual Comprehensive Technical Report For Contract Year 2021 – Findings from the 2020 Maternity Core Set" (Baltimore: Medicaid & CHIP 2022," available at https://medicaid.ms.gov/wp-content/uploads/2022/04/ Health Care Quality Measures – Chart Pack, November 2021), available MSEQR_MS-Annual-Comprehensive-Technical-Report-2021-2022.pdf, at https://www.medicaid.gov/sites/default/files/2021-11/2021-maternity- the values are not in line with what is reported for individual plans or what chart-pack.pdf. the state reported to CMS (i.e., "Maternity Core Set Chart Pack," op. cit.). 74 "Cross-Cutting Initiative: CMS Maternity Care Action Plan," Center for 91 "HEDIS Measures and Technical Resources," National Committee for Medicare and Medicaid Services (December 2022), available at https:// Quality Assurance, available at https://www.ncqa.org/hedis/measures/. www.cms.gov/files/document/cms-maternity-care-action-plan.pdf. 92 "EQR Table 5. Performance Improvement Projects (PIPs) Included in 75 42 C.F.R. § 438.66(e)(2) (2023). External Quality Review (EQR) Technical Reports, 2021–2022 Reporting Cycle, By State and Child and Adult Core Set Domain," available at 76 "Medicaid and CHIP Managed Care Reporting," Centers for Medicare https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed- and Medicaid Services, available at https://www.medicaid.gov/medicaid/ care/quality-of-care-external-quality-review/index.html. managed-care/guidance/medicaid-and-chip-managed-care-reporting/ index.html. 93 42 C.F.R. § 438.330(d) (2023). 77 "Medicaid and CHIP Managed Care Monitoring and Oversight Tools," 94 Centers for Medicare and Medicaid Services, "CMS External Quality Centers for Medicaid and CHIP Services, Informational Bulletin (June 28, Review (EQR) Protocols," (Baltimore: Centers for Medicare and Medicaid 2021), available at https://www.medicaid.gov/federal-policy-guidance/ Services, February 2023), available at https://www.medicaid.gov/ downloads/cib06282021.pdf. medicaid/quality-of-care/downloads/2023-eqr-protocols.pdf. 78 42 C.F.R. § 438.66(e)(3) (2023). 95 Health Services Advisory Group, Inc., "State Fiscal Year 2021 External Quality Review Technical Report for Medicaid Health Plans" (Detroit: 79 "Managed Care Program Annual Report (MCPAR) for Mississippi: Michigan Department of Health and Human Services, March 2022), see Mississippi Coordinated Access Network (MSCAN)," (Jackson: Mississippi Table 5-1 p. 237, available at https://www.michigan.gov/mdhhs/-/media/ Division of Medicaid, December 27, 2022) available at https://medicaid. Project/Websites/mdhhs/Assistance-Programs/Medicaid-BPHASA/ ms.gov/wp-content/uploads/2022/12/Managed-Care-Program-Annual- MI2021_MHP_EQR-TR_Report_F1.pdf?rev=677c4dfa7a314ba59347688a Report-MCPAR-for-Mississippi_-Mississippi-Coordinated-Access- e62c9557&hash=B447E6EC753DB1D2A887CAF30A829F40#page=237. Network-MSCAN-Submitted.pdf. 96 Ibid. at p. 251. 80 "Medicaid Managed Care Program Annual Report (MCPAR) for Michigan: Michigan, Bureau of Specialty Behavioral Health Services," (Michigan 97 "Maternal Infant Health Program (MIHP)," Michigan Department of Department of Health and Human Services, March 29, 2023), available Health and Human Services, available at https://www.michigan.gov/mihp. at https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/ 98 As many as 25 states use Medicaid to fund home visiting programs to Keeping-Michigan-Healthy/BH-DD/Mental-Health/Stats-and-Reports/ support perinatal women and young children. Michigan uses a state- FY22_MCPAR_annual_report.pdf?rev=88898e7d4b3c40d1b78eb64eba1b developed model, but states can finance a variety of models through 4507&hash=1A15644C92D92BA9109D111A0701695B. Medicaid. For more information, see E. Wright Burak, "Medicaid Funding 81 "Managed Care Organization (MCO) Annual Performance Report for Home Visiting: Time to Scale What Works for Young Children and SFY2022," (State of Iowa Department of Health and Human Services, Families," (Washington: Georgetown Center for Children and Families, December 2022), available at https://hhs.iowa.gov/sites/default/files/ May 30, 2023), available at https://ccf.georgetown.edu/2023/05/30/ SFY22%20-%20Annual%20Report%20FINAL%20-%2011.30.2022.pdf. medicaid-funding-for-home-visiting-time-to-scale-what-works-for-young- children-and-families. 