Despite the health benefits of immunizing pregnant women against influenza and pertussis (whooping cough) and protecting them and their infants from these life-threatening diseases, only half of pregnant women are vaccinated against both diseases and only one-third receive both the influenza and pertussis vaccines during pregnancy.
Three states are trying a number of innovative approaches to increase vaccination rates among pregnant women by providing incentives to health plans, increasing access to vaccinations through pharmacies, and using data to identify and target populations, regions, and providers with substandard influenza and Tdap (which protects against pertussis) vaccination rates.
Evidence shows pregnant women are at increased risk of developing complications from certain preventable diseases and can also risk passing those diseases on to their children. Following immunization, data shows that both mothers and infants are less likely to be hospitalized from complications. When a woman is vaccinated during pregnancy, she develops antibodies that are transmitted to her child before birth, which can then protect the infant during the first few months after birth. The US Centers for Disease Control and Prevention (CDC) recommends that women who are pregnant or planning to become pregnant get the flu vaccine and the Tdap vaccine during each pregnancy.
Low Immunization Rates Persist
Despite the CDC’s guidelines, many women do not receive the influenza and pertussis vaccines during pregnancy. According to the CDC’s recent report, Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants — United States, published in Morbidity and Mortality Weekly Report (MMWR), current rates of maternal immunization for influenza and Tdap are 53.7 percent and 54.9 percent, respectively. Only one-third of pregnant women received both the influenza and Tdap vaccines, and the rates are even lower for African-American pregnant women. The report noted that provider recommendations to patients can improve maternal immunization rates – when providers offered vaccinations or provided a referral to pregnant women, 65.7 and 70.5 percent received the flu and Tdap vaccine, respectively. Based on this data, the CDC recommends that providers begin discussing vaccinations with pregnant patients early and continue the conversation during each visit.
Overall, women enrolled in public insurance programs were less likely to be vaccinated during pregnancy than women with private insurance, due in part to access barriers. State Medicaid agencies, which cover 43 percent of all births across the United States and up to 60 percent of births in some states, can use innovative approaches to identify pregnant women in need of vaccinations, gather data to identify strategies and targeted approaches, and encourage providers to increase vaccination rates to improve health and save on costs.
The 2019 MMWR data are especially notable in light of the Healthy People 2020 goal to increase the number of pregnant women vaccinated against influenza to 80 percent. While most states remain far from that goal, California, Colorado, and Wisconsin are working to improve maternal vaccination rates for both their Medicaid populations and privately insured women.
California’s Medi-Cal Strategies
In California, pregnant women covered by Medi-Cal, the state’s Medicaid plan, see providers who are less likely to stock or recommend the Tdap vaccine. Women on Medi-Cal receive prenatal Tdap immunizations at much lower rates than privately insured women, and infants born to mothers with Medi-Cal coverage are twice as likely to contract pertussis compared to privately insured infants. California is using a number of strategies to improve maternal immunization rates for women on Medi-Cal, including setting expectations for contracted health plans, monitoring and providing incentives, and addressing barriers at the clinician and patient level:
- Medi-Cal managed care contracts require health plans to ensure the timely provision of all Advisory Committee on Immunization Practices (ACIP)-recommended immunizations for members, and report data to the California Immunization Registry (CAIR). Medi-Cal managed care contracts also require that contracted health plans monitor their primary care provider sites for the provision of preventive services, including all ACIP-recommended immunizations for adults and children.
- California’s 2019-2020 budget includes funding for incentive payments in the managed care delivery system for timely prenatal care as well as for prenatal providers who administer the Tdap vaccine to pregnant members. Some of California’s Medi-Cal managed care health plans are also trying to lower the financial barriers to providing vaccines by allowing providers to directly bill the health plan outside of capitation rates, providing free Tdap starter doses to clinics, and encouraging group purchasing of vaccines.
- Medi-Cal encourages its health plans to follow up on potential quality of care issues when cases of pertussis in infants born to unvaccinated mothers are identified through public health department notification.
