Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to develop a maternal mental health program designed to promote quality and cost-effective outcomes, as specified.

This bill would require the program to consist of at least one maternal mental health screening during pregnancy, at least one additional screening during the first 6 weeks of the postpartum period, and additional postpartum screenings, if determined medically necessary and clinically appropriate in the judgment of the treating provider. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to develop a maternal mental health program designed to promote quality and cost-effective outcomes, as specified.

This bill would require the program to consist of at least one maternal mental health screening during pregnancy, at least one additional screening during the first 6 weeks of the postpartum period, and additional postpartum screenings, if determined medically necessary and clinically appropriate in the judgment of the treating provider. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to develop a maternal mental health program designed to promote quality and cost-effective outcomes, as specified.

This bill would require the program to consist of at least one maternal mental health screening during pregnancy, and at least one additional screening during the first 6 months weeks of the postpartum period, and additional postpartum screenings, if determined medically necessary and clinically appropriate in the judgment of the treating provider. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to develop a maternal mental health program designed to promote quality and cost-effective outcomes, as specified.

This bill would require the program to consist of at least one maternal mental health screening during pregnancy, and at least one additional screening during the first 6 months of the postpartum period, if determined medically necessary and clinically appropriate in the judgment of the treating provider. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to develop a maternal mental health program designed to promote quality and cost-effective outcomes, as specified.

This bill would require the program to conduct consist of at least one maternal mental health screening during pregnancy, and at least one additional screening during the first 6 months of the postpartum period. period, if determined medically necessary and clinically appropriate in the judgment of the treating provider. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law prescribes the duties of the State Registrar of Vital Statistics and local registrars of births and deaths with respect to the registration of certificates of live birth, fetal death, or death, and marriage licenses. Existing law requires the certificate of live birth to contain specified information, including the full name and date of birth of the child and each parent, and requires the State Registrar to instruct all local registrars to collect the specified information with respect to certificates of live birth.

This bill would make technical, nonsubstantive changes to those provisions.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1936

Author:(Cervantes)

As Amended Ver:August 07, 2024

Majority vote

SUMMARY

Requires a health plan or insurer's existing maternal mental health (MMH) program to include at least one MMH screening during pregnancy, and at least one additional screening during the first six weeks of the postpartum period, and additional postpartum screenings, if determined to be medically necessary and clinically appropriate in the treating provider's judgement.

Senate Amendments

Require at least one additional screening during the first six weeks of the postpartum period and additional postpartum screenings.

COMMENTS

According to a California Health Care Foundation blog in 2022, in California, as in the US overall, about one in five mothers / birthing people suffers from MMH issues (also known as "perinatal mood and anxiety disorders"), negatively impacting the mother / birthing person and the child. Despite this high prevalence of MMH issues, the overwhelming majority of mothers / birthing people experiencing MMH symptoms (75%) do not receive treatment.

MMH Conditions. MMH conditions are the most common complications of pregnancy and childbirth. They include prenatal and postpartum depression and/or anxiety, bipolar disorder, and in extreme cases, postpartum psychosis. According to DPH's Maternal and Infant Health Assessment, 21% of pregnant and postpartum mothers / birthing people in California are affected. The prevalence is estimated to be even higher in some populations. For example, during pregnancy, maternal depression rates rise to as high as one in two for those on Medicaid. This is significant because Medi-Cal covers 45% of the 400,000 babies born in the state annually. Additionally, in California, Black mothers / birthing people report the highest rates of anxiety and depression, compared to all other races, and anxiety has been found to be more common than depression in the perinatal population. Alarmingly, maternal suicide is a leading cause of maternal mortality in the US; it is most common in the white population and occurs most often between six and 12 months postpartum.

Left undetected and untreated, MMH conditions can lead to negative health outcomes for the mother / birthing person, and can negatively affect the mother-child bond and the child's long-term physical, emotional, and developmental health. Additionally, there can be significant financial costs of untreated MMH conditions (e.g., more use of emergency care services, higher rates of absenteeism at work), an estimated $35,000 for each mother / birthing person–child dyad.

Recent California coverage laws. AB 2193 (Maienschein), Chapter 755, Statutes of 2018, establishes a MMH program designed to promote quality and cost-effective outcomes and developed with sound clinical principles and processes. AB 2193 also requires a licensed health care practitioner who provides prenatal or postpartum care for a patient, to offer to screen or appropriately screen a mother for MMH conditions. SB 1207 (Portantino), Chapter 618, Statutes of 2022, further revises the requirements of the MMH program to include quality measures to encourage screening, diagnosis, treatment, and referral. SB 1207 also encourages coverage for doulas, incentivizes training opportunities for contracting obstetric providers, and educates enrollees and insureds about the MMH program. Last year, AB 904 (Calderon), Chapter 349, Statutes of 2023, established a maternal and infant health equity program to address racial health disparities in maternal and infant health outcomes. This bill expands on the existing MMH program to require health plans and insurers to conduct one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period.

According to the Author

According to the Department of Public Health, before the onset of the COVID-19 pandemic, one in five women and birthing people in California experienced symptoms of anxiety or depression during pregnancy or the postpartum period. During the pandemic, that figure increased to one in three women and birthing people. Women and birthing people who are Black, Latina, or Native American; or have low incomes; or have experienced hardships in their childhood or during pregnancy are at heightened risk of experiencing MMH issues. Under existing law, women and birthing people are required to be offered at least one screening for MMH conditions during pregnancy and the postpartum period. Unfortunately, implementation of that law often presents the availability of these screenings to be a choice between either during pregnancy or the postpartum period. According to the author, this bill will help more women and birthing people in California receive proper diagnoses if they are experiencing MMH issues by requiring that a screening be offered to women and birthing people at least once during pregnancy, with an additional screening offered during the first six months of the postpartum period. The author concludes that this increased access to screening will help more women and birthing people in California seek and receive the treatment they need to address MMH issues.

Arguments in Support

The California State Association of Psychiatrists write that screening for perinatal or postpartum depression or other MMH conditions is the first step to detect potential conditions that may have a negative impact during pregnancy or the postpartum period. Because a verified medical diagnostic test has not yet been developed, obstetric and licensed practitioners rely on screening tools, or questionnaires, for detection purposes.

