Reshaping Postpartum Care In Medicaid To Improve Outcomes And Reduce Costs
By Brianna Van Stekelenburg, Emily Proehl, Rebecca G. Whitaker, Robert S. Saunders / July 31, 2025
Pregnancy complications can have a lasting impact on health and well-being and are increasingly linked to future chronic disease. A patient who develops gestational diabetes during pregnancy is seven times more likely to develop type 2 diabetes later in life. A patient with preeclampsia and gestational hypertension has an increased risk of recurrence in future pregnancies and is two times more likely to develop cardiovascular disease. These are just a few of the pregnancy-related complications that patients can develop.
The United States continues to face persistently high rates of maternal morbidity and mortality, with many of these deaths happening in the postpartum period, largely from preventable causes, including mental health and cardiovascular conditions. Medicaid plays a central role in maternal health, providing insurance for nearly half of births nationally, and pregnant women and children represent the largest proportion of beneficiaries. Pregnancy Medicaid benefits historically ended 60 days postpartum, resulting in significant coverage losses for parents who did not meet the income requirements for sustained Medicaid coverage under other benefit categories. Most states have now expanded Medicaid postpartum coverage to 12 months, enhancing coverage stability, increasing access to health care, creating opportunity for longitudinal care relationships, and improving long-term health outcomes for postpartum patients and families.
Leveraging the newly extended coverage period in Medicaid to provide whole-person postpartum care, a personalized approach that integrates physical, behavioral, dental, emotional, and social care for the mother-baby dyad during the entire postpartum period, allowing postpartum patients access to the comprehensive supports and care teams needed to address pregnancy-related health risks and complications and transition to primary care. By focusing on the intersecting impacts of whole-person and longitudinal care centered around prevention, there is an opportunity to improve outcomes and generate cost savings for states. One study found that providing preventative care for postpartum depression in a value-based payment (VBP) model resulted in approximately $734 in savings per person, improving even more when Medicaid insurance churn decreased. Given the Trump administration’s priorities and the Centers for Medicare and Medicaid Services’ (CMS’s) recently announced strategy around evidence-based prevention and cost savings, this Forefront piece will explore cost-effective opportunities that states can consider during the extended Medicaid postpartum coverage period to improve outcomes for pregnant patients and their families.
Opportunities To Improve Maternal Health Outcomes And Save Costs Through Whole-Person, Longitudinal Approaches
States need to ensure people have access to whole-person postpartum care to address health risks within 12 months post-birth, including physical, mental, and social well-being assessments to manage chronic health conditions (for example, hypertension, diabetes), common mental health care needs (for example, postpartum depression, postpartum anxiety), and other drivers of health (for example, access to food, housing, interpersonal safety). Medicaid has not historically built these whole-person services into benefit design due to the loss of coverage after 60 days. However, there are costs associated with leaving behavioral health and other drivers of health untreated. The societal cost of untreated perinatal mood disorders for 2017 pregnancies from conception to five years postpartum was estimated at $14 billion, with the average estimated cost of the mother-baby dyad at $31,800. These disorders are also estimated to contribute to $4.7 billion in productivity losses and $168 million in increased Medicaid and public assistance benefits spending.
Research indicates that postpartum patients are more likely to engage in whole-person care when they have access to coverage. In a Texas Medicaid health plan, use of preventative, contraceptive, and behavioral health services increased significantly following the 12-month coverage expansion. Similarly, in North Carolina Medicaid, the extension enabled beneficiaries to receive care for chronic or behavioral health needs beyond 60 days postpartum.
With the increased prevalence of chronic conditions among pregnant people, such as hypertension, diabetes, and cardiovascular disease, states should consider building longitudinal care models that provide continuous, coordinated care, tailored across different stages of life, into their whole-person postpartum care approaches. This would take the form of transitioning from obstetric-directed care to primary and specialty care management of preventive and chronic health needs, to address the complex health and caregiving challenges in the postpartum period. With postpartum Medicaid coverage now extended to 12 months, there is an opportunity to reshape care around these longitudinal, whole-person models that address the physical, behavioral, and social needs of pregnant patients and their families across care settings to improve short- and long-term health outcomes while reducing Medicaid costs.
We highlight several approaches to finance whole-person, longitudinal elements of the care delivery model to improve outcomes and save costs, including through VBP models, Section 1115 waivers, and state legislation.