- California pharmacists are authorized to provide immunizations without a physician’s order. Most major chain pharmacies in California offer Tdap immunizations as part of their vaccine portfolio. All routinely recommended adult vaccines are covered by Medicaid without prior authorization (in both fee-for-service and managed care plans) when given in a provider’s office or in a pharmacy. Recent state regulations require pharmacists to notify providers of immunizations administered and to enter all doses into the California Immunization Registry, making it possible for providers to know whether vaccine referrals to pharmacies are successful.
Colorado and Wisconsin’s Use of Data
One of the challenges to improving maternal immunization rates is obtaining and monitoring data, especially as many states do not require providers to report immunizations to their Immunization Information Systems (IIS). Quality data, though, is needed by states working to tailor their strategies for improving immunization uptake to the areas of highest need and to monitor trends. Specifically, the Centers for Medicare & Medicaid Services identifies data linking of Medicaid eligibity and claims data with vital statistics data as a critical mechanism for surveillance, programmatic monitoring, and evaluation of maternal immunization.
- Colorado is using data matching to determine the rates of maternal immunization in each county. Colorado has successfully matched 96 percent of patient medical record numbers with Colorado Immunization Information System (CIIS) records. The CIIS data matching has allowed the state to map immunization rates by provider and region and identify gaps in maternal immunization uptake. Colorado is now using this data to determine the areas of highest need in the state to inform and guide outreach programs. Currently, Colorado is also piloting text and email reminders to encourage patients to get vaccinated.
- Wisconsin is also using data matching to obtain baseline immunization rates. Wisconsin matched 96 percent of women who gave birth in 2018, as recorded by the Vital Records Office, with data from the Wisconsin Immunization Registry. Like Colorado, Wisconsin used this data to create data maps to identify influenza and Tdap vaccination levels in each region of the state. Wisconsin was also able to track vaccination rates by age, race, type of insurance, and quality of prenatal care. Next steps for the state include monitoring these trends, identifying areas of highest need, and using the data to improve maternal immunization rates.
In addition to partnering with state public health departments and their immunization programs, state Medicaid agencies can partner with providers to ensure vaccines are stocked and to promote vaccine recommendations for pregnant women so they become routine. For example, the American College of Obstetricians and Gynecologists has released a number of resources designed to support health care providers in increasing maternal vaccination rates, including the Maternal Immunization Tool Kit, strategies for immunization implementation, and a guide to starting an office-based immunization program. The American Academy of Pediatrics also offers recommendations on cost-saving measures for the purchase and administration of immunizations. Finally, the CDC has compiled a toolkit for prenatal care providers that includes resources for provider and patient vaccination education.
In addition to these resources, other states can learn from the work California, Colorado, and Wisconsin have done to identify gaps and improve vaccination rates among pregnant women covered by state Medicaid programs.
The National Academy for State Health Policy (NASHP) would like to thank Abby Klemp at the Wisconsin Department of Health Services, Sarah Royce at the California Department of Public Health, and Karen Mark at the California Department of Health Care Services for their time and insight. NASHP would also like to thank the US Centers for Disease Control and Prevention for their assistance with this blog and for funding this project.
NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.
By Christina Cousart
Updated June 24, 2019
During the 2019 legislative session, states have continued to advance protections for consumers against surprise medical balance bills – charges for unexpected, out-of-network medical care. To date, four new states have enacted multi-pronged policies that prohibit balance bills, institute a process for providers and carriers to resolve billing disputes, and foster pricing transparency between providers, carriers, and consumers to avoid situations that lead to balance bills. Texas also approved legislation strengthening its existing consumer protections. Here are highlights of the new legislation.
