Transforming Maternal Health Model

The United States continues to face a maternal health crisis that sets it apart from its economic peer nations. In response, the Centers for Medicare and Medicaid Services (CMS) launched the Transforming Maternal Health (TMaH) Model—a voluntary, 10-year initiative designed to fundamentally reshape how Medicaid and the Children’s Health Insurance Program (CHIP) deliver care to pregnant women, birthing people, and their newborns.

This guide breaks down everything you need to know about the TMaH Model: why it exists, how it works, and what it means for participating state Medicaid agencies, healthcare providers, and the communities they serve.

Overview of the Transforming Maternal Health (TMaH) Model

The Transforming Maternal Health TMaH Model represents CMS’s most ambitious effort to date to improve maternal health outcomes for people enrolled in Medicaid. Announced in December 2023 and launched in early 2025, this 10-year initiative (running through 2034) focuses on reducing preventable morbidity and mortality among pregnant and postpartum individuals, newborns, and birthing people covered by state Medicaid agencies (SMAs).

At its core, TMaH is designed as a value-based, whole person care model. Rather than treating pregnancy as a series of isolated clinical encounters, the model addresses physical health, mental health, substance use, and social needs across pregnancy, childbirth, and at least one year postpartum.

Here’s what defines the TMaH Model:

• Scope: Supports up to 15 participating state Medicaid agencies through cooperative agreement funding of up to $17 million per state over the decade

• Approach: Implements a whole person approach that integrates medical care with behavioral health services and addresses health-related social needs

• Payment reform: Requires states to develop and implement alternative payment models that shift away from fee-for-service toward value-based arrangements

• Technical assistance: Provides substantial federal support, including data tools, learning collaboratives, and implementation guidance from organizations like the National Opinion Research Center (NORC) at the University of Chicago

• Foundation: Builds on earlier CMS efforts including Strong Start for Mothers and Newborns (2012-2016), the Maternal Opioid Misuse model, and the Integrated Care for Kids model—but with expanded scope and a longer timeline

Why the Transforming Maternal Health Model Is Needed

The United States has the highest maternal mortality rate of any high income country. In 2023, the U.S. maternal mortality rate reached approximately 19 deaths per 100,000 live births—significantly higher than peer nations like the Sweden and Germany where rates are approximately 4 deaths per 100,000 live births. More troubling: over 80% of these deaths are considered preventable.

Medicaid finances roughly 40% of U.S. births annually, with even higher shares in Southern states and rural communities. This makes the program a critical lever for driving meaningful change in maternity care delivery. Yet despite high healthcare spending, outcomes remain poor.

The data reveals persistent disparities that demand urgent attention:

• Black and Indigenous birthing people face maternal mortality rates 2-3 times higher than white counterparts

• Rural residents experience higher rates of severe maternal morbidity than their urban peers and limited access to maternity care—nearly 40% of U.S. counties lack any maternity care providers

• Many pregnancy-related deaths occur during the postpartum period (including 6 weeks to 1 year after delivery), where gaps in coverage, follow-up care, and mental health support are common

• Low birthweight infants cost the healthcare system approximately $4.4 billion annually, with Medicaid bearing a substantial portion

• Fragmented payment systems, fee-for-service incentives, and lack of integrated social support contribute to poor maternal and infant outcomes despite high U.S. spending

The TMaH Model aims to address these systemic failures by transforming how care is organized, delivered, and financed for Medicaid beneficiaries.

Core Pillars of the TMaH Model

CMS organized the TMaH Model around three main pillars: expanding access to high-value care, improving quality and safety, and delivering whole person care. Each pillar contains specific solutions designed to drive measurable improvements in maternal health outcomes.

Pillar 1: Access to High-Value Care

• Focuses on improving access to midwifery, freestanding birth centers, community-based doulas, and perinatal community health workers—especially in maternity care deserts

• Supports home visiting programs and telehealth expansion to reach people in rural areas with limited provider availability

• Enables states to use Medicaid managed care contracts and value-based incentives to drive network expansion and after-hours access

• Addresses workforce capacity through training programs and scope-of-practice reforms that allow providers to practice at the top of their licenses

Pillar 2: Quality and Safety

• Encourages adoption of evidence based interventions through standardized clinical protocols, including hemorrhage and hypertension bundles developed by the Alliance for Innovation on Maternal Health (AIM)

• Promotes engagement with perinatal quality collaboratives to spread best practices across hospitals and birth centers

• Targets reduction in C sections for low risk patients experiencing their first birth

• Supports improved screening and treatment for perinatal substance use disorders

• Guides development of standardized emergency preparedness protocols

• Encourages pursuit of CMS “Birthing-Friendly” designation which includes adherence to safety bundles, with early adopters reporting 20-30% reductions in targeted complications

