The Spectrum of State Approaches to Medicaid Maternity Care Contracting

Abstract

Policy Points.

• Maternal health is influenced by the quality and accessibility of care before, during, and after pregnancy.

• Nationwide, Medicaid covers nearly one in two births and uses managed care as a central means for carrying out these responsibilities. Thus, managed care plays a fundamental role in assuring timely, equitable, quality care and improving maternal health outcomes.

• A close review of managed care contracts makes evident that the absence of a national set of maternal health standards has caused challenges in setting expectations for managed care performance.

• State Medicaid agencies adopt a variety of approaches and underlying philosophies for contracting.

Context

Managed care is how Medicaid agencies principally furnish maternity care. For this reason, the contracts that Medicaid agencies enter into with managed care organizations have attracted strong interest as a means of improving maternal health access, quality, and equity. However, limited research has documented the extent to which states use these agreements to set binding expectations across the maternal health continuum and how states approach the task of maternal health contracting.

Methods

To explore maternal health contracting within Medicaid Managed Care, this study took a three‐phase, sequential approach: (1) an extensive literature review to identify clinical guidelines and expert recommendations regarding maternal health “best practices” for people with elevated health and social needs, (2) a review of the managed care contracts in use across 40 states and Washington, DC, to determine the extent to which they incorporate these best practices, and (3) interviews conducted with four state Medicaid agencies to better understand how states approach maternal health when developing their contracts.

Findings

The evidence on maternal health best practices reveals nearly 60 “best practices,” although the literature review also underscored the extent to which these recommendations are fragmented across numerous professional bodies and government agencies and are thus difficult for Medicaid agencies to ascertain. The contracts themselves reflect an approach to the maternal health continuum in a fragmented and incomplete way. Thematic analysis of interviews with state Medicaid agencies revealed three key approaches to contracting for maternity care: an “organic” approach, an “intentional” approach, and an approach “grounded” in state strategy.

Conclusions

The absence of comprehensive, integrated guidelines reflecting the full maternal health continuum likely complicates the contracting task and contributes to incomplete, ambiguous contracts. A major step would be the development of a “best practices tool” that helps state Medicaid agencies translate evidence into comprehensive, clear contracting expectations.

The united states is currently experiencing a maternal health crisis; high rates of maternal mortality, maternal morbidity, and infant mortality in the United States are only worsening, especially among families of color and low‐income families. ¹ , ² , ³ , ⁴ Between 2018 and 2021, maternal mortality rates steadily rose from 17.5 to 32.9 maternal deaths per 100,000 live births. ¹ During this time period, health disparities continued to widen; Black maternal death rates rose from 37.3 to 69.9—placing Black maternal deaths three times higher than White non‐Hispanic deaths. ¹ These health disparities are rooted in systemic racism, structural inequities, and a lack of access to high‐quality, equitable care. The problem of underserved communities with limited access to maternal health care professionals is also increasing, a phenomenon already underway with the closure of hospital maternity units and intensified by the impact of Dobbs v Jackson Women's Health Organization on the availability of obstetricians. ⁵ , ⁶ , ⁷ These developments have a disproportionate impact on access to care among low‐income individuals and people of color, further contributing to maternal health disparities. ⁷ , ⁸

Because of its size, reach, and unique ability to respond to major population health challenges, ⁹ , ¹⁰ Medicaid plays a central role in assuring the high‐quality and accessible care that is vital to maternal health. In 2022, Medicaid paid for nearly one in two births (Figure 1). ¹¹ Moreover, Medicaid is a major source of coverage for persons of color—providing coverage for 43% of American Indian/Alaska Natives, 39% of Black individuals, 34% of Hispanic individuals, and 18% of Asian Americans—and therefore plays an important role in addressing inequities in maternal health. ¹² Despite its coverage of a large proportion of births, it is worth noting that one in ten mothers still go uninsured because of low Medicaid income eligibility limits in certain states. ¹³ , ¹⁴

Figure 1.

Births Financed by Medicaid in 2022 [Colour figure can be viewed at wileyonlinelibrary.com]

Percentages in this map depend on state‐determined eligibility levels, as well as citizenship status, age, and income distribution of population giving birth in the state.

CDC, Centers for Disease Control and Prevention.