|Colorado (HB 1174)||Nevada (AB 469)||New Mexico (SB 337)||Texas (SB 1264; HB 2041)||Washington (HB 1065)|
|Balance billing protections|
|Holds consumers harmless||✓||✓||✓||✓*||✓|
Prohibition in case of emergencies
Prohibition in case of out-of-network (OON) services delivered at an in-network facility
Applicable providers/ facilities
|Person who is licensed or otherwise authorized in the state to furnish health care services including:
● LaboratoryExcludes ambulance providers, but charges the insurance commissioner with setting payment methods for ambulance services.
|Physician or other health care practitioner who is licensed or otherwise authorized in this state to furnish any health care service; and institutions providing health care services including:
● Surgical centers for ambulatory patients
● Skilled nursing facilities
● Residential facilities for groups
● LaboratoriesEmergency facilities include hospitals or independent centers for emergency medical care
|Licensed health care professionals, hospitals, or other facilities licensed to furnish health care.Facilities include entities providing health care services including:
● Ambulatory surgical centers;
● Birth centers;
● Drug and alcohol treatment centers;
● Laboratory, diagnostic, and testing centers;
● Health provider’s offices or clinics
● Urgent care centers
● Freestanding emergency rooms
● Therapeutic health care settings
|Individual licensed under the laws of this state to practice medicine or health care facilities.Facilities include:
● Licensed ambulatory surgical centers
● Licensed chemical dependency treatment facility
● Renal dialysis facilities
● Birthing centers;
● Rural health clinics;
● Federally qualified health centers
● Freestanding imaging centers;
● Freestanding emergency medical care facilities*
|Person licensed under state law to practice health or health-related services, or an employee or agent of such a person acting in the scope of their employment.Facilities include:
● Rural health care facilities
● Psychiatric hospitals
● Nursing homes
● Community mental health center
● Kidney disease treatment centers
● Ambulatory diagnostic treatment or surgical facilities
● Drug and alcohol treatment facilities;
● Home health agencies.Carriers may not balance bill in the case of emergency services delivered by out-of-state providers.
|Billing dispute and resolution procedures|
|Reimbursement standard||For emergency services the greater of:
● In non-Denver areas:
o 105% of carrier’s median in-network rate for services provided at a similar facility in the same geographic area; or
o Median in-network rate for the same service at a similar facility in the same geographic area based on all-payer claims database (APCD) data.
● In the Denver area:
o Carrier’s median in-network rate for the same service in a similar facility in the same geographic area;
o 250% Medicare rate for the same service in a similar facility in the same geographic area; or
o Median in-network rate for the same service in a similar facility in the same geographic area based on APCD data.
For OON services at an in-network facility, the greater of:
● 108% of the previously contracted rate if the facility had been in-network within the last 12 months.● 115% of the previously contracted rate if the facility had been in-network within the last 12-24 months.● If no such contract existed, an amount the carrier determines to be fair and reasonable.For providers:If a provider had been in-network within the past 12 months:
● The previously contracted rate, if the provider terminated the contract before it was set to expire without cause;
● 108% of the previously contracted rate if the provider terminated the contract for cause;
● A fair and reasonable amount, determined by the carrier, if the carrier terminated the contract for cause;
● The previously contracted rate adjusted by the Consumer Price Index, Medical Care Component for the prior year, if neither party terminated the contract.If a provider had not been in-network in the preceding 12 months, carrier may remit whatever payment it determines.
|A 60th percentile of the allowed commercial reimbursement rate for the service performed by a provider in a similar specialty in the same geographic area.
Should not be less than 150% of 2017 Medicare rate.
A stakeholder group will convene annually to review the reimbursement rate.
|The usual and customary rate or an agreed-to rate, meaning the allowable amount as described by the applicable master benefit plan document or policy.*||Commercially reasonable amount based on similar services provided in a similar geographic area.|
|Process for arbitration||Baseball arbitration (arbiter will pick the final payment offer submitted by either the health plan or the provider/facility), if carrier and provider do not agree to initial payment.
Arbiter will consider:
|Arbiter will either require the provider to accept the payment issued by the carrier as payment in full, or to demand that the carrier remit an additional amount requested by the provider.||Mediation may be requested through the Department of Insurance.