Incentivize Longitudinal Care Models To Manage Chronic Disease, Behavioral Health, And Other Drivers Of Health
Longitudinal care can improve outcomes, but states face challenges designing models that ensure access to services, provide care coordination between obstetric and primary care, and integrate data to link the mother-baby dyad. For example, postpartum follow-up rates are low, with only half of patients successfully transitioning to primary care the year following a pregnancy complication, highlighting where there might be opportunity to improve outcomes such as default primary care scheduling and tailored messaging. VBP can be used to support longitudinal care models to strengthen care coordination efforts (especially for chronic condition management), improve maternal health outcomes, reduce costs, and build relationships to serve the long-term needs of pregnant patients and their families.
Some states have implemented pregnancy-focused alternative payment models (APMs) to enhance maternal health, although many of these bundled pregnancy models end at 60 days postpartum, significantly limiting the ability to facilitate longitudinal care, despite a state’s 12-month extension. Other states are designing novel models to build on existing pregnancy-focused APM infrastructure to enhance engagement of the mother-baby dyad in more whole-person, longitudinal care. For example, Ohio developed a multidisciplinary, health-systemwide dyad program funded by Ohio Medicaid’s Care Innovation and Community Improvement Program where the birthing patient and child are seen together by a primary care provider in a comprehensive patient visit until children turn three. Participating dyads also receive warm hand-offs to care coordination and follow up services. This program has the potential to increase access and improve use and outcomes.
States also have an opportunity to build on the cost savings and improved outcomes from home visiting programs in the postpartum period by expanding coverage of evidence-based services. Approximately half of state Medicaid agencies cover postpartum home visiting services, leaving a gap in care for individuals at high risk for severe maternal mortality. Medicaid VBP models such as Nest Health highlight a potential path toward family-centered, longitudinal care that addresses the physical, behavioral, and social needs of families as a unit through in-home visits. Nest Health uses the Louisiana Health Information Network’s admission, discharge, and transfer feeds to identify when eligible families and postpartum individuals are discharged from the hospital after birth. These feeds prompt Nest Health to schedule a pregnancy transition-of-care appointment to provide the postpartum individual and baby with care within seven days of discharge. Nest Health provides six to seven family visits during the first year of life addressing any physical, behavioral, and social needs. Nest Health’s unique approach of providing family-centered, longitudinal care has demonstrated significant savings and reductions in emergency department visits.
States can also leverage virtual modalities to complement in-person obstetric care. Pomelo Care launched a tech-enabled, dyadic care model that delivers 24/7 virtual preventative care, behavioral health screening and support, and primary care services through 12-months postpartum. This model has shown a 15 percent cost-of-care reduction across a Medicaid population. As states explore VBP models to provide cost-effective, longitudinal postpartum care, these programs provide examples of how the cost savings and improved outcomes of private-sector models could be applied to postpartum Medicaid beneficiaries.
Promote Prevention In Postpartum Care By Integrating Social Drivers Of Health
Addressing social needs during the postpartum period is crucial to effective preventative care, as unmet social needs have been linked to adverse maternal mental health and pediatric outcomes. Historically, many states have funded innovative social drivers of health (SDOH) approaches through 1115 waivers. CMS recently rescinded guidance from the Biden administration on the use of 1115 waivers to address SDOH and will now review applications on a case-by-case basis. States currently using 1115 waivers to address SDOH for pregnant and postpartum patients include:
North Carolina’s Healthy Opportunities Pilots (HOP) program, authorized through an 1115 waiver, has demonstrated improved social needs outcomes, $85 in cost savings per member per month, and fewer unnecessary emergency department and inpatient hospitalizations. North Carolina’s recently approved 1115 waiver renewal expands HOP statewide and extends access to these services to all pregnant and postpartum Medicaid beneficiaries for 12 months postpartum.
New York’s 1115 waiver, modeled after North Carolina’s HOP, aims to reform behavioral health care, SDOH, and primary care integration. Pregnant and postpartum people are considered a high-need population, eligible for nutrition and housing support, case management, and reimbursement for transportation to social needs services. The waiver also outlines Medicaid managed care contracting strategies to support primary care integration and coordinated behavioral health service delivery by connecting postpartum beneficiaries to continued care after their Medicaid eligibility concludes.
Arkansas’s 1115 waiver amendment creates maternal Life360 HOMEs for individuals with high-risk pregnancies, providing intensive care coordination within an evidence-based home visiting model to address SDOH and improve maternal health outcomes. Services can be received up to two years postpartum based on continued need, leveraging the state’s home visiting program infrastructure.