Arguments in Opposition

There is no known registered opposition.

FISCAL COMMENTS

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM HEALTH: 16-0-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Flora, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Sanchez, Santiago, Schiavo, Weber

ASM APPROPRIATIONS: 14-0-1

YES: Wicks, Sanchez, Arambula, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Grayson, Haney, Hart, Pellerin, Ta, Villapudua

ABS, ABST OR NV: Jim Patterson

ASSEMBLY FLOOR: 65-0-15

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gallagher, Garcia, Gipson, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Quirk- Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Soria, Ta, Valencia, Villapudua, Waldron, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Bains, Cervantes, Megan Dahle, Flora, Gabriel, Grayson, Haney, Low, Mathis, Stephanie Nguyen, Petrie-Norris, Luz Rivas, Schiavo, Ting, Wallis

SENATE FLOOR: 33-0-7

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Blakespear, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Stern, Umberg, Wiener, Wilk

ABS, ABST OR NV: Atkins, Becker, Bradford, Menjivar, Skinner, Smallwood-Cuevas, Wahab

SENATE FLOOR: 36-0-4

YES: Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Eggman, Glazer, Gonzalez, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ABS, ABST OR NV: Allen, Alvarado-Gil, Durazo, Grove

UPDATED

VERSION: August 07, 2024

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0004174

 THIRD READING  

Bill No: AB 1936

Author: Cervantes (D), et al.

Amended: 8/7/24 in Senate

Vote: 21

PRIOR SENATE FLOOR VOTE NOT RELEVANT

SENATE HEALTH COMMITTEE: 11-0, 6/5/24

AYES: Roth, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 65-0, 5/9/24 (Consent) - See last page for vote

SUBJECT: Maternal mental health screenings

SOURCE: Author

DIGEST:

This bill requires, as part of an existing requirement on health plans and insurers to develop a maternal mental health (MMH) program, health plans and insurers to include at least one MMH screening during pregnancy, and at least one additional screening during the first six weeks of the postpartum period, and additional screenings if determined to be medically necessary and clinically appropriate in the judgement of the treating provider.

Senate Floor Amendments of 8/7/24 reduce the period of time for the additional screening to be within the first six weeks, instead of the first six months, of the postpartum period; and, allow for additional postpartum screenings, if determined to be medically necessary and clinically appropriate by the treating provider.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [Health and Safety Code (HSC) §1340, et seq., Insurance Code (INS) §106, et seq., and, Welfare and Institutions Code §14000, et seq.]
   
2. Requires health plans and insurers to develop a MMH program designed to promote quality and cost-effective outcomes, developed with sound clinical principals and processes, and to include quality measures to encourage screening, diagnosis, treatment, and referral. Requires guidelines and criteria to be provided to relevant medical providers including contracting obstetric providers. Encourages plans to improve screening, treatment, and referral to MMH services, include coverage for doulas, incentivize training opportunities for contracting obstetric providers, and educate enrollees about the program. Excludes specialized health plans or insurers, except specialized behavioral health-only plans or insurers offering professional mental health services, and includes Medi-Cal managed care plans. [HSC §1367.625 and INS §10123.867]
3. Defines “MMH” as a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression. [HSC §1367.625 and INS §10123.867]
4. Requires a Medi-Cal managed care plan to continue to comply with any quality measures required or adopted by DHCS. [HSC §1367.625 and INS §10123.867]
5. Requires a licensed health care practitioner who provides prenatal, postpartum, or interpregnancy care for a patient to ensure that the mother is offered screening or is appropriately screened for MMH conditions, except when providing emergency services. Defines “health care practitioner” as a physician, naturopathic doctor, nurse practitioner, physician assistant, nurse midwife, or a licensed midwife. [HSC §123640]

This bill requires health plan and health insurer MMH programs required under existing law to consist of at least one MMH screening during pregnancy, and at least one additional screening during the first six weeks of the postpartum period, and additional postpartum screenings if determined to be medically necessary and clinically appropriate in the judgement of the treating provider.

Comments

1. Author’s statement. According to the author, “According to the California Department of Public Health (CDPH), before the onset of the COVID-19 pandemic, one in five women and birthing people in California experienced symptoms of anxiety or depression during pregnancy or the postpartum period. During the pandemic, that figure increased to one in three women and birthing people. Women and birthing people who are Black, Latina, or Native American; or have low incomes; or have experienced hardships in their childhood or during pregnancy are at heightened risk of experiencing MMH issues. This bill will help more women and birthing people in California receive proper diagnoses if they are experiencing MMH issues by requiring that a screening be offered to women and birthing people at least once during pregnancy, with an additional screening offered during the first six months of the postpartum period, if determined medically necessary and is clinically appropriate in the judgment of a provider. This increased access to screening will help more women and birthing people in California seek and receive the treatment they need to address MMH issues.”
   
2. Maternal and Infant Health Assessment (MIHA). MIHA is an annual, statewide-representative survey of California residents with a recent live birth. It is a collaborative effort involving CDPH and the University of California, San Francisco, Center for Health Equity. MIHA collects self-reported information about maternal and infant experiences and maternal attitudes and behaviors before, during, and shortly after pregnancy. The California HealthCare Foundation (CHCF) indicates that 75% of mothers/birthing people experiencing MMH symptoms do not receive treatment, and according to MIHA, 21% of pregnant and postpartum mothers/birthing people in California are affected by MMH. Forty-five percent of all 400,000 births in California are covered by Medi-Cal. Black mothers/birthing people report the highest rates of anxiety and depression, compared to all other races, and anxiety has been found to be more common than depression in the perinatal population. Maternal suicide is a leading cause of maternal mortality in the US; most commonly in the White population, and almost half occur between six and twelve months postpartum.
   
