Pregnancy and Postpartum TCS FAQS

Q1: Why did DHCS develop two categories (high- and moderate-intensity) of TCS for pregnant and postpartum members? Can a pregnant or postpartum member ever be considered lower-risk?

Since January 2024, DHCS classified all pregnant and postpartum members as high-risk, but feedback from MCPs has highlighted challenges with this universal approach. In response, and aligned with our broader Birthing Care Pathway commitments, DHCS developed high- and moderate-intensity pregnancy and postpartum TCS categories (“pregnancy and postpartum TCS”) – with differing requirements– to better meet the unique needs of pregnant and postpartum Medi Cal members. Pregnancy and postpartum TCS categories are part of the broader Birthing Care Pathway efforts, which aim to reduce maternal morbidity and mortality. Due to elevated vulnerability, all pregnant and postpartum members will receive moderate- or high-intensity TCS; a lower-risk TCS category will not apply to this population. Even if an MCP’s RSST algorithm classifies a pregnant or postpartum member as lower-risk, all pregnant and postpartum members must receive at least moderate-intensity pregnancy and postpartum TCS.

Q2: What entity can serve as the ‘care coordination entity’ for moderate-intensity TCS? 

DHCS encourages MCPs to contract with their existing network of perinatal providers to serve as the care coordination entities for moderate-intensity TCS. This can include any type of entity that has the capability to perform the required tasks, including pregnancy provider offices/practices such as obstetrician, family practice, certified nurse midwife, licensed midwife, and/or doula practices or a hospital/health care system. MCPs are encouraged to update their contracts with their qualified network providers to include moderate-intensity TCS services and must provide appropriate training, technical assistance, or other resources to ensure success. While MCPs may contract with qualified providers for moderate-intensity TCS, each member must be assigned a single care coordination entity that is responsible for ensuring completion of all moderate-intensity care coordination activities. The care coordination entity can provide this using multiple staff members rather than a single point of contact. MCPs must provide oversight and monitoring of their contracted entities to ensure implementation of moderate-intensity TCS with fidelity per the PHM Policy Guide.

Q3: What are the expectations for pregnancy and postpartum TCS when a member is enrolled in or working with community-based pregnancy care coordination programs/providers that are not contracted to provide TCS?

DHCS expects that either the TCS care manager (for high-intensity) or the care coordination entity (for moderate-intensity) to be the single entity or person responsible for ensuring completion of all TCS requirements (including the Birthing Supports Checklist), but these requirements can be completed/fulfilled in collaboration with existing community partners. 

Therefore, if a community-based organization has completed a Checklist item (e.g. enrolled a member in WIC), the TCS care manager or care coordination entity should confirm this directly with the organization. This ensures services are verified for the member and avoids duplication.

Q4: Can MCPs and contracted entities adapt their own “user-friendly” version of the Birthing Supports Checklist requirements as outlined in the PHM Policy Guide?

The Birthing Supports Checklist outlines required elements but is not meant to be a required form.   MCPs and their contracted entities must ensure completion of all items that a member qualifies for on the TCS Birthing Supports Checklist for all pregnant and postpartum members; its required elements may not be modified by an individual MCP or contracted entity. However, MCPs or contracted entities may create a more user-friendly version or a version with more local-specific resources that include all required services and supports. DHCS has developed an example user-friendly Birthing Supports Checklist with more details on the services and supports, available on the DHCS website here. DHCS encourages MCPs and contracted entities to integrate and adapt the checklist into existing workflows and Electronic Health Records (EHRs). 

Q5: Is there guidance on how to calculate the Obstetric Comorbidity Index (OCI)?

The OCI is a maternal risk-assessment tool that converts comorbidities/conditions into a single score (0–45), with higher scores indicating greater risk for severe maternal morbidity (SMM). These comorbidities/conditions can be mapped to claims data; MCPs should calculate a member’s OCI score using existing claims data. Each condition contributes a weighted value; the total score is the sum of these values. Members with a score of >6 on the OCI meet criteria for high-intensity pregnancy and postpartum TCS and should receive services accordingly. Members with an OCI score below 6 who do not meet any other high-intensity pregnancy or postpartum TCS criteria outlined in the PHM Policy Guide should receive moderate-intensity pregnancy and postpartum TCS. For guidance on calculating OCI scores, MCPs should see A comorbidity-based screening tool to predict severe maternal morbidity at the time of delivery (Easter et al., AJOG, Vol. 221, Issue 3).

