TMaH (Transforming Maternal Health) Model: Executive Intelligence Brief

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1. Executive Summary and Strategic Context

What Is This Model and What Problem Does It Solve?

The Transforming Maternal Health (TMaH) Model is a 10-year, voluntary, state-based CMMI innovation model running from January 2025 through December 2034. It is the first CMMI model focused exclusively on maternal health care, building on prior CMS maternal health work including the Maternal Opioid Misuse (MOM) Model. The model funds and holds accountable state Medicaid agencies (SMAs) to develop whole-person approaches to pregnancy, childbirth, and postpartum care through a combination of cooperative agreement funding, technical assistance, payment redesign, and care delivery transformation.

The problem the model addresses is structurally severe: despite spending more per capita on maternal health than any other high-income nation, the U.S. has one of the highest maternal mortality rates among peer countries. The CDC reported nearly 33 maternal deaths per 100,000 live births in 2021, with estimates that more than 80% of these deaths were preventable. The maternal health crisis falls disproportionately on Medicaid populations: Medicaid covers approximately 41% of all U.S. births, and Black, American Indian, and Alaska Native women face mortality risks up to five times higher than their white counterparts. Additional structural deficits include:

• 33% of pregnant women not screened for perinatal depression, despite universal screening recommendations
• A provider-to-patient ratio of only 11 OB-GYNs and 4 midwives per 1,000 live births
• Fewer than 50% of rural U.S. counties with hospitals providing obstetric services
• Payment structures that fail to incentivize risk-stratified, team-based, or coordinated care across the full pregnancy episode
• The annual cost of preeclampsia alone estimated at $2.2 billion

TMaH is designed to attack these deficits simultaneously: expanding the maternal health workforce (midwives, doulas, community health workers), integrating behavioral health and social drivers screening into routine maternity care, deploying home monitoring for chronic conditions, and transitioning Medicaid maternity payment from fee-for-service to value-based arrangements.

Strategic Significance for the VBC Market

TMaH represents one of the most operationally complex state-driven care transformation bets CMMI has made in the Medicaid space. Its significance for value-based care stakeholders extends across several dimensions:

Medicaid managed care transformation. In participating states, Managed Care Entities (MCEs) are required collaborators — not optional bystanders. SMAs must engage their MCEs to create and implement participation plans, and technical assistance funding flows through SMAs to MCEs and providers. For Medicaid managed care plans operating in any of the 15 selected states, TMaH will reshape provider contracting requirements, quality measurement frameworks, and payment arrangements for maternity care. Plans that position proactively as implementation partners will have structural advantages in capturing the quality and cost incentive infrastructure that develops through Model Years 3–5.

Workforce pipeline disruption. The model's explicit mandate to expand coverage of midwives, doulas, and perinatal community health workers will generate new Medicaid billing pathways, fee schedule revisions, and credentialing requirements in participating states. Health systems and OB-GYN practices that integrate these workforce types ahead of mandatory coverage timelines will be positioned to capture infrastructure payments (Model Year 3) and performance incentives (Model Year 4 onward).

Data infrastructure investment. TMaH requires participating providers to upgrade health IT, achieve regional interoperability, integrate HRSN screening and referral data with community-based organizations, and link Medicaid claims to vital records, WIC/SNAP data, and hospital discharge data. These are not trivial technical lifts, and the cooperative agreement funding is explicitly authorized to support IT infrastructure investments. Health systems and FQHCs that begin these integrations during the pre-implementation period will be better positioned for the value-based payment model that activates in Model Year 5.

Birth center and alternative site-of-care expansion. The model specifically targets sustainable reimbursement rates for birth centers and free-standing midwifery units. For health systems evaluating their labor and delivery strategies, TMaH creates a policy tailwind for establishing or acquiring birth center affiliations in participating states.

Political Context and Administrative Alignment

TMaH was conceived and launched under the Biden administration, with the January 2025 state selections announced in the final days of that administration. The model is now administered under the Trump administration, with CMS Administrator Dr. Mehmet Oz and CMMI Director Abe Sutton overseeing the Innovation Center's portfolio. As of this writing, TMaH remains an active model with all 15 participating states enrolled.

