Scoping Review Design and Study Selection
We conducted a scoping review to characterize the historical CMS (I.e. Medicaid) reimbursement policies for mental health services in the postpartum as well as provided a scoping review of studies evaluating the impact of CMS reimbursement policies on postpartum mental health outcomes. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting and reporting items for systematic reviews.1
We used the PICOS terminology to frame this work. Participants are pregnant people in the postpartum period who belong to a socioeconomic group with known disparities in postpartum maternal and infant outcomes and who qualify for Medicaid insurance. Interventions of interest are clinical care services reimbursable by Medicaid. The main comparators are outcomes among others with non-Medicaid insurance/reimbursed services. The two primary outcomes of interest are depression symptomology and utilization of mental health services postpartum.
Search StrategyTo characterize the historical CMS (i.e. Medicaid) reimbursement policies for mental health services in the postpartum, we examined CMS policy documents from 1965 to present published on Kaiser Family Foundation, U.S. Center for Medicare and Medicaid Services (CMS) website (CMS.gov), Planned Parenthood, Medicaid.gov, The U.S. official congressional record (congress.gov), and American College of Obstetricians and Gynecologist (ACOG) website.
To examine the impact of CMS reimbursement policies on postpartum mental health outcomes, we searched the following databases for primary studies: MEDLINE® via PubMed and CINAHL® from January 1, 1986 through February 1, 2022. We developed a search strategy for MEDLINE, accessed via PubMed®, based on medical subject headings (MeSH®) terms and text words of key articles that we identified a priori (Appendix 1). Our basic search concepts were ("Medicaid" [TIAB] OR "Affordable Care Act" [TIAB]) AND (maternal health [TIAB] OR perinatal[TIAB] OR postpartum [TIAB] OR pregnancy[TIAB]) AND (mental health [TIAB] OR depression [TIAB]). We first identified potentially eligible studies based on title and abstract. One reviewer reviewed the titles and abstracts based on pre-specified inclusion/exclusion criteria. Two reviewers independently reviewed the papers identified for full text review. All discrepancies for study inclusion were resolved by consensus.
Study SelectionStudy Design. We included studies that assessed impact of CMS funded postpartum services in the U.S., in our target population as defined below. Studies were included if they were of experimental or quasi-experimental design, assessed the primary outcome of depression symptomology and utilization of postpartum mental health services at least 3 months postpartum and were published in English. Studies were excluded if they discussed prenatal coverage of Medicaid did not include mental health service coverage during the postpartum period. Studies that were non-experimental in design were excluded, as were studies published only as abstracts.
Target population. Female adults (age 18+) who delivered a baby, reported postpartum depression symptoms and are eligible for Medicaid. It is important to note that Medicaid eligibility criteria differs by state as some states. (cite) However, some eligibility requirements that apply country wide include low-income families, receive Supplemental Security Income (SSI), must be residents of the state in which they receive Medicaid, US citizens and lawful permanent residents. (cite) Low-income status is determined by the Modified Adjusted Gross Income (MAGI) methodology. (cite) The MAGI methodology considers taxable and tax filling relationships to determine financial eligibility for Medicaid.
Intervention Inclusion/Exclusion. We included any studies that met the criteria above and examined the impact of any services reimbursed through CMS/Medicaid available in the postpartum period to address mental health of birthing people.
Data Extraction and Quality (Risk of Bias) Assessment
Data were extracted and summarized. We reported study characteristics and intervention characteristics, using categories to describe components of included studies to facilitate cross-study comparisons. Primary outcomes were reported for all studies.
All three researchers independently assessed the risk of bias of the XX number included studies using the Cochrane Risk of Bias tool. The specific domains include random sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting, and other source of bias. Any disagreement will be resolved by discussion among the three reviewers.
Search Results
The PRISMA flow diagram for this study is shown in Figure 1 below. The search strategies yielded 135 potentially relevant citations from PubMed. After excluding duplications and screening titles and abstracts for eligibility, 35 studies were retained for full-text evaluation. Of them, XX studies were excluded according to the inclusion and exclusion criteria. A total of X studies (cite) were included in this scoping review.
Figure 1: Study diagram of study selection (attached)
Characteristics of Included Studies
This scoping review included x studies [citations] with a total of XX participants. TheX studies included were conducted in were published between 2012 and 2022. Participants were postpartum women aged ≥18 years. The sample sizes ranged from X to Y. The X included studies (criteria met?). Of them, X studies used X mental health services, X studies explicitly states clinical outcome, and X studies examined Medicaid expansion effects. X studies had X study design, X were policy briefs and X were study design.
Risk of Bias
TBD
Clinical outcomes covered by Medicaid
TBD
Utilization of Postpartum mental health services with Medicaid coverage
TBD