Medicaid has become a dominant force in providing maternal health services, which exist along a “continuum” that spans family planning, preconception care, prenatal care, birth/delivery care, and postpartum care, and is inclusive of behavioral health services, case management, wrap‐around social supports, and team‐based care. This is especially true because of the program's unique coverage design: Medicaid provides a comprehensive array of services, including preventive, primary, acute, and long‐term services and supports as well as protections against more than nominal cost sharing, including complete protection for cost sharing for pregnancy‐related care. Furthermore, to guard against coverage lapses during and after pregnancy, Congress in 2022 amended the Medicaid statute to authorize states to assure continuous coverage both throughout pregnancy and a 12‐month postpartum period, thereby intensifying the value of care. As of 2024, 45 states and Washington, DC, have adopted 12‐month continuous eligibility. ¹⁵ , ¹⁶ Finally, the Medicaid entitlement is not simply one of coverage; federal law entitles beneficiaries to access to care itself. ¹⁷

In 1997, Congress set the stage for a large‐scale movement by states to compulsory managed care enrollment as a condition of Medicaid coverage. Over nearly 30 years, managed care's growth has been enormous: as of 2021, nearly 75% of all beneficiaries were enrolled in managed care organizations (MCOs) offering comprehensive coverage and care. ¹⁸ Managed care contracting is a core activity on the part of most states, who have come to rely on the model as a basic element of program administration. The contracts on which managed care rests are singularly complex, reflecting the need to merge coverage and care into a single legal instrument that spells out contractual duties. As with the Medicaid population generally, managed care has become the central means by which pregnancy‐related care is covered and delivered. ¹⁸

MCOs operate much like private insurers, offering comprehensive care in exchange for a monthly fee covering all services in their contracts. State agencies can and do retain direct coverage responsibilities for various types of services covered under their state plans. However, the managed care norm is inclusion to ensure comprehensive care is furnished through a contractor's provider network and in accordance with quality and accessibility standards. One important task for states is to translate the applicable standard of care—as often expressed in clinical practice guidelines by professional organizations and recommendations by panels of experts—into contractual expectations for their MCOs in the delivery and payment of maternity care for Medicaid enrollees in the state. Federal managed care regulations leave broad discretion to states when contracting with MCOs; for this reason, the contracts states develop offer important insights into how state Medicaid agencies translate their obligation to provide care into legally enforceable duties.

Managed care contracting creates an inherent tension for states because—as with any complex contractual undertaking—a state must decide when to set specific standards that set clear expectations and are more amenable to enforcement and when to give contractors broad direction that sets general expectations but also creates considerable contractor latitude over care and coverage specifics. As complicated as this type of decision is, it grows more so when one considers the serious access challenges that Medicaid beneficiaries have historically faced. In the commercial insurance market, the tendency is toward contracts that spell out coverage with only limited emphasis on network accessibility; by contrast, Medicaid Managed Care (MMC) emphasizes access to a far greater degree. ¹⁹

There are increasing calls for states to use MMC contracts as a lever to improve maternal health and health equity. ²⁰ However, before this study, no baseline, comprehensive review of contractual expectations within Medicaid on the continuum of maternity care services existed. Little is currently known regarding how states approach maternal health contracting and what guides their contracting decision making across the continuum of maternal health from prepregnancy through postpartum. Limited research has documented the level of specificity and expectations that states include in their MMC contracts across the full continuum of maternal health. Few studies have examined the extent to which states address key managed care elements in their contracts, such as care coordination, case management, connection to social supports, availability of robust provider networks, quality improvement efforts, and performance metrics, which have been documented as key to addressing health inequities in the maternal population targeted by Medicaid. ²¹

The purpose of this study is to provide a baseline assessment of the status of managed care contracting by state Medicaid agencies, who are tasked with ensuring that their pregnant and postpartum enrollees have access to effective, high‐quality maternity services. To achieve this goal, this study specifically focuses on the extent to which MMC contracts clearly incorporate the full continuum of maternal health services and best practices, as identified through a comprehensive review of clinical practice guidelines and expert recommendations. Additionally, the study highlights the diversity of Medicaid agency approaches to contracting with MCOs for high‐quality maternity care services.

Methods

The US maternity care system and MMC contracting process are inherently complex. To adequately address the complexity of this issue, our research team took a three‐phase, sequential approach to this study.

First, the study team conducted an extensive, integrative literature review to identify the current clinical guidelines and expert recommendations for maternity care among MMC populations. To our knowledge, such a review has not been conducted within the past decade. The goal of this review was to understand the services, approaches, and standards that states might expect when purchasing high‐quality care from MCOs.