The current administration's posture toward CMMI models generally — and toward Medicaid program integrity specifically — introduces meaningful uncertainty. The Department of Government Efficiency (DOGE), led by Elon Musk in an advisory capacity, has reviewed federal program expenditures broadly, and CMMI models are not categorically exempt from restructuring or termination review. However, several factors suggest TMaH carries lower political risk than some other CMMI models: it is explicitly focused on a bipartisan priority (reducing maternal mortality), it operates through state Medicaid agencies rather than imposing federal payment rules on providers directly, and it generates cost reduction as an explicit program goal rather than merely quality improvement. HHS Secretary RFK Jr.'s stated focus on preventive care and reducing chronic disease burden aligns directionally with TMaH's emphasis on prenatal screening, chronic condition management, and postpartum continuity. Stakeholders should nonetheless monitor any CMMI portfolio review announcements and maintain contingency planning for potential model modifications.

Market Transformation Implications

The 15 selected participating states — Alabama, Arkansas, California, District of Columbia, Illinois, Kansas, Louisiana, Maine, Minnesota, Mississippi, New Jersey, Oklahoma, South Carolina, West Virginia, and Wisconsin — represent a geographically and demographically diverse cohort, with significant representation from states with both high maternal mortality rates (Alabama, Arkansas, Louisiana, Mississippi) and large Medicaid managed care markets (California, Illinois, New Jersey). This selection is strategically deliberate: states with the worst outcomes create the greatest delta for measurable improvement, while large managed care states provide scale for payment model innovation.

For the broader VBC market, TMaH establishes a template for how CMMI intends to drive maternity payment reform through state Medicaid programs rather than through Medicare fee-for-service mechanisms. If the model demonstrates measurable reductions in low-risk cesarean rates, severe maternal morbidity, and low birthweight incidence — the model's primary outcome targets — it creates a replicable framework for expansion to additional states or potential federal Medicaid policy adoption. Organizations with national footprints should treat TMaH's 15-state cohort as a proof-of-concept laboratory with direct implications for their maternity care strategies across all states.

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2. Model Architecture and Payment Structure

Participation Structure and Eligibility

State Medicaid Agencies (SMAs) are the sole eligible applicants to TMaH. Medicaid agencies in all 50 states, Washington D.C., and U.S. territories were eligible to apply; CMS awarded participation to up to 15 SMAs, with the 15 selected states announced in January 2025. No other entity — hospital, MCO, physician group, community organization, or private company — may apply directly to the model.

Within each participating state, a layered collaboration structure governs implementation:

Participant Type	Role	Eligibility Mechanism
State Medicaid Agency (SMA)	Primary participant; signs Cooperative Agreement with CMS; receives and distributes funding	Direct applicant and awardee
Managed Care Entities (MCEs)	Collaborate with SMAs to create and implement participation plans in managed care states	Engaged by SMA; not direct applicants
Hospitals and Health Systems	Partner care delivery sites; receive provider infrastructure payments in MY3	Coordinated through SMA/MCE
Birth Centers	Alternative care delivery sites; receive coverage and reimbursement expansion support	Coordinated through SMA
OB-GYN Practices / Midwives	Provider participants; receive incentive payments MY4+	Must be enrolled in state Medicaid, contracted with MCEs where applicable, and hold NPI
Doulas / Perinatal CHWs	Extended care team; receive coverage expansion and billing pathway support	Must be licensed/credentialed per state Medicaid authority
FQHCs / Rural Health Clinics	Safety net provider sites	Coordinated through SMA
Community-Based Organizations (CBOs)	HRSN referral and follow-up; behavioral health connections	Coordinated through SMA
Perinatal Quality Collaboratives (PQCs)	AIM patient safety bundle implementation; quality improvement infrastructure	Coordinated through SMA

Provider eligibility requirements for participation in model payments include: enrollment in the applicable state Medicaid program; active contracts with local managed care plans where managed care enrollment is mandatory for beneficiaries; current licensure and credentialing in good standing with applicable state and federal oversight bodies; and possession of a National Provider Identifier (NPI) through the National Plan and Provider Enumeration System.