Pillar 3: Whole Person and Culturally Responsive Care

• Integrates behavioral health services into prenatal care and postpartum care, including screening and treatment for perinatal depression (affecting 10-20% of pregnancies), anxiety, and substance use

• Requires routine screening for health-related social needs such as housing instability, food insecurity, and transportation barriers

• Establishes linkages to community based organizations that can assist with care navigation and address social needs beyond what clinical settings provide

• Emphasizes culturally and linguistically appropriate care, including supporting community-led models and diversifying the maternity care workforce to better reflect the populations served

• Mandates development of health equity plans addressing racial, ethnic, and rural disparities

The Role of Medicaid and CHIP in Transforming Maternal Health

Medicaid and the health insurance program CHIP serve as the central payers for maternity care in the United States, disproportionately insuring low-income families, rural residents, and people of color. This positions these programs as powerful tools for driving systemic change in how maternal care is delivered.

Medicaid’s policy tools—including Section 1115 demonstration waivers, managed care contracts, and alternative payment models—can require or incentivize providers to adopt maternity care redesign elements central to the TMaH Model. States have significant flexibility to shape these tools to meet local needs.

Key Medicaid/CHIP levers supporting TMaH goals include:

• Extended postpartum coverage: The American Rescue Plan Act and Consolidated Appropriations Act enabled states to extend postpartum Medicaid coverage from 60 days to 12 months, aligning with TMaH’s emphasis on the full postpartum period

• Managed care requirements: States can embed quality improvement expectations, value-based payment arrangements, and network adequacy standards in contracts with managed care organizations

• Benefit expansions: Adding covered services for doulas, community health workers, and home visiting programs supports the access and whole-person care pillars

• Performance incentives: States are encouraged to tie plan bonuses to reduced severe maternal morbidity rates or improved postpartum visit completion rates

• Data integration: Medicaid’s administrative data systems can be leveraged for risk stratification, outcome tracking, and quality improvement

Because Medicaid sets standards for a substantial share of births, TMaH-driven reforms in participating states can influence community hospitals, obstetric practices, and managed care organizations beyond just the 15 states receiving direct federal support.

Design Features of the Transforming Maternal Health Model

The TMaH Model spans a full decade (2025-2034), combining planning, implementation, and evaluation phases designed to build capacity gradually while ensuring accountability for outcomes.

Timeline and Phases

• Pre-implementation period (approximately 2025-2027): States receive technical assistance to develop infrastructure, establish partnerships, and meet planning milestones before full implementation

• Implementation phase (approximately 2028-2034): States execute their models with key partners including managed care plans, perinatal quality collaboratives, hospitals, birth centers, rural health clinics, and community based organizations

• CMS expects states to gradually scale from pilots to broader statewide application, with ongoing refinement based on performance data

Alternative Payment Model Requirements

• TMaH requires states to implement value-based payment tied to maternal and infant outcomes

• Payment models may include episode-based payments for maternity care, shared-savings arrangements, or capitated models with quality withholds

• Accountability flows through quality measures including severe maternal morbidity rates, low birthweight infant rates, timely postpartum visits, and perinatal depression screening completion

• The goal is reducing overall program expenditures while improving outcomes—moving away from fee-for-service incentives that can reward volume over value

State Selection and Support

• 15 states were competitively selected based on proposals submitted in 2024, with attention to geographic diversity and burden of maternal health disparities

• Selected states include Alabama, Arkansas, California, District of Columbia, and West Virginia, among others

• CMS provides financial support (up to $17 million per state over 10 years), targeted technical assistance, and data dashboards to assist implementation

• States must demonstrate commitment to the model’s goals and capacity to execute complex reforms

Partners and Evaluation

• Organizations like NORC at the University of Chicago, the Lewin Group, and academic partners provide implementation support and conduct independent evaluation

• Baseline performance assessments establish starting points for measuring improvement

• Learning collaboratives enable states to share strategies and troubleshoot common challenges

• Feedback loops allow for mid-course corrections based on early results

Addressing Equity and Closing Maternal Health Gaps

Equity—especially racial, ethnic, and geographic equity—is central to the TMaH Model’s design. The disproportionate burden of maternal mortality and severe maternal morbidity on Black, Indigenous, and other birthing people of color demands targeted interventions that go beyond uniform approaches.

The evidence is stark: Black mothers experience maternal mortality rates 2-3 times higher than white mothers. Rural residents face 50% higher postpartum hemorrhage rates and limited access to specialty care. These gaps persist even when controlling for income and education, pointing to systemic factors including implicit bias, structural racism, and unequal access to high-quality care.