3. Screening and treatment recommendations. The United States Preventive Services Task Force (USPSTF) was created in 1984, and is an independent, volunteer panel of national experts in prevention and evidence-based medicine. USPSTF makes evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications. The USPSTF posts the final recommendation statement, final evidence review, and an evidence summary on its website. The recommendation statement and the evidence summary are also published in a peer-reviewed scientific journal. The 2019 Perinatal Depression Prevention Intervention recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. As part of this recommendation, USPSTF indicates that there is no accurate screening tool for identifying women at risk of developing perinatal depression and who might benefit from preventive interventions. However, USPSTF indicates that clinical risk factors that may be associated with the development of perinatal depression include a personal or family history of depression, history of physical or sexual abuse, having an unplanned or unwanted pregnancy, current stressful life events, pregestational or gestational diabetes, and complications during pregnancy. Social factors such as low socioeconomic status, lack of social or financial support, and adolescent parenthood have also been shown to increase the risk of developing perinatal depression. USPSTF indicates that there is no data on the ideal timing for offering or referral to counseling interventions; however, most were initiated during the second trimester of pregnancy. Ongoing assessment of risks that develop in pregnancy and the immediate postpartum period is reasonable, and referral could occur at any time. USPSTF is in the process of updating their recommendation. One of the proposed contextual questions is, are there reliable and valid prognostic tools for identifying individuals who are at increased risk of developing perinatal depression and when is the most effective time to provide interventions to prevent perinatal depression.
   
4. Maternal Mental Health Leadership Alliance (MMHLA). There is no current standard for perinatal mental health patient education and screening. MMHLA and partner organizations are developing a screening framework for when to provide patient education and screening, and to address barriers to screening. The first phase report was presented in January 2023. The framework includes education and screening at initiation of prenatal care and during each trimester of pregnancy, prior to discharge from hospital or birthing center and three weeks postpartum, and throughout the full year postpartum at all regularly scheduled obstetric and pediatric visits. MMHLA states that areas for further action are: (1) provider education and training; (2) provider reimbursement; (3) referral resources; (4) screening tools for screening the full range of disorders and that adequately address cultural and racial differences; and, 5) equity and trust to adapt to specific situations and prevent failures within the health care system.
   
5. American Academy of Pediatrics (AAP) policy statement. A January 2019 AAP policy statement published in the journal Pediatrics indicates that postpartum depression leads to increased costs of medical care, inappropriate medical treatment of the infant, discontinuation of breast-feeding, family dysfunction, and an increased risk of abuse and neglect. Postpartum depression can be treated and pediatric medical homes are recommended to coordinate care more effectively with prenatal providers for women with prenatally diagnosed maternal depression, establish a system to implement screening at the first, second, forth, and sixth month well child visits, use community resources for treatment and referral of the mother with depression, and provide support for the maternal-child (dyad) relationship. This statement recommends advocacy for payment and increased training for screening and treatment.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 8/6/24)

California State Association of Psychiatrists

Children Now

Mental Health America of California

OPPOSITION: (Verified 8/6/24)

None received

ARGUMENTS IN SUPPORT: The California State Association of Psychiatrists writes that screening for perinatal or postpartum depression or other MMH conditions is the first step to detect potential conditions that may have a negative impact during pregnancy or the postpartum period. Because a verified medical diagnostic test has not yet been developed, obstetric and licensed practitioners rely on screening tools, or questionnaires, for detection purposes. While the existing framework provides some benefit, condition onset can occur at any time, making it crucial that screenings take place more often and during both the pregnancy and postpartum periods.

ASSEMBLY FLOOR: 65-0, 5/9/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gallagher, Garcia, Gipson, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Soria, Ta, Valencia, Villapudua, Waldron, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO VOTE RECORDED: Bains, Cervantes, Megan Dahle, Flora, Gabriel, Grayson, Haney, Low, Mathis, Stephanie Nguyen, Petrie-Norris, Luz Rivas, Schiavo, Ting, Wallis

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

8/9/24 16:37:59

**** END ****

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1936

Author:(Cervantes)

As Amended Ver:June 11, 2024

Majority vote

SUMMARY

Requires a health plan or insurer's existing maternal mental health (MMH) program to include at least one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period, if determined to be medically necessary and clinically appropriate in the treating provider's judgement.

Senate Amendments

Make technical and nonsubstantive changes to this bill.

COMMENTS

According to a California Health Care Foundation blog in 2022, in California, as in the US overall, about one in five mothers / birthing people suffers from MMH issues (also known as "perinatal mood and anxiety disorders"), negatively impacting the mother / birthing person and the child. Despite this high prevalence of MMH issues, the overwhelming majority of mothers / birthing people experiencing MMH symptoms (75%) do not receive treatment.

MMH Conditions. MMH conditions are the most common complications of pregnancy and childbirth. They include prenatal and postpartum depression and/or anxiety, bipolar disorder, and in extreme cases, postpartum psychosis. According to DPH's Maternal and Infant Health Assessment, 21% of pregnant and postpartum mothers / birthing people in California are affected. The prevalence is estimated to be even higher in some populations. For example, during pregnancy, maternal depression rates rise to as high as one in two for those on Medicaid. This is significant because Medi-Cal covers 45% of the 400,000 babies born in the state annually. Additionally, in California, Black mothers / birthing people report the highest rates of anxiety and depression, compared to all other races, and anxiety has been found to be more common than depression in the perinatal population. Alarmingly, maternal suicide is a leading cause of maternal mortality in the United States; it is most common in the white population and occurs most often between six and 12 months postpartum.

Left undetected and untreated, MMH conditions can lead to negative health outcomes for the mother / birthing person, and can negatively affect the mother-child bond and the child's long-term physical, emotional, and developmental health. Additionally, there can be significant financial costs of untreated MMH conditions (e.g., more use of emergency care services, higher rates of absenteeism at work), an estimated $35,000 for each mother / birthing person–child dyad.