In the case of mediation of facilities, the mediator shall determine if the amount charged by provider is excessive, and if the amount paid by the insurer is unreasonably low or not the usual and customary rate.
In the case of mediation for other providers, the mediator shall take into account whether there is gross disparity between the amount charged by the provider and how much the provider or similarly qualified providers receive for similar services. Other factors may include:*
|Baseball arbitration (arbiter will pick the final payment offer submitted by either the health plan or the provider/facility), if carrier and provider do not agree to initial payment.
Arbiter may consider:
|Data collection and reporting tools||State APCD||Benchmarking database maintained by a nonprofit organization specified by the insurance commissioner.
Enables the commissioner to require carriers to report:
|The insurance commissioner is charged with selecting an organization to maintain a benchmarking database.||Requires state APCD to establish a dataset that provider, facilities, and carrier s may use to determine reasonable rates and to resolve payment disputes.
Carriers shall provide information concerning the utilization of OON providers and cost savings yielded from the law as part of their annual rate filing.
|Provider must refund excess payments made by consumers
|Penalty for violations||✓||✓||✓*||✓|
|Must provide disclosure of potential repercussions of OON services
|● Providers||● Carriers
|Requires cost estimates to consumers
|Additional requirements:||On carriers:
● Must arrange for patient transfer within 24 hours of receiving notice that person is stable and can be transferred.On providers:
● Must send notice to carrier, no later than eight hours after person presents at an OON facility
● Must send notice to carrier that the beneficiary has stabilized and may be transferred to an in-network facility within 24 hours of stabilization
● Must make claims status information available to providers.On providers:
● Must post in a publicly accessible manner and online information about which carriers it contracts with.
● Must notify the carrier of a beneficiary’s admission within a reasonable period after stabilization.
● Any communication regarding bills, shall clearly state that the beneficiary is responsible only for in-network cost sharing amounts.
● Explanation of benefits must include information about balance billing protections; the total amount the provider may bill the enrollee under the enrollee’s health benefit plan; and an itemization of cost-sharing included in that total.* 
● Facilities must post notice that
o it may charge a facility fee
o it may charge rates comparable to a hospital emergency room
o the facility or a physician at the facility may be OON and bill separately
o Lists all the carriers it contracts with
● Facilities must provide patients with a disclosure that:*
o Lists the facility fees that may result from the visit
o Lists the carriers the facility is in-network with
o Lists other cost information such as median facility fees and observation fees.
● Prohibits facilities from using logos or language to misrepresent that it might be in an insurers network.
● Must immediately arrange for an alternate plan of treatment if an agreement on post-stabilization services cannot be reached with the emergency provider.
● Must update provider directory within 30 days after the addition or termination of a provider.On providers:
● The provider must contact the carrier within 30 minutes of stabilization before rendering further services.
● Must post online information about which carriers it contracts with.
● Must provide carriers with updated lists of non-employed providers working at the facility
*Indicates changes made by the new Texas law.
 Texas’ 2019 law amends and enhances already existing protections in the state. Changes made by the new law are noted by asterisk.
 Does not apply when: 1) Services are received at a critical access hospital; 2) A person is covered by insurance sold outside of the state; 3) Services provided more than 24 hours after notification has been provided and a person has been stabilized.
 In the case of a beneficiary who cannot reasonably access a preferred provider, the protections extend to 1) medical screening and examinations require to determine if a medical emergency exists; 2) necessary emergency services to treat and stabilize; 3) services originating in an emergency facility following stabilization; and 4) supplies related to the services rendered by that facility.
 Does not apply if the consumer affirmatively consented to receive OON services.
 Only applies when; 1) A participating provider is unavailable; 2) Medically necessary care is unavailable in the beneficiary’s network (determined by the provider in conjunction with the health plan); or 3) the patient did not consent to receive services from the OON provider.