Sub-state vs. statewide implementation: SMAs may implement TMaH either within a defined sub-state region (specified by ZIP codes in the application) or statewide. CMS encourages sub-state awards as they permit in-state comparison groups for more rigorous evaluation. Statewide implementations require CMS and the SMA to define an out-of-state comparison group matched on demographic composition, resource availability, population size and density, birth outcomes, and Medicaid policy. Proposals for either approach are subject to CMS approval.

Model Timeline and Phased Implementation

Phase	Model Years	Calendar Period	Key Activities
Pre-Implementation Period	MY1–3	January 2025 – December 2027	State-specific TA; milestone achievement; payment model development; provider infrastructure payment dispersal begins MY3
Implementation Period – Year 1	MY4	January 2028 – December 2028	Quality and cost performance incentive payments to providers based on MY4 performance
Implementation Period – Year 2+	MY5–10	January 2029 – December 2034	Full value-based payment model transition; state-specific APM operational

Application and selection timeline (completed):

Milestone	Date
TMaH Model Announcement	December 2023
Application Period Opens	Spring 2024
Applications Due	Summer 2024
CMS Reviews and Selects States	Fall 2024
State Selections Announced	January 2025
Pre-Implementation Period Begins	January 2025
Implementation Period Begins	January 2028
Model Ends	December 2034

Cooperative Agreement Funding

Each selected SMA is eligible to receive up to $17 million in total cooperative agreement funding over the 10-year model period. The webinar transcript specifies this breaks down as approximately up to $8 million during the Pre-Implementation Period (MY1–3) and up to $9 million during the Implementation Period (MY4–10). Funding is authorized under Section 1115A of the Social Security Act.

Authorized uses of cooperative agreement funding include:

• Medicaid agency staff time and personnel hiring for model implementation
• IT infrastructure investments and data system upgrades
• Staff training
• Partnership development with MCEs, providers, and CBOs
• Other precursor activities required for the Implementation Period

Beginning in Model Year 3, SMAs are required to disperse a portion of their cooperative agreement funding directly to participating providers as Provider Infrastructure Payments.

Payment Methodology: Three-Stage Architecture

Stage 1 — Provider Infrastructure Payments (Model Year 3)

In MY3, SMAs disburse a portion of cooperative agreement funding to providers within their implementation region to support care delivery transformation activities. CMS will conduct data analyses to create risk-adjusted payment amounts, with state and local healthcare spending for maternity care considered in the methodology. Categories of fundable activities include:

• Patient Safety Initiatives and Maternal Care Assessment: Implementation of PQC-led AIM patient safety bundles (without duplicating HRSA, CDC, or other federal/state funding); attainment of CMS "Birthing-Friendly" hospital designation; deployment of medical and social risk assessments
• Quality Measure Reporting: Data reporting on mandatory quality performance measures and select quality assurance measures
• Data Integration and Data-Driven Maternity Care: Health IT and data infrastructure upgrades; regional and state-level interoperability; integration of HRSN screening, referral, and data exchange with CBOs
• Team-Based Care: Regular interprofessional care team meetings and planned quality improvement activities
• Enhanced Access to Care: At least one alternative to traditional office visits (e.g., telehealth, expanded hours)
• Connections to CBOs to Address HRSNs and Behavioral Health Needs: Identification and integration of local entities into screening, referral, and follow-up workflows

Stage 2 — Quality and Cost Performance Incentive Payments (Model Year 4)

SMAs pay providers upside-only performance incentive payments based on MY4 performance, overlaid on existing provider reimbursement structures. These payments are not reconciled against base payments — they represent incremental rewards for quality and cost excellence.

Performance incentive weighting:

Component	Weight
Quality Performance	80%
Cost Performance	20%

Anticipated quality performance measures (subject to final NOFO specifications):

• Low-risk cesarean delivery rate
• Timeliness of prenatal care
• Timeliness of postpartum care
• Screening for Depression and Follow-up
• Severe Obstetric Complications

States receive one-on-one technical assistance from CMS and a team of analytic experts to construct cost and quality benchmarks using 2–3 years of Medicaid claims and administrative data.