The literature review necessarily took an integrative approach, which differs from a systematic review in that it summarizes findings from a range of study designs and literature (i.e., primary research studies, along with other documents including clinical guidelines, discussion papers, opinions, and policy documents) to provide a more comprehensive understanding of a health care problem. ²² , ²³ , ²⁴ Moreover, an integrative review includes an evaluation phase, in which the literature identified as most relevant to the research question is included in the final results.

The literature review was undertaken by four researchers with decades of experience in maternal health, MMC, and health services research. ²⁵ , ²⁶ Using their deep experience, the study team first created a typology of maternal health domains to scan, including the continuum of maternal health from prepregnancy to postpartum, related services (e.g., mental health, substance use disorder [SUD], doula services, housing support, nutrition), and related key initiatives (e.g., perinatal quality collaboratives [PQCs]).

Using this typology, the study team conducted their extensive scan for relevant clinical guidelines and recommendations between May 2022 and August 2022. Researchers identified many relevant sources, including professional organizations (e.g., the American College of Obstetricians and Gynecologists [ACOG], American Medical Association, Association of Certified Nurse Midwives), relevant government agencies (e.g., the US Department of Health and Human Services, Centers for Medicare and Medicaid Services [CMS], and Health Resources and Services Administration [HRSA]), and relevant scientific advisory bodies (e.g., US Preventive Services Task Force). Across these sources, the researchers identified hundreds of recommendations and guidelines within the typology. On completion, the researchers entered the “evaluation” phase of the integrative literature review and flagged the most relevant and recent recommendations and guidelines for inclusion in the review. (Expert recommendations and clinical guidelines released within the last 10 years were prioritized.)

The evaluation phase of the literature review resulted in the identification of over 150 accompanying clinical guidelines and expert recommendations. These guidelines and recommendations were analyzed and sorted into 60 “best practices” for maternity care among Medicaid populations. The review also notes the current Medicaid coverage of each approach.

In phase 2, the study team conducted a contractual review to identify how extensively the maternal health “best practices” were integrated into state MMC contracts. In September 2022, standard MMC contracts (current as of that month) were pulled from state Medicaid websites for all 40 states and Washington, DC. “Standard” or “model” MMC contracts—which act as a template for all agreements the state enters into with MCOs—must be posted and kept current on state Medicaid websites.

Each contract was closely reviewed by at least two members of the research team using a “contract review instrument.” The review instrument included 35 domains of maternity care that were directly derived and consolidated from the 60 “best practices” identified in the integrative literature review. Contractual language was extracted into four tables that detail the following: (1) whether the contract addresses each care domain (yes/no), (2) the relevant and verbatim contractual language from the state documents, and (3) the name, year, and version of the contract reviewed. All four tables were analyzed to identify and quantify the number of states addressing each maternity care domain, the “strength” of language within each domain, and the key themes emerging across all state contracts.

In phase 3, interviews were conducted with four state Medicaid agencies to better understand the diversity of state approaches to maternity care contracting. States were carefully chosen to represent different geographical areas, varied maternal health outcomes, diversity of contracting (based on the findings from our contract review phase), differing Medicaid environment (i.e., Medicaid expansion. length of time using managed care), and state policies to address maternal health (i.e., state engaging in efforts to build the maternity workforce). ²⁷ Additionally, states were chosen if they met the criteria that >75% of Medicaid beneficiaries are enrolled in MMC. ¹⁸

Four states were selected to provide variation across the categories described above (Illinois, Kansas, Oregon, and Tennessee). Between February 2022 and April 2022, the study team recruited and interviewed state Medicaid agency representatives from each of these four states. Representatives spanned a range of administrator and clinical roles, and the number ranged from one to two participants per state. To guide these conversations, the team developed a standard interview guide tailored to each state's MMC contract. Each guide included relevant contractual language in its footnotes and was sent to interviewees at least 1 week in advance to allow state agencies to prepare their responses. Most states were interviewed over Zoom for 45–60 minutes, whereas one state preferred to send their responses over email. All individuals were assured that their identities would be kept confidential and that all findings would be reported out only in the aggregate, per the study protocol approved by The George Washington University Institutional Review Board.

The qualitative data were analyzed using thematic analysis, with the following protocol: all transcripts (and state email responses) were separately read by at least three researchers, and each researcher engaged in writing memos separately to identify themes. The three researchers convened to discuss themes and then delineated the top themes via consensus.