82 Centers for Medicaid and CHIP Services, Medicaid and CHIP Managed Care Monitoring and Oversight Tools, Information Bulletin (July 6, 2022), 99 "Illinois Maternal Morbidity and Mortality Report 2016-2017," op. cit. available at https://www.medicaid.gov/federal-policy-guidance/downloads/ 100 Ibid. at p. 59. cib07062022.pdf. 101 A. Corcoran et al., "Transparency in Medicaid Managed Care: Findings 83 42 C.F.R. § 437.15 at 88 FR 60314 (August 2023), op. cit. from a 13-State Scan," (Washington: Center for Children and Families, 84 "Maternal & Infant Health - Data and Measurement," Centers for September 2021), available at https://ccf.georgetown.edu/wp-content/ Medicare and Medicaid Services, available at https://www.medicaid.gov/ uploads/2021/09/MCO-13-state-scan-v3.pdf. medicaid/quality-of-care/quality-improvement-initiatives/maternal-infant- 102 A. Schneider, A Corcoran, and E. Hurler, "Transparency in Medicaid health-care-quality/data-and-measurement/index.html. Managed Care for Children and Youth in Foster Care," (Washington: 85 42 C.F.R. § 437.15 at 88 FR 60314 (August 31, 2023), available at https:// Center for Children and Families, October 2021), available at https://ccf. www.govinfo.gov/content/pkg/FR-2023-08-31/pdf/2023-18669.pdf. georgetown.edu/wp-content/uploads/2021/10/MCO-Foster-Care-v4.pdf. 86 "Adult Health Care Quality Measures," Centers for Medicare and 103 K. Knocke, et al., op. cit., see page 3. Medicaid Services, available at https://www.medicaid.gov/medicaid/ quality-of-care/performance-measurement/adult-and-child-health-care- quality-measures/adult-health-care-quality-measures/index.html. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 36 104 "Working Together to Reduce Black Maternal Mortality," (CDC, April 119 "Maternal Morbidity Structural Measure," Centers for Medicare & 2023), available at https://www.cdc.gov/healthequity/features/maternal- Medicaid Services, available at https://www.cms.gov/files/document/ mortality/index.html. maternal-morbidity-structural-measure-specifications.pdf. 105 E. Hinton and J. Raphael (July), op. cit. 120 "Find & compare providers near you," Medicare.Gov, Centers for Medicare and Medicaid Services, available at https://www.medicare.gov/ 106 "What is prenatal care and why is it important?" National Institute of care-compare/?providerType=Hospital. Child Health and Human Development, available at https://www.nichd.nih. gov/health/topics/pregnancy/conditioninfo/prenatal-care. 121 "FY 2023 Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospitals (LTCH PPS) Final Rule – CMS-1771-F 107 "Core Set of Children's Health Care Quality Measures for Medicaid Maternal Health," Centers for Medicare and Medicaid Services (August 1, and CHIP (Child Core Set): Technical Specifications and Resource 2022), available at https://www.cms.gov/newsroom/fact-sheets/fy-2023- Manual for Federal Fiscal Year 2023 Reporting," Centers for Medicaid hospital-inpatient-prospective-payment-system-ipps-and-long-term- and CHIP Services, available at https://www.medicaid.gov/sites/default/ care-hospitals-ltch-pps-1. files/2023-06/medicaid-and-chip-child-core-set-manual.pdf#page=118. 122 87 FR 48780 (August 10, 2022) at 49220-49233, op. cit. 108 "FAQ for Teens – Having a Baby," The American College of Obstetricians and Gynecologists, available at https://www.acog. 88 FR 58640 (August 28, 2023) at 59172, available at https://www. 123 org/womens-health/faqs/having-a-baby#:~:text=It%20includes%20 govinfo.gov/content/pkg/FR-2023-08-28/pdf/2023-16252.pdf. medical%20care%2C%20education,to%20set%20up%20an%20 124 Patel, S. and Zephrin, L., "Medicaid Managed Care Opportunities to appointment. Promote Equity in Primary Care," (New York: The Commonwealth Fund, 109 The American Academy of Pediatrics and the American College of December 19, 2022), available at https://www.commonwealthfund.org/ Obstetricians and Gynecologists, Guidelines for Prenatal Care, 8th ed. blog/2022/medicaid-managed-care-opportunities-promote-health-equity- (Washington: ACOG, 2017), available at https://www.acog.org/clinical- primary-care. information/physician-faqs/-/media/3a22e153b67446a6b31fb051e46918 125 M. Clark, "New Rule Lays Groundwork for Hospital Transparency and 7c.ashx#page=169. Accountability for Maternity Care," (Washington: Georgetown Center 110 A. Glover, "5 Reasons Why You Need a Postpartum Support Network," for Children and Families, August 12, 