Guidance on care coordination to support maternal health

Not later than 2 years after the date of enactment of this Act, the Secretary shall issue guidance for State Medicaid programs on improved care coordination, continuity of care, and clinical integration to support the needs of pregnant and postpartum women for services eligible for Medicaid payment. Such guidance shall identify best practices for care coordination for such women, both with respect to fee-for-service State Medicaid programs and State Medicaid programs that contract with Medicaid managed care organizations or other specified entities to furnish medical assistance for such women, and shall illustrate strategies for— (1) enhancing primary care and maternity care coordination with specialists, including cardiologists, specialists in gestational diabetes, dentists, lactation specialists, genetic counselors, and behavioral health providers; (2) integrating behavioral health providers to provide screening, assessment, treatment, and referral for behavioral health needs, including substance use disorders, maternal depression, anxiety, intimate partner violence, and other trauma; (3) integrating into care teams or coordinating with nonclinical professionals, including (if licensed or credentialed by a State or State-authorized organization) doulas, peer support specialists, and community health workers, and how these services provided by such professionals may be eligible for Federal financial participation under Medicaid; (4) screening pregnant and postpartum women for social needs and coordinating related services during the prenatal and postpartum periods to ensure social and physical supports are provided for such women during such periods and for their children; (5) supporting women who have had a stillbirth; (6) screening for maternal health, behavioral health, and social needs during well-child and pediatric care visits; and (7) streamlining and reducing duplication in care coordination efforts across and among providers, plans, and other entities for such women.