The findings from all three phases of this study were analyzed sequentially so as to inform each subsequent phase. Additionally, using a combined team of experts in health law and in maternal health, data from all three phases were analyzed in tandem at the conclusion of the study to identify key themes and policy recommendations.

Results

Literature Review Findings

The integrative literature review identified robust evidence to support nearly 60 maternal health “best practices” regarding coverage and performance obligations in MMC. However, in the process of culling the clinical guidelines and expert recommendations that promote these “best practices,” the study team confirmed that maternity care guidelines and recommendations are deeply fragmented across numerous professional organizations, government agencies, and advisory bodies. The 150 guidelines and recommendations that support these “best practices” were spread across over 20 of these organizations.

US maternity guidelines and recommendations are currently fragmented between numerous government agencies and professional bodies. Although the United States benefits from many existing clinical standards (e.g., those of the ACOG), the full continuum of maternity care includes numerous services, workforces, approaches, and quality metrics that are not currently captured in one set of guidelines. For example, although the “Guidelines for Perinatal Care” are published in an eighth edition, those guidelines are narrowly focused around the time of birth and mainly address hospital services. ²⁸ Moreover, they have not been translated to MMC.

This review underscored the lack of a comprehensive source for maternity care guidelines across the maternal health continuum, such as what exists in other areas of health care that require complex management. Moreover, this review revealed that maternity care recommendations and guidelines are not currently translated to MMC. Recommendations and guidelines do not provide tangible guidance to states or MCOs as to how to operationalize maternity guidelines in the unique environment of managed care. For example, clinical guidelines are not translated into a useful tool that can guide states, MCOs, and providers on the best approaches to assure a full care continuum, build comprehensive maternity team‐based care/networks, provide maternity case management, and robustly measure maternity care effectiveness.

Contract Review Findings

The study team's review of all standard MMC contracts (current as of September 2022) yielded four detailed tables of findings. The tables identify which states address 35 domains of maternity care and provide the relevant contractual language. The review found that states vary widely in how they use their contracts to address key aspects of maternal health. Among these wide variations, five key findings emerged. These key findings are summarized in Table 1 and are detailed further below.

Table 1.

Summary of Maternal Health Contractual Findings

	Finding 1: State Addresses the Full Continuum of Maternal Health Care			Finding 2: State Addresses Maternity Case Management and Risk Assessments		Finding 3: State Addresses Maternal Mental Health and SUD Needs		Finding 4: State Addresses Maternal Health Access to Care and Coverage of Key Providers				Finding 5: State Addresses Maternity‐Specific Payment Reform and Performance Measures
State	Full Continuum of Maternal Health Care Referenced a	Detailed Expectations for Preconception Care b	Detailed Expectations for Postpartum Care c	Detailed Expectations for Maternity Case Management and Care Coordination d , e	Expectations for Perinatal Risk Assessments f	Expectations for Maternity‐Related Mental Health Services g	Expectations for Maternity‐Related SUD Services h	Expectations for Maternity‐ Specific Access i	Expectations for Maternity‐Specific Transport j	Requires Coverage of Maternal–Fetal Medicine Specialists k	Requires Coverage of Doula Services l	Expectations for Maternity‐ Specific Payment Reform m	Expectations for Maternity‐Specific Performance Measures n , o , p
AZ	X	X	X		X	X r , s	X	X t	X			X	X
CA			X		X q
CO							X	X					X
DC						X r		X
DE				X				X t				X	X
FL			X	X				X			X	X	X
GA	X	X			X			X				X	X
HI			X	X		X r	X	X		X
IA							X	X
IL	X	X	X	X	X	X r , s	X	X		X			X
IN			X	X	X	X	X		X			X	X
KS					X		X	X t				X
KY										X		X	X o
LA	X	X	X	X e	X q		X	X t		X		X	X o
MA		X			X		X	X
MD			X	X	X	X	X	X			X
MI				X e	X				X				X o
MN				X e	X	X r , s		X	X		X	X	X
MO				X e	X		X	X t	X				X
MS				X e	X	X	X	X	X			X	X p
ND								X t
NE			X	X		X	X					X	X
NH				X	X		X	X	X	X		X	X
NJ						X		X t		X	X	X	X
NM				X e	X	X	X						X
NV				X e	X	X	X	X t			X	X
NY				X	X	X		X
OH						X						X	X
OR						X r	X				X	X
PA			X	X	X	X r , s	X	X t	X		X	X	X p
RI			X	X	X			X			X
SC				X
TN			X	X e	X	X	X						X
TX	X	X	X	X	X	X	X	X t
UT	X	X		X e	X	X		X					X
VA			X	X e	X	X r	X	X t			X	X	X p
WA						X r , s	X	X					X p
WI			X	X	X	X r		X t		X
WV			X		X			X
Total	6	7	16	24	25	22	22	29	8	7	9	18	23

CMS, Centers for Medicare and Medicaid Services; HEDIS, Healthcare Effectiveness Data and Information Set; MCO, managed care organization; SUD, substance use disorder.

