TMaH (Transforming Maternal Health) Model

Analysis updated November 9, 2026

Strategic questions for your team

Given that TMaH is a state-based model where only State Medicaid Agencies are eligible applicants and hospitals/health systems participate as downstream partners rather than direct participants, has your organization identified and begun engaging your state Medicaid agency in one of the 15 selected states (Alabama, Arkansas, California, DC, Illinois, Kansas, Louisiana, Maine, Minnesota, Mississippi, New Jersey, Oklahoma, South Carolina, West Virginia, or Wisconsin) to secure a formal partnership role before the 3-year Pre-Implementation Period (January 2025–December 2027) concludes and infrastructure payment flows begin in Model Year 3?
Does your organization have the financial runway and operational capacity to invest in TMaH-required care delivery transformations — including doula coverage infrastructure, AIM patient safety bundle implementation, home monitoring for diabetes and hypertension, and HRSN screening and referral workflows — during Model Years 1–3 without receiving direct CMS payment, given that Provider Infrastructure Payments from SMA cooperative agreement funds (up to $17 million over 10 years) do not flow to providers until Model Year 3, and upside-only Quality and Cost Performance Incentive Payments do not begin until Model Year 4?
Is your organization prepared to meet the Model Year 4 quality performance benchmarks — specifically low-risk cesarean delivery rates, timeliness of prenatal care, timeliness of postpartum care, screening for depression and follow-up, and severe obstetric complications — understanding that these five measures will drive 80% of the performance incentive weighting, with cost performance comprising the remaining 20%, and that CMS will use 2–3 years of Medicaid claims data to set the benchmarks against which your performance will be judged?
By Model Year 5, your organization will be required to transition from fee-for-service to a value-based payment model that may include risk-adjusted prospective payments with retrospective reconciliation on quality and cost outcomes — have you modeled the financial impact of this shift on your Medicaid maternal health service line, and does your current data infrastructure support the risk stratification and cost benchmarking analytics that CMS will use to design your state's specific value-based payment arrangement?
Does your organization have the health IT and data infrastructure — including the ability to link Medicaid claims to vital records, federal food and housing program data (WIC/SNAP), and hospital discharge data, and to use a validated HRSN screening instrument such as the Accountable Health Communities tool or PRAPARE — required to meet TMaH's mandatory data collection and reporting obligations, and have you assessed the capital investment needed to close any gaps before Model Year 3 infrastructure payments are distributed?
Has your CMO and clinical leadership assessed whether your maternal health workforce can execute the full scope of TMaH's required care team expansion — specifically covering doula services through Medicaid authorities, increasing access to midwives and birth centers, integrating perinatal community health workers, and implementing interprofessional team-based care meetings — given that the model targets a ratio of only 11 OB-GYNs and 4 midwives per 1,000 live births nationally, and that workforce shortages are a primary driver of the model's design?
If your organization operates in a state participating in both TMaH and either the Innovation in Behavioral Health (IBH) Model or the AHEAD Model, have you determined whether your hospitals and practices can receive TMaH provider payments without being simultaneously disqualified from IBH Model payments, or whether your geographic footprint conflicts with the requirement that TMaH and AHEAD must operate in separate, non-overlapping sub-state regions with no provider-level overlap in global budget payments?
Has your organization evaluated whether your state's SMA intends to implement TMaH at the sub-state level (which CMS actively encourages for evaluation rigor and allows in-state comparison groups) versus statewide (which requires an out-of-state comparison group), and does your patient population and geographic footprint align with the likely implementation region, since providers outside the designated implementation geography will not be eligible to receive Model Year 3 infrastructure payments or Model Year 4 performance incentives?
Does your organization have the behavioral health integration infrastructure required by TMaH's Whole-Person Care Delivery component — specifically, established screening and referral protocols for perinatal depression, anxiety, tobacco use, and substance use disorder, partnerships with community-based organizations to address food insecurity, housing instability, and transportation needs, and telehealth platforms for remote monitoring of gestational diabetes and hypertension — and if not, what is the realistic timeline and cost to build these capabilities before the Implementation Period begins in January 2028?
Given the 10-year model horizon (2025–2034), the current Trump administration's focus on Medicaid spending reduction under CMS Administrator Dr. Mehmet Oz and CMMI Director Abe Sutton, and the inherent model risk that CMMI could modify, pause, or terminate innovation models that do not demonstrate expenditure reduction alongside quality improvement, has your executive team stress-tested your TMaH participation strategy against scenarios where the Roadmap to Value-Based Care payment methodology is restructured or the cooperative agreement funding terms are renegotiated before Model Year 5?