Recent California coverage laws. AB 2193 (Maienschein), Chapter 755, Statutes of 2018, establishes a MMH program designed to promote quality and cost-effective outcomes and developed with sound clinical principles and processes. AB 2193 also requires a licensed health care practitioner who provides prenatal or postpartum care for a patient, to offer to screen or appropriately screen a mother for MMH conditions. SB 1207 (Portantino), Chapter 618, Statutes of 2022, further revises the requirements of the MMH program to include quality measures to encourage screening, diagnosis, treatment, and referral. SB 1207 also encourages coverage for doulas, incentivizes training opportunities for contracting obstetric providers, and educates enrollees and insureds about the MMH program. Last year, AB 904 (Calderon), Chapter 349, Statutes of 2023, established a maternal and infant health equity program to address racial health disparities in maternal and infant health outcomes. This bill expands on the existing MMH program to require health plans and insurers to conduct one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period.

According to the Author

According to the Department of Public Health, before the onset of the COVID-19 pandemic, one in five women and birthing people in California experienced symptoms of anxiety or depression during pregnancy or the postpartum period. During the pandemic, that figure increased to one in three women and birthing people. Women and birthing people who are Black, Latina, or Native American; or have low incomes; or have experienced hardships in their childhood or during pregnancy are at heightened risk of experiencing MMH issues. Under existing law, women and birthing people are required to be offered at least one screening for MMH conditions during pregnancy and the postpartum period. Unfortunately, implementation of that law often presents the availability of these screenings to be a choice between either during pregnancy or the postpartum period. According to the author, this bill will help more women and birthing people in California receive proper diagnoses if they are experiencing MMH issues by requiring that a screening be offered to women and birthing people at least once during pregnancy, with an additional screening offered during the first six months of the postpartum period. The author concludes that this increased access to screening will help more women and birthing people in California seek and receive the treatment they need to address MMH issues.

Arguments in Support

The California State Association of Psychiatrists write that screening for perinatal or postpartum depression or other MMH conditions is the first step to detect potential conditions that may have a negative impact during pregnancy or the postpartum period. Because a verified medical diagnostic test has not yet been developed, obstetric and licensed practitioners rely on screening tools, or questionnaires, for detection purposes.

Arguments in Opposition

There is no known registered opposition.

FISCAL COMMENTS

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM HEALTH: 16-0-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Flora, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Sanchez, Santiago, Schiavo, Weber

ASM APPROPRIATIONS: 14-0-1

YES: Wicks, Sanchez, Arambula, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Grayson, Haney, Hart, Pellerin, Ta, Villapudua

ABS, ABST OR NV: Jim Patterson

ASSEMBLY FLOOR: 65-0-15

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gallagher, Garcia, Gipson, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Soria, Ta, Valencia, Villapudua, Waldron, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Bains, Cervantes, Megan Dahle, Flora, Gabriel, Grayson, Haney, Low, Mathis, Stephanie Nguyen, Petrie-Norris, Luz Rivas, Schiavo, Ting, Wallis

SENATE FLOOR: 36-0-4

YES: Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Eggman, Glazer, Gonzalez, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ABS, ABST OR NV: Allen, Alvarado-Gil, Durazo, Grove

UPDATED

VERSION: June 11, 2024

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0003563

 CONSENT  

Bill No: AB 1936

Author: Cervantes (D), et al.

Amended: 6/11/24 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 6/5/24

AYES: Roth, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

ASSEMBLY FLOOR: 65-0, 5/9/24 (Consent) - See last page for vote

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SUBJECT: Maternal mental health screenings

SOURCE: Author

DIGEST:

This bill requires, as part of an existing requirement on health plans and insurers to develop a maternal mental health (MMH) program, health plans and insurers to include at least one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period, if determined to be medically necessary and clinically appropriate in the judgement of the treating provider.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [Health and Safety Code (HSC) §1340, et seq., Insurance Code (INS) §106, et seq., and, Welfare and Institutions Code §14000, et seq.]
   
2. Requires health plans and insurers to develop a MMH program designed to promote quality and cost-effective outcomes, developed with sound clinical principals and processes, and to include quality measures to encourage screening, diagnosis, treatment, and referral. Requires guidelines and criteria to be provided to relevant medical providers including contracting obstetric providers. Encourages plans to improve screening, treatment, and referral to MMH services, include coverage for doulas, incentivize training opportunities for contracting obstetric providers, and educate enrollees about the program. Excludes specialized health plans or insurers, except specialized behavioral health-only plans or insurers offering professional mental health services, and includes Medi-Cal managed care plans. [HSC §1367.625 and INS §10123.867]
3. Defines “MMH” as a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression. [HSC §1367.625 and INS §10123.867]
4. Requires a Medi-Cal managed care plan to continue to comply with any quality measures required or adopted by DHCS. [HSC §1367.625 and INS §10123.867]
5. Requires a licensed health care practitioner who provides prenatal, postpartum, or interpregnancy care for a patient to ensure that the mother is offered screening or is appropriately screened for MMH conditions, except when providing emergency services. Defines “health care practitioner” as a physician, naturopathic doctor, nurse practitioner, physician assistant, nurse midwife, or a licensed midwife. [HSC §123640]

This bill requires health plan and health insurer MMH programs required under existing law to consist of at least one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period, if determined to be medically necessary and clinically appropriate in the judgement of the treating provider.

Comments

1. Author’s statement. According to the author, “According to the California Department of Public Health (CDPH), before the onset of the COVID-19 pandemic, one in five women and birthing people in California experienced symptoms of anxiety or depression during pregnancy or the postpartum period. During the pandemic, that figure increased to one in three women and birthing people. Women and birthing people who are Black, Latina, or Native American; or have low incomes; or have experienced hardships in their childhood or during pregnancy are at heightened risk of experiencing MMH issues. This bill will help more women and birthing people in California receive proper diagnoses if they are experiencing MMH issues by requiring that a screening be offered to women and birthing people at least once during pregnancy, with an additional screening offered during the first six months of the postpartum period, if determined medically necessary and is clinically appropriate in the judgment of a provider. This increased access to screening will help more women and birthing people in California seek and receive the treatment they need to address MMH issues.”
   