Findings are summarized from detailed contractual tables (https://www.commonwealthfund.org/sites/default/files/2023‐05/Rosenbaum_Appendix%201_Tables.pdf). If states’ 2022 Medicaid Managed Care contracts included contractual language on a topic in the table, the state received an “X” for the topic.

^a The contract includes care specifications along the “full maternal health continuum of care,” including family planning, preconception care, prenatal care, birth/delivery, and postpartum care.

^b The contract provides expectations for preconception care.

^c The contract provides expectations for postpartum care.

^d The contract explicitly mentions maternity‐specific care management and/or care coordination.

^e States that have contracts that require MCOs to assess maternity patients’ “risk” levels to determine their level of case management and/or care coordination need.

^f The contract requires the MCO to conduct perinatal risk assessments.

^g The contract explicitly mentions maternity‐specific mental health services.

^h The contract explicitly mentions maternity‐specific SUD services.

ⁱ The contract contains any of the following requirements: perinatal‐specific travel time and distance requirements, perinatal‐specific appointment wait times requirements, telehealth rules for maternity visits, or special access rules/network composition requirements for perinatal persons with high medical or social risk.

^j The contract requires transportation services for maternity patients.

^k The contract includes network requirements or other practice‐related provisions for maternal–fetal medicine providers (i.e., requirements for in‐network inclusion or referral to these specialists without utilization management).

^l The contract includes network requirements or other practice‐related provisions for doulas.

^m The contract explicitly mentions maternity‐related payment reform approaches, including the following: bundled payments (e.g., what is included in bundle, what period of care is covered, who are providers), value‐based payments (e.g., linked to performance measures), or in lieu of and value‐added services (i.e., not covered in the contract).

ⁿ The contract explicitly names maternity‐specific performance measures that MCOs must report on. All states marked with an “X” require maternity‐specific performance measures from the CMS Core Set or HEDIS.

^o States that do not explicitly require maternity‐specific CMS or HEDIS measures but do require maternity‐specific performance measures from other stewards.

^p States that require maternity‐specific performance measures from the CMS Core Set or HEDIS plus maternity‐specific performance measures from other stewards.

^q States that have contracts that require risk assessments during the postpartum period.

^r States that describe the services required.

^s States that describe the services required during the postpartum period.

^t States that require tighter access time frames for individuals deemed “high risk.”

First, contracts often approach the maternity care continuum in a fragmented and incomplete way. Only six states’ contracts contain care specifications for the full continuum of maternal health care, including family planning, preconception care, prenatal care, birth/delivery care, and postpartum care (Arizona, Georgia, Illinois, Louisiana, Texas, and Utah). The absence of a clear reference to the full care continuum may reflect the fragmentation underlying the current US maternal health guidelines and the absence of a single, authoritative, integrated description of the scope of maternal health practice. Certain phases along the maternal health continuum—such as the prepregnancy and postpartum phase—are not referenced in most MMC contracts. For example, seven states use their contracts to describe prepregnancy services covered, and 16 states use their contracts to describe specific postpartum services covered.

Second, 24 states require maternal health case management or care coordination, ten of which require MCOs to assess maternity patients’ risk levels to determine their level of case management. Twenty‐five contracts require perinatal risk assessments by the MCO or a provider; however, most of these contracts do not require risk assessments throughout the full continuum of care. Only two states require risk assessment in the postpartum period (California and Louisiana).

Third, express reference to specific maternal mental health and SUD services within MMC contracts is limited. In all, 22 states describe services expected for mothers with SUD, such as screening, referral, and treatment. Although 22 states reference maternal mental health in their contracts, only ten states describe the services expected (such as perinatal depression screening, referral, or treatment) and only five specify these services during the postpartum period.