 Does not apply in the case of a beneficiary that elects, in writing and in advance, to receive services from the out-of-network provider, or in the case that the provider does provide the enrollee with a written disclosure that they are out-of-network and provides an estimate of the projected amount the enrollee will be responsible for. Explicitly includes protections for OON services delivered by diagnostic imaging or labs.
 Prior law allowed mediation requests only in the case of claims over $500 and that were for either emergency services, or services rendered by a provider or supplier at an in-network facility.
 Refund must be issued within 60 days, or interest will accrue.
 Refund must be issued within 45 days, or interest will accrue.
 Refund must be issued within 30 days, or interest will accrue.
 Punished by a fine of not more than one thousand dollars, or by imprisonment in the county jail for not more than one year, or both.
 Insurance superintendent may impose a fine on any provider that offers an unlawful rebate or inducement to entice a person to seek OON services
 The Attorney General may bring civil action against entities that exhibit a pattern of repeatedly violating billing protections. Authorizes applicable agencies to take action against providers or facilities who violate billing protections. The Secretary of State may suspend or revoke a license, or bring civil action against entities who violate the disclosure requirements outlined under Texas law. The Department of Health may impose penalties up to $1,000 for certain violations.
 Authorizes the Department of Health or an appropriate authority to levy fines against providers or facilities who violate these policies. Commissioner may levy a fine against carriers who violate these policies. Repeated violation may constitute unprofessional conduct and risk licensure of a provider or facility.
 If an OON provider has advanced notice that the beneficiary is OON, they must notice the beneficiary of their OON status and recommend the beneficiary contact their carrier to discuss options.
 A provider must issue a cost estimate within three days if requested by a patient.
 Carrier must provide an estimate of out-of-pocket costs for OON services upon request.
 Applicable to Health Maintenance Organizations.
Colorado and Michigan have joined Oklahoma to become the nation’s pioneering states with approved State Plan Amendments (SPAs) that enable Medicaid alternative payment models (APMs) for prescription drugs in the form of outcome-based contracts with pharmaceutical manufacturers.
In early May, state experts from Oklahoma, Colorado, and Michigan shared their experiences implementing their APMs during a NASHP webinar. A recording of the webinar is available here.
The SPAs enable states to negotiate contracts based on agreed-upon outcome measures tailored for specific drugs. Outcomes measures vary but may include measures such as patient adherence or reduced hospitalizations. If the drug’s performance fails to meet agreed-upon outcomes and triggers the need for additional manufacturer payments to the state, those payments are made in the form of supplemental rebates. The contract template was developed with the support of the State Medicaid Alternative Reimbursement and Purchasing Test for High-cost Drugs (SMART-D).
Though these outcomes-based APMs are valuable tools for states to manage escalating drug costs, APMs are best understood as “one more tool in our toolbox,” which are most effective when used in tandem with other strategies rather than in isolation, explained Cathy Traugott, pharmacy office director of the Colorado Department of Health Care Policy and Financing. Though these APMs may help states manage payment for high-cost drugs, the high-list prices themselves remain a problem that states are also attempting to address head on. During this year’s state legislative session alone, 47 states have filed 254 drug-cost-related bills (as of May 22, 2019).
Executing and implementing outcome-based contracting can be a time-consuming endeavor for states because of the necessity for state officials to engage with multiple manufacturers in exploratory discussions to identify drug candidates, followed by the data analysis necessary to design, and then track the outcome-based measures.
Oklahoma, whose work NASHP supported through a subgrant from the Laura and John Arnold Foundation, found that the process took longer than anticipated. Terry Cothran, director of the University of Oklahoma’s College of Pharmacy, advised states that pursue outcomes-based contracting to consider dedicating a project coordinator to execute the work most effectively.