Stage 3 — Roadmap to Value-Based Care (Model Year 5 onward)

By the end of Model Year 5, SMAs transition from their current payment methodology (e.g., fee-for-service) to a state-specific value-based alternative payment model designed to incentivize whole-person maternity care, improve health outcomes, reduce disparities, and maintain or reduce Medicaid and CHIP program expenditures. The MY5 payment model architecture may include risk-adjusted prospective payments to providers with retrospective reconciliation on quality and cost outcomes. CMS works collaboratively with each SMA to design the specific payment methodology, informed by the infrastructure payments, performance incentives, and current research on maternity value-based payment arrangements.

Three-Pillar Care Delivery Design

Pillar 1: Access, Infrastructure, and Workforce

Required elements: Increase access to the midwifery workforce (including fee schedule analysis, billing pathway creation for midwife-MFM specialist consultations); increase access to birth centers (including sustainable reimbursement rate development); cover doula services through Medicaid authorities (including doula advisory councils, enrollment guidance, billing pathway support); improve data infrastructure (Medicaid-vital records linkage, cross-program data matching with WIC/SNAP, demographic data stratification); develop a state-specific maternity payment model.

Optional elements: Cover Certified Midwives and Certified Professional Midwives licensed in the state; cover perinatal Community Health Workers; create regional partnerships in rural areas among birth centers, CBOs, community hospitals, and health systems; extend Medicaid coverage to 12 months postpartum.

Pillar 2: Quality Improvement and Patient Safety

Required elements: Support implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles in partnership with Perinatal Quality Collaboratives (facilitated by HRSA recommendations, without duplicating existing federal/state funding); support hospital attainment of the CMS "Birthing-Friendly" hospital designation, including guidance on criteria alignment and provider directory display.

Optional elements: Promote shared decision-making through patient decision aid resources; expand coverage of group perinatal care.

Pillar 3: Whole-Person Care Delivery

Required elements: Home monitoring of diabetes and hypertension (telehealth platforms, equipment, training, Medicaid coverage analysis); risk assessment and screening with referral and follow-up protocols for perinatal depression, anxiety, tobacco use, substance use disorder, and Health-Related Social Needs (minimum screening domains: food insecurity, housing instability, transportation); develop a Health Equity Plan (including disparity data analysis, improvement goals, translation and transportation needs assessment).

Optional elements: Expand oral health care (addressing barriers, provider education, payment analysis); increase use of home visits, mobile clinics, and telehealth.

Model Overlap Policies

Concurrent participation in other CMMI models is permitted under specific conditions:

Overlapping Model	State-Level	Sub-State	Provider-Level
Making Care Primary (MCP)	Permitted	Permitted	Permitted
Cell and Gene Therapy (CGT) Access Model	Permitted	Permitted	N/A (no provider participants)
Innovation in Behavioral Health (IBH)	Permitted	Permitted	Not Permitted (hospitals/FQHCs cannot receive both TMaH and IBH payments simultaneously)
AHEAD Model	Permitted	Not Permitted (must operate in separate non-overlapping sub-state regions)	Not Permitted (hospitals/practices cannot receive both TMaH and AHEAD global budget payments)

Beneficiary-level overlap is permitted for all four models listed above — Medicaid and CHIP beneficiaries may receive services from multiple overlapping models concurrently.

Health Equity Architecture

TMaH's overarching health equity goal is stated specifically as reducing disparities in severe maternal morbidity among pregnant and postpartum Medicaid and CHIP beneficiaries. Each SMA is required to develop, implement, and evaluate a Health Equity Plan (HEP) across the full 10-year model. During the Pre-Implementation Period, CMS supports HEP development through disparity analysis, goal-setting, and progress tracking. During the Implementation Period, the HEP operationalizes through HRSN data collection and screening protocols, patient safety improvement initiatives, and targeted interventions in high-need areas. The HEP guides staff hiring, data collection infrastructure decisions, community engagement strategy, and prioritization of populations for intervention planning.