Fourth, 29 states include specific maternity care access expectations in their contracts. However, states vary in terms of the specificity of these expectations: 12 states set a rule that patients with new pregnancy should be able to access an initial prenatal visit within 10 days of request, whereas others specify visits within 14 days. Twelve states set tighter time frames for pregnancies designated as high risk, requiring that high‐risk mothers should be able to access an initial prenatal visit within 3 days. Several contracts provide more detailed requirements regarding transportation benefits to reach these visits: eight contracts specify maternity‐specific transport. States also differ regarding the network of maternity providers that they require MCOs to cover. All MCOs are required to include obstetrician gynecologists (OB‐GYNs) in network, and seven states explicitly require high‐risk obstetrician specialists (maternal–fetal medicine). Thirty‐five states reference coverage of midwives, and nine states include doulas. The number of states referencing doula coverage will likely increase as states continue to approve Medicaid reimbursement of doula care.

Last, over half of states set expectations for maternity performance measures or payment reform in their contracts. Twenty‐three states’ contracts explicitly name maternity‐specific performance measures that MCOs must adhere to. Twenty states require maternity performance measures from the CMS Maternity Core Set, ²⁹ including measures of “timeliness of prenatal care,” “timeliness of postpartum care,” and “receipt of contraception postpartum.” Seven states include additional measures that are not in the CMS Maternity Core Set, including “initiation of injectable progesterone for preterm birth prevention,” “dental visits among pregnant women,” “prenatal complications,” “low birthweight births,” “receipt of home visiting,” and “prenatal or postpartum depression screening.” Eighteen states require maternity payment reforms, such incentive payments or payment withholding based on maternity performance. (Each state's specific performance measures and maternity payment reform language can be found in the footnotes of the detailed contractual tables, found in the Supplemental Materials)

State Medicaid Agency Interview Findings

Key informant interviews with the state Medicaid agencies in Illinois, Kansas, Oregon, and Tennessee yielded deeper understanding as to what guides states’ decision making in maternity care contracting. Specifically, these conversations illuminated state considerations, approaches, and challenges when contracting for maternity services. Although these states have distinct histories with MMC, each has also had long‐term challenges in improving maternal health and reducing disparities in birth outcomes.

All state officials interviewed acknowledged the importance of ensuring high‐quality maternity care for Medicaid beneficiaries, especially in the context of worsening outcomes and disparities among families of color and low‐income families. Officials in all four states reported regularly joining maternal health advisory councils, coalitions, working groups, or maternal mortality review boards; several states report using these opportunities to understand what's occurring “on the ground” and to inform their managed care approaches.

However, states perceive challenges in translating the work conducted in these councils and working groups into MMC, including enforcing the latest maternity practice guidelines and recommendations. State officials shared that guidelines “get lost” amid maternity guidance fractured among numerous professional organizations, government agencies, and advisory bodies. Moreover, states struggle to identify the best mechanisms to ensure that MCOs and managed care networks implement new clinical guidance, such as the 2021 ACOG guidelines recommending that all postpartum persons receive a 3‐week touchpoint with their provider. ³⁰

Extensive conversation explored the rationale for including specific maternity care stipulations in MMC contracts. Thematic analysis identified three state approaches to including and modifying specific maternity care contractual language: (1) an “organic” approach, (2) an “intentional” approach, and (3) a “grounded” approach.

The first approach, as described by a Medicaid agency representative, is one in which “initiatives reached the level of contractual language ‘organically’ once they are considered essential to spread statewide.” In this approach, once the state Medicaid agency repeatedly hears about or observes a promising maternity care initiative implemented by health plans, health systems, or neighboring states, the agency conducts an internal review and vetting process of the initiative. If approved, the state may then require the maternity care initiative for all Medicaid beneficiaries in the next contract amendment. Thus, greater contract specificity is tied to what state officials hear emerging rather than a tool that can systematically improve knowledge about what works.

An “intentional” approach emerges when an agency is deliberately trying to shift toward a more complete and clear approach to maternal health contractual expectations. States may move toward greater clarity if they receive evidence of specific problems rather than preemptively adopting evidence‐based specifications calibrated to generate better results. One Medicaid agency representative noted the increasing importance of agency efforts to “get in the weeds, or we won't see the results we want.” A state using this approach may require the use of specific evidence‐based public health interventions known to improve maternal health outcomes. However, in the absence of clear and complete guidance, states are left without specifics regarding expectations and their operationalization.