2022), available at https://ccf. (Washington: American College of Obstetricians and Gynecologists, georgetown.edu/2022/08/12/new-rule-lays-groundwork-for-hospital- October 2020), available at https://www.acog.org/womens-health/experts- transparency-and-accountability-for-maternity-care/. and-stories/the-latest/5-reasons-why-you-need-a-postpartum-support- 126 Centers for Medicare & Medicaid Services, "Health Plans Committed network. to Using the Birthing-Friendly Designation," available at https://www.cms. 111 Trost et al., op. cit. See Table 3. "Distribution of pregnancy-related gov/files/document/plans-using-birthing-friendly-designation.pdf. deaths by timing of death in relation to pregnancy, data from Maternal 127 42 C.F.R. § 438.330 (a)(2) (2023). Mortality Review Committees in 36 US states, 2017-2019." "Postpartum Depression Screening and Follow-up (PDS)," National 128 112 Quality of Maternal and Perinatal Health Care in Medicaid and CHIP, op. Committee for Quality Assurance, available at https://www.ncqa.org/ cit. hedis/measures/postpartum-depression-screening-and-follow-up/. 113 "Core Set of Adult Health Care Quality Measures for Medicaid (Adult 129 "2023 and 2024 Core Set of Behavioral Health Measures for Medicaid Core Set): Technical Specifications and Resource Manual for Federal and CHIP (Behavioral Health Core Set)" Centers for Medicare and Fiscal Year 2023 Reporting," available at https://www.medicaid.gov/sites/ Medicaid Services, available at https://www.medicaid.gov/sites/default/ default/files/2023-06/medicaid-adult-core-set-manual-jun2023.pdf. files/2023-03/2023-bh-core-set.pdf. 114 "Presidential Task Force on Redefining the Postpartum Visit," 130 L. Cuello, "Are You Leveraging Your Medical Care Advisory (Washington: American College of Obstetricians and Gynecologists, Committee?" (Washington: Georgetown Center for Children and Families, May 2018), available at https://www.acog.org/clinical/clinical-guidance/ January 4, 2023), available at https://ccf.georgetown.edu/2023/01/04/ committee-opinion/articles/2018/05/optimizing-postpartum-care. are-you-leveraging-your-medical-care-advisory-committee/. Federal 115 A. Schneider et al., "A Guide for Child Health Advocates: Medicaid regulations require that state Medicaid agencies support a Medical Care Managed Care Accountability Through Transparency," (Washington: Advisory Committee that includes a range of program stakeholders Georgetown Center for Children and Families, July 2021), available including beneficiaries. All of the study states except Tennessee support at https://ccf.georgetown.edu/2021/07/16/a-guide-for-child-health- an MCAC. We reviewed the agendas and minutes of the MCAC meetings advocates-medicaid-managed-care-accountability-through-transparency/. that took place in those 11 states during 2022 (commonly three or four times) to determine whether maternal mortality, maternal health, or MCO 116 S. Young, A. Miller, and R. Grapevine, "Centene Showers Politicians performance on maternal health were topics of discussion. None of these With Millions as It Courts Contracts and Settles Overbilling Allegations," MCAC meetings addressed these subjects directly, but some touched on KFF Health News (November 4, 2022), available at https://kffhealthnews. related issues. MCACs in Georgia, Illinois, Mississippi, and New Jersey org/news/article/centene-political-donations-medicaid-contracts- were briefed on 12-month postpartum coverage; the MCAC in Michigan overbilling-allegations/. discussed coverage of doulas; and the New Mexico MCAC received a 117 Soucie, J. et al., "How Health Plans Could Improve the Collection of presentation on obstetrical access (maternity care deserts). Race and Ethnicity Data," (New York: The Commonwealth Fund, April 3, 131 Georgetown Center for Children and Families, "A Guide for Health 2023), available at https://www.commonwealthfund.org/blog/2023/how- Care Advocates: Medicaid Managed Care Procurement" (Washington: health-plans-could-improve-collection-race-ethnicity-data. Georgetown Center for Children and Families: July 2022), available 118 87 FR 48780 (August 10, 2022) at 49282-49288, available at https:// at https://ccf.georgetown.edu/wp-content/uploads/2022/07/MCO- www.govinfo.gov/content/pkg/FR-2022-08-10/pdf/2022-16472.pdf. procurement-v4.pdf. October 2023 CCF.GEORGETOWN.EDU mcos and Maternal Health 37