Providers and health systems are preparing to weigh in on the Center for Medicare and Medicaid Services' ideas for how to use Medicare to improve maternal health.
While Medicare covers fewer pregnant, birthing, and postpartum patients than other payers —including Medicaid — CMS has asked for feedback on whether the program's conditions of participation should be used to set a national standard for maternal health quality. The agency requested input on its ideas as part of the proposed fiscal 2025 Inpatient Prospective Payment System, and comments are due June 10. Industry leaders are hoping CMS opts to increase obstetric care pay and are urging the agency to balance quality improvement efforts and access.
Related: 3 strategies that are improving Black obstetric outcomes
Here’s what to know about how CMS is considering using Medicare participation requirements to improve maternal morbidity and mortality by adding baseline safety and quality standards for obstetrical services.
How are maternal care services covered by Medicare?
Of the 67 million people enrolled in Medicare, around 1 million women of childbearing age qualify for and receive Medicare coverage due to a long-term disability, according to data from KFF. Between 9,000 and 12,000 births are covered by Medicare each year.
Typically, Medicare Part A and Part B cover inpatient and outpatient pregnancy-related services from the start of the pregnancy to six weeks after the delivery date, including prenatal visits, labor and delivery services, postpartum care and other medically necessary tests or treatments. The insurer does not cover childcare, support services or other non-medical expenses related to pregnancy and childbirth.
Nearly 52% of patients who gave birth in 2021 were covered by private insurance, 41% used Medicaid to pay for the delivery and 3% used other types of coverage like Medicare, according to data from KFF.
What maternal health issues is CMS trying to fix?
Racial disparities and an overall lack of access to quality maternal care are the main issues faced by pregnant patients.
In 2022, the overall maternal mortality rate was 22.3 deaths per 100,000 live births, according to data from the Centers for Disease Control and Prevention. Among Black women, the maternal mortality rate was 49.5 deaths per 100,000 live births, compared with 19 deaths among white women, 16.9 among Hispanic women and 13.2 among Asian women. Around 84% of these deaths were determined to be preventable, the CDC found.
Black women are also more likely to receive a cesarean section or experience infection compared with their white counterparts, according to the CDC.
Across the country, 36% of counties do not have obstetric providers, including a hospital or birth center offering obstetric care, according to a report released in 2023 from nonprofit organization March of Dimes.
What gaps in maternal care quality and pay is CMS aiming to fill?
CMS said it is aiming to set a higher standard for how maternal health services are delivered and reimbursed, possibly through the first federal quality and safety participation requirements for obstetrics care and increasing Medicare payment rates for pregnancy care.
Care disparities exacerbated by the COVID-19 pandemic pushed the Biden administration to double down on improvements to maternal health and birth outcomes. Last year, CMS launched a birthing-friendly hospital designation and a 10-year maternal health program with millions in funding to support state Medicaid agencies implementing a whole-person approach to pregnancy, childbirth, and postpartum care, as well as increasing access to midwives, birthing centers and doula services.
Payment for maternal health services is another concern. Because Medicaid tends to reimburse providers at a lower rate than other payers, obstetric units with a disproportionate amount of Medicaid-covered patients can struggle to stay open, and obstetricians and gynecologists may choose not to participate in the Medicaid program.
What changes is CMS considering for Medicare participation?
To reduce rates of maternal morbidity and mortality, CMS said it is thinking about requiring hospitals to provide obstetrical services in accordance with nationally recognized standards of care and evidence-based best practices.
As part of the proposed fiscal 2025 inpatient hospital pay rule, the agency asked providers and healthcare organizations for feedback on how an obstetrical services condition of participation could impact hospitals and access to care for pregnant, birthing and postpartum patients. Responses are expected to focus on regulatory changes tied to care quality, as well as whether CMS should require pregnancy care training for non-obstetrical staff.
New Medicare participation requirements could include mandates for hospitals to develop processes for pregnant patients at risk of hemorrhage or severe hypertension, or to maintain minimum obstetrical care supplies and supervision by an experienced certified nurse practitioner, physician assistant, certified nurse midwife or doctor.
CMS said it plans to recommend baseline health and safety standards for obstetrical services in the 2025 Outpatient Prospective Payment System proposed rule, based in part on public comments the agency it receives.
Why use Medicare to improve maternal healthcare?
The sheer number of Medicare beneficiaries and providers enrolled in the program makes its participation requirements one of CMS’ most powerful tools, said Michael Bagel, associate vice president for public policy at the Alliance of Community Health Plans.
By implementing obstetrics-based conditions of participation, CMS can pressure hospitals to provide a certain standard of care at the risk of otherwise losing their Medicare payments, he said.
CMS also has more direct influence on hospital operations through Medicare than Medicaid because Medicaid is partially controlled by individual state agencies, said Erin Alston, senior manager of health policy at the American College of Obstetricians and Gynecologists.
“Leveraging Conditions of Participation allows for consistency. Whether you're getting care in Alaska, Florida, Texas or Maine, you're still getting a high level of care and at the same standard,” Bagel said.
Hopefully state Medicaid agencies and other insurers will adopt similar participation requirements to hold health systems accountable on all payer fronts, he said.
What do industry leaders think CMS should do to improve maternal health?
Some providers, like Dr. Adam Lewkowitz, a member of the Division of Maternal-Fetal Medicine at Women and Infants Hospital in Providence, Rhode Island, want CMS to help restructure obstetric care reimbursement to better account for the services given to higher acuity maternal health patients. These patients often need more time with physicians and nurse educators and more antenatal testing, which aren’t usually covered by standard bundled payments for pregnancy care, he said.
Families USA, a nonprofit patient advocacy organization, wants CMS to require hospitals to provide patients with access to doulas, as they have been proven to help lower rates of C-sections and preterm births, said Ben Anderson, the group’s deputy senior director for health policy.
While CMS is moving in the right direction with initiatives like the birthing-friendly hospital designation, the agency needs a better way to ensure people are utilizing available resources and complying with best practices around safe maternal care, Alston said.
Does Medicare's maternal health services pay influence other insurers?
CMS asked how heavily other payers base their own obstetrics services reimbursement rates on Medicare's hospital inpatient pay system and whether Medicare pay has affected maternal health outcomes.
Even though the majority of pregnant patients are not Medicare beneficiaries, the payer still sets the benchmark when it comes to maternal care reimbursement and physician payment, Alston said .
“Medicaid agencies will typically take a percentage of Medicare reimbursement for a certain service, including the maternity global code,” Alston said. “Same for commercial payers — they’ll take the Medicare reimbursement rate and set their own fee schedule based on that.”
Increasing Medicare’s reimbursement of maternal care could have a downstream effect on other payer populations, causing other insurers to follow the precedent set and start paying more for pregnancy-related services, she said.