2. Maternal and Infant Health Assessment (MIHA). MIHA is an annual, statewide-representative survey of California residents with a recent live birth. It is a collaborative effort involving CDPH and the University of California, San Francisco, Center for Health Equity. MIHA collects self-reported information about maternal and infant experiences and maternal attitudes and behaviors before, during, and shortly after pregnancy. The California HealthCare Foundation (CHCF) indicates that 75% of mothers/birthing people experiencing MMH symptoms do not receive treatment, and according to MIHA, 21% of pregnant and postpartum mothers/birthing people in California are affected by MMH. Forty-five percent of all 400,000 births in California are covered by Medi-Cal. Black mothers/birthing people report the highest rates of anxiety and depression, compared to all other races, and anxiety has been found to be more common than depression in the perinatal population. Maternal suicide is a leading cause of maternal mortality in the US; most commonly in the White population, and almost half occur between six and twelve months postpartum.
   
3. Screening and treatment recommendations. The United States Preventive Services Task Force (USPSTF) was created in 1984, and is an independent, volunteer panel of national experts in prevention and evidence-based medicine. USPSTF makes evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications. The USPSTF posts the final recommendation statement, final evidence review, and an evidence summary on its website. The recommendation statement and the evidence summary are also published in a peer-reviewed scientific journal. The 2019 Perinatal Depression Prevention Intervention recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. As part of this recommendation, USPSTF indicates that there is no accurate screening tool for identifying women at risk of developing perinatal depression and who might benefit from preventive interventions. However, USPSTF indicates that clinical risk factors that may be associated with the development of perinatal depression include a personal or family history of depression, history of physical or sexual abuse, having an unplanned or unwanted pregnancy, current stressful life events, pregestational or gestational diabetes, and complications during pregnancy. Social factors such as low socioeconomic status, lack of social or financial support, and adolescent parenthood have also been shown to increase the risk of developing perinatal depression. USPSTF indicates that there is no data on the ideal timing for offering or referral to counseling interventions; however, most were initiated during the second trimester of pregnancy. Ongoing assessment of risks that develop in pregnancy and the immediate postpartum period is reasonable, and referral could occur at any time. USPSTF is in the process of updating their recommendation. One of the proposed contextual questions is, are there reliable and valid prognostic tools for identifying individuals who are at increased risk of developing perinatal depression and when is the most effective time to provide interventions to prevent perinatal depression.
   
4. Maternal Mental Health Leadership Alliance (MMHLA). There is no current standard for perinatal mental health patient education and screening. MMHLA and partner organizations are developing a screening framework for when to provide patient education and screening, and to address barriers to screening. The first phase report was presented in January 2023. The framework includes education and screening at initiation of prenatal care and during each trimester of pregnancy, prior to discharge from hospital or birthing center and three weeks postpartum, and throughout the full year postpartum at all regularly scheduled obstetric and pediatric visits. MMHLA states that areas for further action are: 1) provider education and training; 2) provider reimbursement; 3) referral resources; 4) screening tools for screening the full range of disorders and that adequately address cultural and racial differences; and, 5) equity and trust to adapt to specific situations and prevent failures within the health care system.
   
5. American Academy of Pediatrics (AAP) policy statement. A January 2019 AAP policy statement published in the journal Pediatrics indicates that postpartum depression leads to increased costs of medical care, inappropriate medical treatment of the infant, discontinuation of breast-feeding, family dysfunction, and an increased risk of abuse and neglect. Postpartum depression can be treated and pediatric medical homes are recommended to coordinate care more effectively with prenatal providers for women with prenatally diagnosed maternal depression, establish a system to implement screening at the first, second, forth, and sixth month well child visits, use community resources for treatment and referral of the mother with depression, and provide support for the maternal-child (dyad) relationship. This statement recommends advocacy for payment and increased training for screening and treatment.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 6/18/24)

California State Association of Psychiatrists

Children Now

Mental Health America of California

OPPOSITION: (Verified 6/18/24)

None received

ARGUMENTS IN SUPPORT: The California State Association of Psychiatrists writes that screening for perinatal or postpartum depression or other MMH conditions is the first step to detect potential conditions that may have a negative impact during pregnancy or the postpartum period. Because a verified medical diagnostic test has not yet been developed, obstetric and licensed practitioners rely on screening tools, or questionnaires, for detection purposes. While the existing framework provides some benefit, condition onset can occur at any time, making it crucial that screenings take place more often and during both the pregnancy and postpartum periods.

ASSEMBLY FLOOR: 65-0, 5/9/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gallagher, Garcia, Gipson, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Soria, Ta, Valencia, Villapudua, Waldron, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO VOTE RECORDED: Bains, Cervantes, Megan Dahle, Flora, Gabriel, Grayson, Haney, Low, Mathis, Stephanie Nguyen, Petrie-Norris, Luz Rivas, Schiavo, Ting, Wallis

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

6/18/24 13:52:34

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: AB 1936

SUBJECT: Maternal mental health screenings

SUMMARY:

Requires, as part of an existing requirement on health plans and insurers to develop a maternal mental health (MMH) program, health plans and insurers to include at least one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period, if determined to be medically necessary and clinically appropriate in the judgement of the treating provider.

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program.[HSC §1340, et seq., INS §106, et seq., and, WIC §14000, et seq.]
   
2. Requires health plans and insurers to develop a MMH program designed to promote quality and cost-effective outcomes, developed with sound clinical principals and processes, and to include quality measures to encourage screening, diagnosis, treatment, and referral. Requires guidelines and criteria to be provided to relevant medical providers including contracting obstetric providers. Encourages plans to improve screening, treatment, and referral to MMH services, include coverage for doulas, incentivize training opportunities for contracting obstetric providers, and educate enrollees about the program. Excludes specialized health plans or insurers, except specialized behavioral health-only plans or insurers offering professional mental health services, and includes Medi-Cal managed care plans. [HSC §1367.625 and INS §10123.867]
3. Defines “MMH” as a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression. [HSC §1367.625 and INS §10123.867]
4. Requires a Medi-Cal managed care plan to continue to comply with any quality measures required or adopted by DHCS. [HSC §1367.625 and INS §10123.867]
5. Requires a licensed health care practitioner who provides prenatal, postpartum, or interpregnancy care for a patient to ensure that the mother is offered screening or is appropriately screened for MMH conditions, except when providing emergency services. Defines “health care practitioner” as a physician, naturopathic doctor, nurse practitioner, physician assistant, nurse midwife, or a licensed midwife. [HSC §123640]