To date, these contracts are with state Medicaid agencies only, and have not included inter-agency efforts. Rita Subhedar, state assistant administrator for Michigan’s Department of Health and Human Services, stressed the importance of broad engagement within a Medicaid department to effectively implement these APMs, including pharmacy, medical, and behavioral health staff. A separate, subscription-based payment approach, known as the “Netflix” model, utilizes a cross-agency approach engaging both Medicaid and a state corrections department. This approach was explored in another NASHP webinar, How States Pay for Hep C Drugs Using a “Netflix-style” Subscription Model.
The first results from outcome-based contracting will come from Oklahoma, whose first, one-year contract is scheduled to end July 2019, with three other contracts concluding soon after. Colorado and Michigan have not yet executed contracts.
As states struggle with the increasing cost of prescription drugs, they are testing various alternative payment models (APMs) to curb costs. The Oklahoma Health Care Authority is a national leader with four APMs through direct contracts with pharmaceutical manufacturers. These contracts are each based on a specific drug, agreed upon outcomes, and approaches to measurement. Since Oklahoma began implementation, Michigan and Colorado had State Plan Amendments approved to advance similar APMs. Join this NASHP webinar to learn more about these states and their experiences engaging in APMs.
The moderator is NASHP Executive Director Trish Riley. Speakers include:
- Terry Cothran, Director, University of Oklahoma College of Pharmacy, Pharmacy Management Consultants
- Cathy Traugott, Pharmacy Manager, Colorado Department of Health Care Policy & Financing
- Trish Bouck, Pharmacy Management Division Director, Michigan Department of Health & Human Services
- Rita Subhedar, State Assistant Administrator, Michigan Department of Health & Human Services
Listen to the Dec. 12, 2019 webinar Medicaid Alternative Payment Models for Prescription Drugs: Do They Add Value for States? here.
Listen to the May 9, 2019, webinar Medicaid Alternative Payment Models for Prescription
Drugs: A Look at Three States here.
Substance use disorders (SUD) and mental health conditions are prevalent among pregnant and parenting women in the United States, and they have far-reaching consequences for the health and well-being of women and their children. Integrated care models that support pregnant and parenting women’s physical and behavioral health and social service needs can improve outcomes for women and children and reduce health care costs.
Through the Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the federal Maternal and Child Health Bureau of the Health Resources and Services Administration (MCHB, HRSA), the National Academy for State Health Policy (NASHP) is working with states to support and advance innovative policy initiatives that improve access to quality health care for pregnant and parenting women.
As part of the MCH PIP initiative, NASHP is convening a two-year policy academy including eight state teams made up of representatives from state Medicaid agencies, public health agencies, mental health/substance use agencies, and other state stakeholders. States selected to participate in the first cohort of the NASHP policy academy include:
- New Jersey
- South Carolina
Over the next two years, these states will identify, promote, and advance innovative, state-level policy initiatives to improve access to care for Medicaid-eligible pregnant and parenting women with or at risk of SUD and/or mental health conditions. NASHP will work with the states to identify high-priority policy issues, challenges, and opportunities through targeted technical assistance, peer-to-peer learning, analyses of policy issues, and development of policy briefs and other resources that will be disseminated nationally.
While many states have identified pregnant and parenting women as a priority population for their SUD and behavioral health efforts, challenges and opportunities persist. NASHP recently published two Issue Hubs that provide valuable resources, including information on the Centers for Medicare & Medicaid Services’ Maternal Opioid Misuse (MOM) Model. They are available at:
- Resources to Help States Improve Integrated Care for Pregnant and Parenting Women: This Issue Hub provides valuable resources for states interested in using the Maternal Opioid Misuse (MOM) model and others to improve access to comprehensive and coordinated care and implement innovative payment and care delivery models for pregnant and parenting women eligible for Medicaid.
- Resources to Help States Improve Integrated Care for Children: This Issue Hub provides valuable resources for states interested in the Integrated Care for Kids (InCK) Model and others working to implement payment, coverage, and cross-agency strategies to improve for integrated care coordination of behavioral, physical and health-related social needs for children eligible for Medicaid or the Children’s Health Insurance Program (CHIP).