Address Postpartum Behavioral Health Needs Through An Integrated Care Approach
Pregnant individuals with chronic conditions coming into pregnancy, such as diabetes and hypertension, are vulnerable to increased risk of mental health diagnoses and complications during pregnancy. Mental health conditions are frequently cited as a cause of preventable pregnancy-related deaths, including deaths by suicide and substance use disorder (SUD)-related overdoses. Postpartum depression, a pregnancy-related mental health condition, can appear up to a year post-birth. Higher rates of perinatal depression screenings are associated with lower rates of postpartum depression symptoms, marking the importance of early preventative intervention. However, recent research indicates that maternal depression screening during well-child visits and pregnancy medical homes are among the least frequently covered evidence-based services. If left untreated, postpartum depression can have lasting impacts on the pregnant patient and infant’s health. To improve outcomes and address behavioral health needs for postpartum patients, states are testing innovative approaches via 1115 waivers, state plan amendments (SPAs), legislation, and Medicaid policy:
Texas’s Healthy Texas Women (HTW) Plus offers enhanced postpartum benefits through 12 months postpartum, targeting behavioral and physical health conditions that contribute to maternal morbidity and mortality. HTW Plus builds on its state-funded women’s health and family planning program for Medicaid beneficiaries and includes psychotherapy services, peer specialist support, SUD screening, intervention, referral, outpatient care, and medication-assisted treatment services.
California’s 1115 waiver and recent addendum expand upon its continuum of care for Medicaid beneficiaries with significant, high-risk behavioral health needs to offer prevention and early intervention, outpatient care, intensive inpatient care, peer and recovery services, inpatient residential treatment, crisis services, and community-based supports for one year postpartum.
While many states have pursued innovative care models through 1115 waiver authorities, with the changing policy and coverage landscape, states should also explore alternative funding mechanisms (for example, SPAs, 1332 waivers, and 1915(b) waivers) for expanded whole-person postpartum and preventative care. For instance, New York is using a 1332 waiver to reduce cost sharing for postpartum outpatient and mental health services in the Marketplace. This wraparound approach could reduce churn and encourage primary care continuity for individuals who lose Medicaid eligibility after 12 months. Similarly, South Carolina leveraged a Section 1915(b) home visiting program to fund nutrition support and intimate partner violence education for Medicaid-covered postpartum patients.
Support Expanded Perinatal Workforce In The Postpartum Period
All these approaches can be supported by an expanded perinatal workforce. Recent federal reports suggest that Medicaid managed care organizations are missing opportunities to cover all evidence-based postpartum care services, including contracting with community health workers and doulas to serve as trusted community members and create strong relationships with local care teams. Research shows that using doulas during labor, birth, and the postnatal period is associated with improved postpartum mental health. However, clinical and non-clinical perinatal workforce shortages impact access to postpartum care, necessitating innovative approaches to fill care gaps:
Pennsylvania allows state-certified doulas to serve as in-network maternal health supports and bill for services through the postpartum period.
California issued a standing recommendation for doula services, simplifying the process for connecting postpartum patients to community-based resources without the burden of additional referrals. Under this recommendation, Medicaid-covered doulas can provide support for labor and delivery, reproductive health, and postpartum via Medicaid managed care, ensuring more whole-person and accessible care.
Michigan prioritizes community-based partnerships to address SDOH in its Medicaid managed care procurement process.
Conclusion
States have an opportunity to create whole-person, longitudinal systems of care that address perinatal mental health, chronic disease, and social needs, as the percentage of pregnant patients experiencing these challenges increases. Preventive care starting in the first year postpartum is critical in addressing pregnancy-related chronic diseases that threaten long-term health and well-being. The 12-month postpartum extension in Medicaid has been an important step states have taken to improve the health of pregnant patients and their families. However, there is still work to do on implementation as many beneficiaries don’t know they have access, are incorrectly disenrolled, or live in a maternity care desert. The federal government can leverage existing guidance to encourage states and providers to promote the extended postpartum period, by educating patients and encouraging use of benefits, building on learnings from states such as Louisiana and Alabama, which issued guidance to inform Medicaid providers and beneficiaries about the extended postpartum coverage period. States are making some progress on promoting use of benefits, but further work is needed to ensure we create and invest in a whole-person, longitudinal care model that efficiently and effectively addresses the physical, behavioral, and social needs of pregnant patients and their families.