Traps and concerns

Value-Based Payment Design Vacuum Creates Cliff Risk
The model defers full value-based payment (VBP) design until Model Year 5 (January 2029), yet SMAs must operationalize the transition from FFS by the end of that year. The payment methodology is explicitly described as 'informed by infrastructure payments, quality and cost performance incentive payments, as well as the latest research on maternity value-based payment arrangements' — meaning the final architecture does not exist at model launch. States that fail to build adequate actuarial infrastructure and Medicaid managed care contract amendments during the 3-year pre-implementation period (MY1-3, January 2025–December 2027) will face an abrupt payment redesign cliff with no fallback. The $17 million total cooperative agreement funding — split roughly $8 million pre-implementation and $9 million implementation — is the only financial cushion, and it must simultaneously fund IT infrastructure, staff time, training, and provider infrastructure payments beginning in MY3. States that underspend early on data and actuarial analytics will be unable to construct the risk-adjusted prospective payment model with retrospective reconciliation contemplated for MY5, creating stranded costs and potential federal clawback exposure.
Quality Benchmark Data Immaturity Undermines MY4 Incentive Payments
Performance incentive payments to providers are triggered by Model Year 4 (January 2028) performance against quality and cost benchmarks constructed from only 2–3 years of Medicaid claims data. For states starting in January 2025, that baseline window is MY1–MY3 — a period during which care delivery is actively being transformed, meaning baseline data will not reflect stable pre-intervention utilization patterns. The five anticipated performance measures (low-risk cesarean delivery, timeliness of prenatal care, timeliness of postpartum care, screening for depression and follow-up, and severe obstetric complications) are explicitly noted as 'subject to change,' and the cost benchmark carries a 20% weighting. If benchmark-setting methodology is finalized late or based on contaminated baseline data, providers may receive windfall upside payments unrelated to true performance improvement, or conversely face unachievable benchmarks that suppress provider participation and undermine the workforce expansion goals central to the model's access strategy.
MCE Contract Non-Alignment Blocks Provider Payment Flow
TMaH's payment flow requires SMAs to pass cooperative agreement funding and performance incentives through to providers — but in managed care states, this requires affirmative amendments to existing managed care entity (MCE) contracts. The model documentation identifies participating MCEs as collaborators who 'will create and implement a plan to participate,' but MCE contract renegotiation cycles, state procurement rules, and actuarial soundness certification requirements under 42 CFR Part 438 can extend 12–24 months. States where Medicaid enrollment is predominantly managed care — and where enrollment in an MCE is mandatory for beneficiaries — face the highest risk: provider infrastructure payments due in MY3 and quality performance incentives due in MY4 cannot legally flow to providers without valid MCE contract vehicles. States with large managed care penetration that delay MCE engagement in MY1 may miss the MY3 provider payment window entirely, forfeiting the infrastructure-building phase that the entire payment progression depends upon.
AHEAD and IBH Overlap Restrictions Create Sub-State Geographic Fragmentation
The TMaH Overlaps Policy Fact Sheet prohibits simultaneous operation of TMaH and the AHEAD Model within the same sub-state region, and prohibits providers from simultaneously receiving TMaH payments and AHEAD global budget hospital payments. It also prohibits providers from simultaneously receiving TMaH payments and IBH Model payments. For the 15 selected states — which include states like Illinois, Minnesota, and New Jersey that have strong interest in multi-model participation — these restrictions create a complex geographic carve-out requirement. A hospital system operating across both a TMaH sub-state region and an AHEAD region would need to bifurcate its quality improvement workflows, billing infrastructure, and care coordination protocols by geography, with different incentive payment structures applying to clinically identical patients. The administrative burden of tracking provider NPI and TIN-level overlap exclusions across two concurrent federal models in real time is substantial, and misclassification of a provider as eligible for both payment streams triggers federal compliance exposure under the cooperative agreement terms.
Doula and Midwife Workforce Pipeline Cannot Meet Enrollment Timelines
A required model element is coverage of doula services and expansion of midwifery workforce access — yet as of the model's launch context, only 10 states and D.C. covered doulas under Medicaid, and the national ratio stands at only 4 midwives per 1,000 live births. The model requires SMAs to establish doula advisory councils, create billing pathways, and enroll doulas in Medicaid during the 3-year pre-implementation period. However, doula Medicaid enrollment requires credentialing, NPI acquisition, and managed care plan contracting — each step carrying multi-month timelines — for a workforce that is largely informal and unaccustomed to healthcare billing systems. States like Alabama, Arkansas, Mississippi, and West Virginia — which are among the 15 selected participants and face the most acute maternal mortality disparities — also have the least developed doula workforce infrastructure. If the workforce pipeline is not built by MY3, provider infrastructure payments cannot be disbursed to doulas and midwives as intended, and the access expansion goal that anchors the entire care delivery model fails before the implementation period begins.
Health-Related Social Needs Data Infrastructure Has No Interoperability Mandate
A required model element is collection and stratification of HRSN data, including screening for food insecurity, housing instability, and transportation, and integration with CBO referral networks. The model requires linking Medicaid claims to vital records, WIC/SNAP data, and hospital discharge data — but the cooperative agreement provides no federal interoperability mandate or data sharing authority over non-Medicaid systems. State agencies controlling vital records, public housing data, and SNAP enrollment operate under separate statutory authorities, and data sharing agreements require independent negotiation. For states implementing sub-state models (which CMS explicitly encourages for evaluation rigor), this fragmentation is compounded: HRSN data must be stratified at the zip-code level to support the in-state comparison group methodology, a granularity that Medicaid claims data alone cannot achieve. States that enter MY4 without functioning HRSN data pipelines will be unable to demonstrate performance on health equity metrics within the Health Equity Plan, jeopardizing model continuation and exposing the SMA to cooperative agreement compliance findings.
Trump Administration Policy Realignment Threatens Model Continuity
TMaH was designed and launched under Biden-era CMS leadership and explicitly references alignment with the 'White House Blueprint for Addressing the Maternal Health Crisis' and the 'Biden-Harris Administration's commitment to improve maternal health.' Under the current Trump administration, with CMS Administrator Dr. Mehmet Oz and CMMI Director Abe Sutton overseeing the Innovation Center, and DOGE-driven pressure to reduce federal program expenditures, the model faces material political and administrative continuity risk across its 10-year span (2025–2034). CMMI models operate under Section 1115A authority, which gives the Secretary discretion to terminate models that are not improving quality or reducing expenditures. The 3-year pre-implementation period (MY1–MY3) produces no measurable cost savings and requires $8 million in upfront cooperative agreement disbursements per state — a profile that is vulnerable to DOGE-style scrutiny. States that have committed significant internal staff time and IT infrastructure investment based on the full 10-year model architecture face stranded cost exposure if the model is restructured, paused, or terminated before the MY5 value-based payment transition, with no federal indemnification mechanism provided in the cooperative agreement structure.