The model encourages states to develop comprehensive health equity strategies:

• Targeted investments in community based organizations led by and serving communities of color

• Workforce diversification initiatives to recruit, train, and retain providers who reflect the populations they serve

• Language access programs ensuring services are available in patients’ preferred languages

• Implicit bias training and cultural humility education for clinical staff

• Data stratification by race, ethnicity, geography, and other factors to identify and address disparities

It’s worth noting that federal guidance around explicit race-conscious policies has shifted in recent years. Some states may frame equity work through proxies like geography, income, or social risk factors rather than explicit racial categories. Resources from organizations like the National Partnership for Women & Families offer playbooks that can supplement formal CMS guidance and help states navigate this landscape.

Implementation Challenges, Critiques, and Opportunities for Reform

While the TMaH Model represents a significant advancement in federal support for maternal health, experts and advocates have raised legitimate concerns about its funding level, scope, and operational complexity. Understanding these challenges is essential for states considering participation and advocates pushing for improvements.

Funding Limitations

• The roughly $17 million per state over a decade translates to less than $40 per Medicaid-financed birth in some high-burden states

• For context: comprehensive doula training programs can cost $500,000+ to establish statewide; upgrading rural hospital emergency preparedness requires multi-million-dollar investments

• Critics argue the funding level may be insufficient to drive the transformative change the model envisions, particularly in states with large Medicaid populations or significant existing infrastructure gaps

Data and Measurement Hurdles

• Effective implementation requires standardized, cross-state data systems integrating Medicaid claims, vital records, and social service data through the postpartum period

• Many states lack robust health information exchanges and electronic health record interoperability

• Without clear national data infrastructure, states may continue reporting fragmented or incomparable outcome measures, limiting the ability to evaluate what works

Leadership and Policy Stability

• The 10-year timeline spans multiple presidential administrations and congressional sessions

• Leadership turnover and shifting federal priorities can undermine long-term planning and erode state confidence in sustained support

• States may hesitate to make major investments if they fear future administrations will deprioritize or defund the initiative

Opportunities for Strengthening the Model

• Expand scope to include coordinated mother-child services through the first two years of life, recognizing that maternal and infant health are deeply interconnected

• Increase per-state funding to levels that can support meaningful infrastructure development, workforce expansion, and payment reform implementation

• Embed more explicit requirements for evidence based interventions with strong track records, such as Nurse-Family Partnership home visiting or structured parenting support programs

• Develop national data standards and shared infrastructure to enable rigorous cross-state comparison and learning

Looking Ahead: Scaling, Sustainability, and National Impact

The TMaH opportunity extends beyond the 15 participating states. If successful, the model can generate evidence and momentum for transforming maternal health nationwide—but only if lessons are captured, shared, and embedded into permanent policy.

Scaling Successful Strategies

• States can adapt approaches from high-performing programs like California’s Maternal Quality Care Collaborative, which helped cut the state’s maternal mortality in half over about a decade through systematic quality improvement

• The TMaH Model creates a natural laboratory for testing innovations that can spread to non-participating states through Medicaid policy diffusion

• California’s Department of Health Care Services is already integrating TMaH within its Birthing Care Pathway, an integrated, whole person care delivery model for pregnancy and postpartum, in a 5-county pilot, with plans to scale evidence-based practices statewide

Embedding Reforms into Routine Medicaid Policy

• Sustainable change requires baking TMaH elements—such as extended postpartum coverage, comprehensive perinatal benefits, and value-based maternity payments—into permanent state plans, contracts, and regulations

• States should avoid treating TMaH as a time-limited project and instead use it as a catalyst for lasting structural reform

• Managed care contract renewals, waiver extensions, and state plan amendments offer opportunities to lock in successful innovations

Cross-Sector Collaboration

• Maintaining momentum beyond the federal model’s 2034 end date requires partnerships among Medicaid agencies, public health departments, hospital systems, community based organizations, and family advocates

• Building coalitions now creates the political will needed to sustain investments after federal funding ends

• States that engage mothers and families as partners in design and implementation are more likely to create models that truly improve outcomes

A Call to Action

The Transforming Maternal Health Model offers a foundation—not a finished structure—for reimagining how we support mothers, birthing people, and their newborns. Its success depends on sustained commitment from policymakers who fund and authorize reforms, clinicians who implement evidence-based care, community leaders who connect people to support, and advocates who hold systems accountable.

For states currently participating, the work ahead involves translating federal support into operational reality through partnership development, payment reform, and quality improvement infrastructure. For states watching from the sidelines, TMaH offers a template and a potential proof point for what’s possible when Medicaid prioritizes maternal health.

The United States spends more on healthcare than other high income countries while producing worse maternal outcomes. The next decade offers an opportunity to prove that coordinated, value-based, whole person maternity care can become the standard—not the exception. Whether we seize that opportunity depends on choices made today to optimize the health of mothers, babies, and families.