Q6: When is the OCI required to be calculated to assess whether a member qualifies for high-intensity pregnancy and postpartum TCS?

The OCI must be calculated when the member is first identified as being pregnant. Subsequently, members already identified as meeting criteria for high-intensity TCS should continue receiving high-intensity TCS without the MCP needing to recalculate OCI. For all other members who do not meet criteria for high-intensity TCS (i.e., those receiving moderate-intensity TCS), the OCI should be recalculated upon identification of any new diagnosis that is included in the OCI, and upon delivery or the end of pregnancy.

Q7: How should MCPs proceed if claims data related to OCI are incomplete or there are delays in claims submission? 

DHCS encourages MCPs to work with their contracted providers who may be using the OCI in their clinical practice, including perinatal providers and hospitals, to set up methods of sharing the OCI score with plans. (This can be through real-time data exchange or via required referrals or notifications for any OCI score greater than 6). For instances where the provider is not using or calculating an OCI, DHCS expects MCPs to use the data they do receive in a timely manner. DHCS recognizes that it may be incomplete and that claims data has a lag compared to clinical data; however, DHCS expects the MCP to use the data they do receive in a timely manner consistent with Data Exchange Framework (DxF) requirements APL-12

Q8: How does DHCS define a “suspected significant mental health or substance use disorder (SUD)” that would qualify a member for high-intensity pregnancy and postpartum TCS under the Behavioral Health criteria? 

Under Behavioral Health Transformation (BHT), DHCS has created a definition of significant behavioral health that uses claims and encounter data as well as other administrative data to identify members with a “suspected significant mental health or substance use disorder”. Members that meet this definition will be identifiable in Medi-Cal Connect with a flag identifying the individual as having a significant behavioral health need. When this flag is available in Medi-Cal Connect, plans must use this flag to identify members that meet this definition. Before the flag becomes available, MCPs may rely on their own claims data (including utilization, diagnoses, and medications) to identify members with a known or suspected significant mental health condition or substance use disorder using their own methods at the MCP’s discretion. 

Q9: Are MCPs accountable for providing TCS to infants under the pregnancy and postpartum TCS categories (in addition to pregnant and postpartum members)? 

Pregnancy and postpartum TCS includes limited support related to infant(s),3 and is focused on assisting the pregnant or postpartum member in ensuring their infant attends well-child visits and is enrolled in health insurance. If additional TCS (including high-risk TCS for the infant) or other care coordination and management services is needed for the infant, it would be provided directly to the infant as a member, only if the infant is enrolled and deemed eligible by the MCP

Q10: If a member experiences an end of pregnancy event and then a non-delivery discharge within the 12-month postpartum period, what timeframe is required for the end of TCS?

The pregnancy and postpartum TCS categories apply to events (inclusive of delivery and non-delivery events) occurring during pregnancy and through 12 months postpartum. Pregnant and postpartum members must receive TCS services when all needs are met and through at least 60 days following the end of pregnancy or 30 days post-discharge if the member is admitted during the postpartum period for reasons other than delivery (whichever is later). See example scenarios below:

• -Member A is admitted early in pregnancy, triggering high-intensity pregnancy and postpartum TCS for the duration of pregnancy. Member A is then admitted again for delivery and discharged 2 days after delivery. TCS will end 60 days after delivery, as the admission occurred earlier in pregnancy and 60 days after delivery is the later date.
• -Member B has an end of pregnancy event and is readmitted to the hospital 2 weeks later. Member B is discharged a second time 18 days after the end of pregnancy. TCS will continue for 60 days after the end of pregnancy event, as 60 days after the end of pregnancy is later than 30 days after their second discharge.
• -Member C delivers a baby and is readmitted to the hospital 6 weeks later and discharged 7 weeks after their delivery. Member C must continue receiving TCS services through at least 30 days after their second discharge, as 30 days after the final discharge is later than 60 days after delivery.
• -Member D has an end of pregnancy event and receives TCS services for 60 days. Five months later the member has an admission to the hospital. Upon discharge, Member D must receive high-intensity pregnancy and postpartum TCS for a minimum of 30 days following the discharge date.