This bill: Requires health plan and health insurer MMH programs required under existing law to consist of at least one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period, if determined to be medically necessary and clinically appropriate in the judgement of the treating provider.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, minor and absorbable costs to DMHC and CDI.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, according to the California Department of Public Health (CDPH), before the onset of the COVID-19 pandemic, one in five women and birthing people in California experienced symptoms of anxiety or depression during pregnancy or the postpartum period. During the pandemic, that figure increased to one in three women and birthing people. Women and birthing people who are Black, Latina, or Native American; or have low incomes; or have experienced hardships in their childhood or during pregnancy are at heightened risk of experiencing MMH issues. This bill will help more women and birthing people in California receive proper diagnoses if they are experiencing MMH issues by requiring that a screening be offered to women and birthing people at least once during pregnancy, with an additional screening offered during the first six months of the postpartum period, if determined medically necessary and is clinically appropriate in the judgment of a provider. This increased access to screening will help more women and birthing people in California seek and receive the treatment they need to address MMH issues.
   
2. Maternal and Infant Health Assessment (MIHA). MIHA is an annual, statewide-representative survey of California residents with a recent live birth. It is a collaborative effort involving CDPH and the University of California, San Francisco, Center for Health Equity. MIHA collects self-reported information about maternal and infant experiences and maternal attitudes and behaviors before, during, and shortly after pregnancy. The California HealthCare Foundation (CHCF) indicates that 75% of mothers/birthing people experiencing MMH symptoms do not receive treatment, and according to MIHA, 21% of pregnant and postpartum mothers/birthing people in California are affected by MMH. Forty-five percent of all 400,000 births in California are covered by Medi-Cal. Black mothers/birthing people report the highest rates of anxiety and depression, compared to all other races, and anxiety has been found to be more common than depression in the perinatal population. Maternal suicide is a leading cause of maternal mortality in the US; most commonly in the White population, and almost half occur between six and twelve months postpartum.
   
3. Screening and treatment recommendations. The United States Preventive Services Task Force (USPSTF) was created in 1984, and is an independent, volunteer panel of national experts in prevention and evidence-based medicine. USPSTF makes evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications. The USPSTF posts the final recommendation statement, final evidence review, and an evidence summary on its website. The recommendation statement and the evidence summary are also published in a peer-reviewed scientific journal. The 2019 Perinatal Depression Prevention Intervention recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. As part of this recommendation, USPSTF indicates that there is no accurate screening tool for identifying women at risk of developing perinatal depression and who might benefit from preventive interventions. However, USPSTF indicates that clinical risk factors that may be associated with the development of perinatal depression include a personal or family history of depression, history of physical or sexual abuse, having an unplanned or unwanted pregnancy, current stressful life events, pregestational or gestational diabetes, and complications during pregnancy. Social factors such as low socioeconomic status, lack of social or financial support, and adolescent parenthood have also been shown to increase the risk of developing perinatal depression. USPSTF indicates that there is no data on the ideal timing for offering or referral to counseling interventions; however, most were initiated during the second trimester of pregnancy. Ongoing assessment of risks that develop in pregnancy and the immediate postpartum period is reasonable, and referral could occur at any time. USPSTF is in the process of updating their recommendation. One of the proposed contextual questions is, are there reliable and valid prognostic tools for identifying individuals who are at increased risk of developing perinatal depression and when is the most effective time to provide interventions to prevent perinatal depression.
   
4. Maternal Mental Health Leadership Alliance (MMHLA). There is no current standard for perinatal mental health patient education and screening. MMHLA and partner organizations are developing a screening framework for when to provide patient education and screening, and to address barriers to screening. The first phase report was presented in January 2023. The framework includes education and screening at initiation of prenatal care and during each trimester of pregnancy, prior to discharge from hospital or birthing center and three weeks postpartum, and throughout the full year postpartum at all regularly scheduled obstetric and pediatric visits. MMHLA states that areas for further action are: 1) provider education and training; 2) provider reimbursement; 3) referral resources; 4) screening tools for screening the full range of disorders and that adequately address cultural and racial differences; and, 5) equity and trust to adapt to specific situations and prevent failures within the health care system.
   
5. American Academy of Pediatrics (AAP) policy statement. A January 2019 AAP policy statement published in the journal Pediatrics indicates that postpartum depression leads to increased costs of medical care, inappropriate medical treatment of the infant, discontinuation of breast-feeding, family dysfunction, and an increased risk of abuse and neglect. Postpartum depression can be treated and pediatric medical homes are recommended to coordinate care more effectively with prenatal providers for women with prenatally diagnosed maternal depression, establish a system to implement screening at the first, second, forth, and sixth month well child visits, use community resources for treatment and referral of the mother with depression, and provide support for the maternal-child (dyad) relationship. This statement recommends advocacy for payment and increased training for screening and treatment.
   
6. Related legislation. AB 2556 (Jackson) requires health plans and insurers to provide notice to subscribers and policyholders related to the benefits of behavioral health and wellness screenings for children. AB 2556 is scheduled to be heard in this Committee on June 5, 2024.
   
7. Prior legislation. SB 904 (Calderon, Chapter 349, Statutes of 2023) requires health plans and insurers to develop a maternal and infant health equity program to address racial disparities through the use of doulas.
   

AB 1207 (Portantino, Chapter 618, Statutes of 2022) requires health plan and insurer MMH programs to include quality measures to encourage screening, diagnosis, treatment and referral, requires program guidelines and criteria to be provided to providers; and requires education of enrollees and insureds about the plan’s or insurer’s program.

AB 1477 (Cervantes, Chapter 535, Statues of 2021) requires a health care practitioner who provides interpregnancy care to ensure that a mother is offered screening or is appropriately screened for MMH conditions. Expands the definition of “MMH condition” to include a condition that occurs during interpregnancy care.

