Maternal Depression Screening

Maternal Depression Screening

Children with depressed mothers have increased risk of developmental concerns or delays such as behavior problems and poor cognitive outcomes. Despite evidence that maternal depression is common and can negatively affect the development of young children, it is often undiagnosed and untreated. Since the rate of depression is disproportionately higher among low-income women, Medicaid can play a leading role in identifying at-risk mothers and connecting them to treatment. In 2016, CMS issued a bulletin clarifying that state Medicaid agencies may allow maternal depression screenings to be claimed as a service for the child as part of the EPSDT benefit. The American Academy of Pediatrics’ 4th edition of Bright Futures recommends maternal depression screening during the 1, 2, 4, and 6 month well-child visits. Below there is a map that highlights state Medicaid policies around maternal depression screening during well-child visits, including reimbursement.  A second map highlights recommended or required screening tools.

By Rebecca Cooper and Carrie Hanlon

Michigan Works to Improve Health Equity for Mothers and Infants

In her 2020 state of the state address, Michigan Gov. Gretchen Whitmer announced her budget proposal to extend health coverage for low-income mothers from 60 days to one full year following delivery, which can help new mothers heal and address any postpartum depression. She also proposed moving the first postpartum visit to within three weeks of delivery, and a comprehensive visit within four months. Previously, the Michigan Department of Health and Human Services created a plan to address maternal and infant health disparities rooted in racial inequity by aligning and leveraging maternal behavioral health resources, Medicaid, and child welfare and human services.

Infant health is indelibly connected to maternal health, and a state’s ability to identify maternal depression during well-child visits is an example of an effective two-generation approach that considers the health needs of a child within the context of a family unit. New research by the National Academy for State Health Policy (NASHP) finds that more states are working to improve maternal health through early identification of depression during well-child visits and connecting mothers to follow-up services.

Maternal depression during and after pregnancy is very common and can negatively affect the development of children, yet is often undiagnosed and untreated. Additionally, mental health conditions are a leading underlying cause of maternal mortality in pregnancy-related deaths. 

About one in nine women experience postpartum depression, and lower-income women have disproportionately higher rates of depression. Implementing Medicaid policies to identify postpartum depression as part of well-child visits is a way states are improving outcomes and advancing health equity. 

In 2016, the Centers for Medicare & Medicaid Services (CMS) issued a bulletin enabling state Medicaid agencies to cover maternal depression screening as part of well-child visits.  As of February 2020, 43 states* including Washington, DC – up from 37 in September 2018 – allow, recommend, or require maternal depression screening during well-child visits covered by Medicaid. Currently:

  • Twelve states allow screening for maternal depression during well-child visits;
  • Twenty-five states recommend screening for maternal depression during well-child visits;
  • Six states require screening for maternal depression during well-child visits; and
  • Eight states do not have an active maternal depression screening policy in place. 

The American Academy of Pediatrics’ (AAP) Bright Futures periodicity schedule, which many states adopted for their Early and Periodic Screening, Diagnostic and Treatment (EPSDT) programs, includes guidance for maternal depression screenings during well-child visits.

  • Twenty states follow Bright Futures for maternal depression screening periodicity during well-child visits;
  • Twenty-three states have guidance in addition to or in place of Bright Futures;
  • Three states have no guidance for frequency of screening;
  • Six states allow screenings as medically necessary; and
  • Twenty-five states explicitly limit screenings (ranging from one to six screenings a year).

Almost every state with a maternal depression screening policy recommends or requires scientifically validated and standardized tools. Sixteen states allow other caregivers besides mothers to be screened. Eleven states distinguish between positive and negative screens, with different reimbursement codes, modifiers, or requirements for reporting positive screenings. Thirty-two states report a protocol for tracking, referral and follow-up for positive screens. 

Ensuring women with an identified need receive treatment is a critical step in the system of care. Medicaid coverage typically ends 60 days postpartum for women who qualify for the program due to their pregnancy. This change in eligibility can make it difficult for providers to track women postpartum and for women to access follow-up treatment for postpartum depression. Several states have implemented policies to extend postpartum coverage, and others, such as Michigan, are also exploring this option to meet women’s health needs and improve maternal and infant outcomes.

Maternal depression screening during well-child visits is one strategy to identify at-risk mothers, but at least twenty-two states have additional strategies to identify and treat postpartum women at risk for depression, including through a State Health Improvement Plan, Title V programs , and other relevant state performance measures or mental health work groups. For more details, explore NASHP’s Maternal Depression Screening Resources

States continue to make progress in identifying maternal depression, and state-specific guidance makes it easier for standardized screening to occur during well-child visits and to ensure systems for necessary connections to treatment. As states focus on maternal depression, maternal mortality, and implications for child and family health, NASHP will continue to track state initiatives to ensure early identification and delivery of treatment. 

* The six states with a policy identified since 2018 are Louisiana, Missouri, Oklahoma, Oregon, Utah, and Wyoming.

State Medicaid Policies for Maternal Depression Screening During Well-Child Visits

Policy Trends

  • 43 states recommend, require, or allow maternal depression screening to be provided as part of a well-child visit.
  • The most commonly used CPT code is 96161 and reported fee-for-service reimbursement rates range from $1.78 to $30.
  • 11 states distinguish between positive and negative screens in claims data using specific codes or modifiers.
  • At least 4 states (Oregon, Pennsylvania, Rhode Island, and Wisconsin) have performance measures related to maternal or perinatal depression screening.

A detailed, downloadable chart of maternal depression screening by state is available here.

Legend:

Require (6 states) – Georgia, Maryland, Mississippi, New Mexico, Pennsylvania, Washington

Recommend (25 states) – Alabama, California, Delaware, District of Columbia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Massachusetts, Minnesota, Montana, North Carolina, North Dakota, Ohio, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, West Virginia, Wyoming

Allow (12 states) – Colorado, Connecticut, Louisiana, Maine, Michigan, Missouri, Oklahoma, Oregon, Nevada, New York, Virginia, Wisconsin

Learn more about how Virginia seeks to improve birth and maternal outcomes through behavioral risk screening (including maternal depression screening), case management services, and expanded prenatal services here.

State Medicaid Recommendations and Requirements for Maternal Depression Screening Tools

Policy Trends

  • 19 states require providers to use specific or standardized maternal depression screening tools.
  • 21 states recommend that providers use specific or standardized maternal depression screening tools.
  • States most commonly require or recommend the Edinburgh Postnatal Depression Scale (EPDS), Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PHQ), and the Beck Depression Inventory (BDI).
  • In 16 states a primary caregiver other than a mother can be screened for depression during a well-child visit.

States continue efforts to monitor referrals and maternal or caregiver health outcomes after a positive depression screening.

Legend:

Requires specific tools (19 states) – Alabama, California, Connecticut, Delaware, Idaho, Illinois, Indiana, Iowa, Maine, Massachusetts, Mississippi, Montana, New Mexico, North Carolina, North Dakota, Pennsylvania, South Dakota, Texas, Vermont

Recommends specific tools (21 states) – Colorado, District of Columbia, Georgia, Hawaii, Maryland, Michigan, Minnesota, Nevada, New York, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming

Does not require or recommend specific tools (3 states) – Kentucky, Louisiana, Missouri

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