A final, “grounded” approach is one in which contracting is “led by state policy priorities,” such as the state's overarching quality improvement strategy or a governor's priority framework. In the former case, the contract language aims to “sync” to the state Medicaid agency's quality improvement strategy while incorporating a pay‐for‐performance plan and measures. In the latter case, changes that emphasize maternal care are more likely to come from sources external to the Medicaid agency, such as the state legislature, a state oversight body, or the governor's office.

In developing contractual language, all states identified an ongoing tension between (1) being prescriptive with their maternal health expectations in their contracts and (2) delegating maternal health care approaches to health plan discretion. States describe using a prescriptive approach to ensure the results they want, particularly to align with state policy priorities. States cited multiple reasons for providing plans with discretion, including that they view MCOs as the entities with the resources and expertise, want to allow plans to provide service variation by geography, and view being prescriptive as “diluting the risk model.” State officials reported that they acquire specific contractual language from a variety of sources—such as neighboring states’ contracts, language required by the state legislature, and/or recommended changes from maternity experts. (Several states described processes to solicit feedback from maternity experts and advocates during the annual contract amendment process.)

All four states also identified key areas of maternity care they have been rethinking in their MCO contracts, recognizing the need for maternity care improvement. For example, several state agencies are exploring expanding perinatal case management approaches from maternity patients who are “high risk” to all maternity patients. Most states are in conversations about coverage of doulas and community health workers, and several states view these supports as approaches to tackle implicit bias. In the context of extension of Medicaid benefits to 1‐year postpartum, several states are rethinking “how standard postpartum care should be defined.” Last, states recognize that the performance measures they include in their contracts are those that MCOs focus their time and resources on. As such, states are being strategic about the maternity measures they require.

Discussion and Implications

When analyzing the three pillars of this study together, it is clear that states use contracts to communicate expectations and priorities to their contractors. This main finding is in line with prior studies. ³¹ , ³² , ³³ What is also clear, however, is that state Medicaid agencies adopt a variety of approaches and have varied underlying philosophies that drive their contracting choices. More specifically, we identified three main state contracting approaches from the sample of states selected for the study: “organic,” “intentional,” and “grounded.”

Regardless of the approach espoused by a given state Medicaid agency in our sample, we found that states find maternity care contracting complicated. States struggle with the absence of robust guidance on which to base their choices, coupled with the challenge of balancing prescriptive language against deference to plan discretion. State interviewees agreed that being too prescriptive may run contrary to the risk model inherent to managed care. Yet, states also understand that relying solely on generalized outcomes and a “results” approach may leave too much to contractor discretion and can leave beneficiaries, providers, and agencies vulnerable to incomplete care. For example, greater specificity regarding maternal mental health and SUD within MMC contracts may be highly warranted given that behavioral health challenges are currently the leading cause of maternal mortality (via suicide and overdose). ³⁴

States also highlighted the lack of clear maternity guidelines, making it difficult to set clear expectations as a result. Our comprehensive review of the literature confirmed the existence of a multitude of clinical guidelines and expert recommendations produced by various professional societies on specific aspects of maternal health care. States confirmed that the absence of a national set of fully integrated guidelines—spanning all the services and disciplines involved in maternal health care and translated to MMC—made it difficult to articulate their expectations to MCOs.

In addition to the lack of uniform guidelines on maternity care, states expressed several other challenges in providing maternity care in managed care, which the Medicaid program alone cannot reasonably be expected to solve. These challenges include the following: enormous inequities in access to high‐quality care (particularly by race and ethnicity), which disproportionately affect maternal health outcomes; the lack of providers and capacity in the full continuum of maternity care sometimes necessitating a relaxation of standards; the need for numerous partnerships to address the drivers of access because not all of these drivers can be addressed through a managed care contract; and the tensions at play among health professions, such as among physicians, midwives, and doulas. Each of these challenges can have significant impacts on the provision of maternity care and may result in inequitable and subpar care on the basis of race, ethnicity, and rural/urban status.

In this context, there are numerous opportunities for states and MCOs to bring resources to bear to improve maternity care and improve maternal health equity. Contracting efforts can provide clear expectations for MCO provision of maternal health “best practices” such as community‐based approaches (i.e., doulas, community health workers, and midwives) and ready access to a range of essential workforces, such as maternal–fetal medicine and behavioral health specialists. By the definition of the individuals Medicaid serves, efforts to hold Medicaid MCOs to higher maternity care standards are also efforts to address disparities and inequities.