AB 2193 (Maienschein, Chapter 755, Statutes of 2018) requires health plans and insurers to develop, consistent with sound clinical principles and processes, a MMH program, as specified. Requires a health care practitioner who provides prenatal or postpartum care for a patient, to offer to screen or appropriately screen a mother for MMH conditions.

1. Support. The California State Association of Psychiatrists writes that screening for perinatal or postpartum depression or other MMH conditions is the first step to detect potential conditions that may have a negative impact during pregnancy or the postpartum period. Because a verified medical diagnostic test has not yet been developed, obstetric and licensed practitioners rely on screening tools, or questionnaires, for detection purposes. While the existing framework provides some benefit, condition onset can occur at any time, making it crucial that screenings take place more often and during both the pregnancy and postpartum periods.

SUPPORT AND OPPOSITION:

Support: California State Association of Psychiatrists

Mental Health America of California

Oppose: None received.

-- END --

Date of Hearing: May 1, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 1936

Author:(Cervantes) – As Amended Ver:April 8, 2024

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill requires a health plan or insurer’s maternal mental health (MMH) program to consist of at least one maternal mental health screening during pregnancy, and at least one additional screening during the first six months of the postpartum period, if the treating provider determines it medically necessary and clinically appropriate.

FISCAL EFFECT:

Minor and absorbable costs to the Department of Managed Health Care and Department of Insurance.

COMMENTS:

1. Purpose. According to the author:

Women and birthing people who are Black, Latina, or Native American; or have low incomes; or have experienced hardships in their childhood or during pregnancy are at heightened risk of experiencing maternal mental health issues.

Under existing law, women and birthing people are required to be offered at least one screening for maternal mental health conditions during pregnancy and the postpartum period. Unfortunately, implementation of that law often presents the availability of these screenings to be a choice between either during pregnancy or the postpartum period. Assembly Bill 1936 will help more women and birthing people in California receive proper diagnoses if they are experiencing maternal mental health issues by requiring that a screening be offered to women and birthing people at least once during pregnancy, with an additional screening offered during the first six months of the postpartum period. This increased access to screening will help more women and birthing people in California seek and receive the treatment they need to address maternal mental health issues.

1. Prior Legislation.
   1. AB 904 (Calderon), Chapter 349, Statutes of 2023, established a maternal and infant health equity program to address racial health disparities in maternal and infant health outcomes. AB 904 expands on the existing MMH program to require health plans and insurers to conduct one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period.
   2. SB 1207 (Portantino), Chapter 618, Statutes of 2022, revises the requirements of the MMH program to include quality measures to encourage screening, diagnosis, treatment, and referral. SB 1207 also encourages coverage for doulas, incentivizes training opportunities for contracting obstetric providers, and educates enrollees and insureds about the MMH program.
   3. AB 2193 (Maienschein), Chapter 755, Statutes of 2018, establishes a MMH program designed to promote quality and cost-effective outcomes, and requires a licensed health care practitioner who provides prenatal or postpartum care for a patient to offer to screen or appropriately screen a mother for MMH conditions.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 16, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 1936

Author:((Cervantes) – As Amended Ver:April 8, 2024

SUBJECT: Maternal mental health screenings.

SUMMARY: Requires a health plan or insurer’s maternal mental health (MMH) program to conduct at least one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period, if determined to be medically necessary and clinically appropriate in the treating provider’s judgement.

EXISTING LAW:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 and the California Department of Insurance (CDI) to regulate health and other insurance. [Health and Safety Code (HSC) §1340, et seq., Insurance Code (INS) §106, et seq.]
2. Establishes as California's essential health benefits (EHBs) benchmark under the federal Patient and Protection and Affordable Care Act (ACA), the Kaiser Small Group Health Maintenance Organization contract, existing California health insurance mandates, and the 10 ACA mandated EHBs, including mental health (MH) and substance use disorder (SUD) coverage. [HSC § 1367.005 and INS § 10112.27]
3. Defines “basic health care services” as all of the following:
   1. Physician services, including consultation and referral;
   2. Hospital inpatient services and ambulatory care services;
   3. Diagnostic laboratory and therapeutic radiologic services;
   4. Home health services;
   5. Preventive health services;
   6. Emergency health care services; and,
   7. Hospice care. [HSC § 1345]
4. Requires health plans to ensure that all services are readily available at reasonable times to each enrollee consistent with good professional practice, and to the extent feasible, a health plan to make all services readily accessible to all enrollees consistent with existing law on timely access to health care services. [HSC § 1367]
5. Requires every health plan contract and insurance policy that provides hospital, medical, or surgical coverage to provide coverage for medically necessary treatment of MH and SUDs under the same terms and conditions applied to other medical conditions, as specified. [HSC § 1374.72 and INS § 10144.5]
6. Requires health plans and insurers to develop a MMH program designed to promote quality and cost-effective outcomes, developed with sound clinical principals and processes, and to provide, upon request, guidelines and criteria to medical providers including contracting obstetric providers. Encourages health plans and health insurers to improve screening, treatment, and referral to MMH services, include coverage for doulas, incentivize training opportunities for contracting obstetric providers, and educate enrollees and insureds about the MMH program. [HSC §1367.625 and INS §10123.867]
7. Requires a licensed health care provider who provides prenatal or postpartum care to, by July 1, 2019, ensure that the mother is offered or is appropriately screened for MMH conditions. [HSC §123640]

FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. The author states that according to the Department of Public Health (DPH), before the onset of the COVID-19 pandemic, one in five women and birthing people in California experienced symptoms of anxiety or depression during pregnancy or the postpartum period. During the pandemic, that figure increased to one in three women and birthing people. Women and birthing people who are Black, Latina, or Native American; or have low incomes; or have experienced hardships in their childhood or during pregnancy are at heightened risk of experiencing MMH issues. Under existing law, women and birthing people are required to be offered at least one screening for MMH conditions during pregnancy and the postpartum period. Unfortunately, implementation of that law often presents the availability of these screenings to be a choice between either during pregnancy or the postpartum period. According to the author, this bill will help more women and birthing people in California receive proper diagnoses if they are experiencing MMH issues by requiring that a screening be offered to women and birthing people at least once during pregnancy, with an additional screening offered during the first six months of the postpartum period. The author concludes that this increased access to screening will help more women and birthing people in California seek and receive the treatment they need to address MMH issues.
2. BACKGROUND. According to a California Health Care Foundation blog in 2022, in California, as in the US overall, about one in five mothers / birthing people suffers from MMH issues (also known as “perinatal mood and anxiety disorders”), negatively impacting the mother / birthing person and the child. Despite this high prevalence of MMH issues, the overwhelming majority of mothers / birthing people experiencing MMH symptoms (75%) do not receive treatment.
   1. MMH Conditions. MMH conditions are the most common complications of pregnancy and childbirth. They include prenatal and postpartum depression and/or anxiety, bipolar disorder, and in extreme cases, postpartum psychosis. According to DPH’s Maternal and Infant Health Assessment, 21% of pregnant and postpartum mothers / birthing people in California are affected. The prevalence is estimated to be even higher in some populations. For example, during pregnancy, maternal depression rates rise to as high as one in two for those on Medicaid. This is significant because Medi-Cal covers 45% of the 400,000 babies born in the state annually. Additionally, in California, Black mothers / birthing people report the highest rates of anxiety and depression, compared to all other races, and anxiety has been found to be more common than depression in the perinatal population. Alarmingly, maternal suicide is a leading cause of maternal mortality in the US; it is most common in the white population and occurs most often between six and 12 months postpartum.

Left undetected and untreated, MMH conditions can lead to negative health outcomes for the mother / birthing person, and can negatively affect the mother-child bond and the child’s long-term physical, emotional, and developmental health. Additionally, there can be significant financial costs of untreated MMH conditions (e.g., more use of emergency care services, higher rates of absenteeism at work), an estimated $35,000 for each mother / birthing person–child dyad.

• 1. Recent California coverage laws. AB 2193 (Maienschein), Chapter 755, Statutes of 2018, establishes a MMH program designed to promote quality and cost-effective outcomes and developed with sound clinical principles and processes. AB 2193 also requires a licensed health care practitioner who provides prenatal or postpartum care for a patient, to offer to screen or appropriately screen a mother for MMH conditions. SB 1207 (Portantino), Chapter 618, Statutes of 2022, further revises the requirements of the MMH program to include quality measures to encourage screening, diagnosis, treatment, and referral. SB 1207 also encourages coverage for doulas, incentivizes training opportunities for contracting obstetric providers, and educates enrollees and insureds about the MMH program. Last year, AB 904 (Calderon), Chapter 349, Statutes of 2023, established a maternal and infant health equity program to address racial health disparities in maternal and infant health outcomes. This bill expands on the existing MMH program to require health plans and insurers to conduct one MMH screening during pregnancy, and at least one additional screening during the first six months of the postpartum period.

1. SUPPORT. The California State Association of Psychiatrists write that screening for perinatal or postpartum depression or other MMH conditions is the first step to detect potential conditions that may have a negative impact during pregnancy or the postpartum period. Because a verified medical diagnostic test has not yet been developed, obstetric and licensed practitioners rely on screening tools, or questionnaires, for detection purposes.
2. RELATED LEGISLATION.
   1. AB 2556 (Jackson) requires health plan and insurer’s to provide notice to legal guardians related to the benefits of behavioral health and wellness screenings. AB 2556 is pending in Assembly Appropriations Committee.
   2. AB 3059 (Weber) requires coverage of human milk. AB 3059 is pending in Assembly Health Committee.
3. PREVIOUS LEGISLATION.
   1. AB 904 requires a health plan or health insurer, on or before January 1, 2025, to develop a maternal and infant health equity program that addresses racial health disparities in maternal and infant health outcomes through the use of doulas. Requires the DMHC, in consultation with CDI, to collect data and submit a report describing the doula coverage and the maternal and infant health equity programs to the Legislature by January 1, 2027.
   2. SB 1207 revises the requirements of the MMH program to include quality measures to encourage screening, diagnosis, treatment, and referral. Encourages health plans and health insurers to improve screening, treatment, and referral to MMH services, include coverage for doulas, incentivize training opportunities for contracting obstetric providers, and educate enrollees and insureds about the MMH program.
   3. AB 935 (Maienschein) of 2021 would have required health plans and health insurers, including Medi-Cal managed care plans, by July 1, 2022, to provide access to a telehealth consultation program that meets specified criteria and provides providers who treat children and pregnant and certain postpartum persons with access to a MH consultation program, as specified. AB 935 was held in Assembly Appropriations Committee.
   4. AB 1357 (Cervantes) of 2021 would have required DPH, for purposes of a statewide, comprehensive community-based perinatal services program, to develop and maintain on its internet website a referral network of community-based MH providers and support services addressing postpartum depression, prenatal, delivery, and postpartum care, neonatal and infant care services, and support groups, to improve access to postpartum depression screening, referral, treatment, and support services in medically underserved areas and areas with demonstrated need. Governor Newsom vetoed this bill, stating in part:

“AB 1357 is duplicative as there are existing resources available to pregnant and postpartum individuals. The Department of Health Care Services maintains a website that provides information about how individuals can seek mental health services through their local county. State programs such as the Adolescent Family Life Program, Black Infant Health Program, California Home Visiting Program, Perinatal Equity Initiative, and the Comprehensive Perinatal Services Program work to ensure pregnant and postpartum individuals are assessed, informed, linked, and referred to appropriate health and social services, including mental health services. Local health jurisdictions also inform pregnant and postpartum individuals of services and providers that are available and unique to each county. Finally, an individual's source of health coverage, whether it be Medi-Cal, a county mental health plan, or commercial health plan can arrange for care through its local provider network.”

• 1. AB 2193 requires health plans and health insurers, by July 1, 2019, to develop, consistent with sound clinical principles and processes, a MMH program, as specified. Requires, by July 1, 2019, a licensed health care practitioner who provides prenatal or postpartum care for a patient, to offer to screen or appropriately screen a mother for MMH conditions.

REGISTERED SUPPORT / OPPOSITION:

Support

California State Association of Psychiatrists
Mental Health America of California

Opposition

None on file.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097