Although the sample of states in the qualitative study was small, from the vantage point of a qualitative research design, it met the goal of maximizing variation across a number of important factors and thus allowed us to place state approaches on a spectrum of general approaches to contracting. Although additional research would be needed to confirm that these approaches apply to a larger number of states, we believe we know enough to propose some key next steps at both the national and state level.

First, states and health plans currently lack access to fully integrated guidelines that reflect all of the evidence‐based and professionally recommended services and approaches involved in maternal health care. Thus, the nation needs a set of comprehensive maternal health care guidelines that span the full continuum of care that can support the provision of equitable care and more helpfully steer MMC performance in the right direction. Based on our comprehensive review of the literature, such guidelines should address the following at a minimum: prepregnancy care and family planning services, comprehensive prenatal care, birth services in and out of hospitals, postpartum visits and intensive follow‐up as needed, and care coordination and other support services. (The Alliance for Innovation on Maternal Health patient safety bundles are an example of guidelines that would be included in a comprehensive set of guidelines and reviewed with an equity lens. ³⁵ ) A tool that consolidates and translates these guidelines to MMC could function as a roadmap for states and plans—to assist states in articulating their expectations for high‐quality maternity care to MCOs, as well as to assist MCOs in articulating their expectations to their network providers. As states rethink and redesign maternity care around the extension of Medicaid coverage to 1‐year postpartum and the launch of the Transforming Maternal Health (TMaH) Model, states and MCOs would deeply benefit from these guidelines. ³⁶

Second, building on current efforts by the CMS that focus on improving the quality of maternity care (e.g., the Birthing Friendly Hospital Initiative), CMS and states should develop new, complementary initiatives to align maternal health guidelines and state contracting practices. These initiatives could include the creation of new Medicaid demonstrations and/or state learning networks to share innovative approaches that could be adapted and implemented across states. The CMS adopted a similar approach with Medicaid Section 1115 SUD waiver demonstrations, through which it tied its approval to a state adopting the treatment guidelines of the American Society of Addiction Medicine. Similarly, states have willingly participated in learning collaboratives in the past in which they are exposed to best practices and given concrete tips on how to adapt and implement them in their individual settings. ³⁷ , ³⁸ Such an approach could dovetail with the new CMS TMaH Model, which will support state Medicaid agencies to partner with MCOs and providers to increase access to maternity providers, improve the quality and safety of maternity care, and address mothers’ whole‐person needs. ³⁹

Finally, states can promote equity by—among other steps—creating a consultative process that can ensure robust provider, advocate, patient, and PQC input into annual contractual updates and the request for proposals process.

Limitations

There are several limitations to this study. First, model MMC contracts were the primary documents evaluated during the “contract review” phase of this study. (Note, any documents referenced within the contract were also reviewed, including the most recent external quality review documents.) These model contracts are the foremost vehicle that states use to legally hold MCOs to maternity care expectations. However, we acknowledge that there are other state policy documents and laws that outline state expectations for MCOs that may not have made it into standard contracts. Such documents (e.g., provider manuals, state law that supersedes health payer decisions) would not have been reviewed for this study.

Second, our case study states were carefully chosen to represent a diversity of geographies, maternal health outcomes, and Medicaid policies. However, despite using a highly purposive sample to provide broad representation, our findings cannot be generalized to all MMC states.

Last, our Medicaid agency interviews were primarily conducted with one to two representatives of each agency. In several cases, the individuals we spoke with had consulted upwards of 10–15 other individuals to answer the questions posed in the interview guide, which provided additional perspectives. However, all responses were ultimately filtered through the perspective of one to two individuals, which could have resulted in personal bias. Future studies should explore triangulation of the perspectives shared in this study.

Conclusion

This study is, to our knowledge, the first of its kind both in terms of its comprehensiveness and its approach. Our analysis of standard managed care contracts found dramatic variation across states in the expectations they have included in these contracts with their health plans. These expectations varied from minimal and vague to more numerous and precise. However, none rose to the level of explicitness and clarity necessary to clearly signal to plans the quality of care expected by states and the delivery system needed to make the full continuum of quality care a reality. Our combined findings from our literature review and key informant interviews shed light on some of the reasons why this is the case, including the prevalence of numerous, fragmented maternity guidelines, as well as different approaches or philosophies to contracting.

Our recommendations seek to encourage development of comprehensive guidelines at the national level, with actions and steps that are within the authority of the CMS and state Medicaid agencies to strengthen managed care so that pregnant and postpartum persons receive high‐quality equitable care at the right time and in the right place.

Conflict of Interest Disclosures

No disclosures were reported.