Maternity Services for Medi-Cal Members

Comprehensive Risk Assessment 

Network providers must implement a comprehensive risk assessment tool for all pregnant and postpartum members that is comparable to American College of Obstetricians & Gynecologists (ACOG) and Comprehensive Perinatal Services Program (CPSP) standards. Providers may also utilize American Academy of Family Physicians (AAFP), American College of Nurse Midwives (ACNM) or National Association of Certified Professional Midwives (NACPM) standards. 

• When to administer: At an early prenatal visit, once each trimester thereafter and at the postpartum visit. 
• Content areas: Obstetric, nutrition, psychosocial and health education interventions. 
• Documentation: Maintain assessment results in the member's medical record. Develop an individualized care plan (ICP). 
• Missed assessments: The Alliance's Care Coordination team works directly with members and maternity providers to complete missed assessments. 
• Telehealth: Risk assessments may be completed virtually with member consent. 

Intimate Partner Violence (IPV) Screening 

IPV screening is a covered preventive service and U.S. Preventive Services Task Force (USPSTF) Grade B recommendation. 

IPV screening must be incorporated into the comprehensive risk assessment at the initial prenatal appointment (or an alternative prenatal appointment), each trimester and during the postpartum assessment. Screening must occur without the intimate partner present to ensure safe disclosure. Refer positive screens to ongoing support services. 

Resources 

• CDPH CPSP Resources 
• DHCS Medi-Cal Provider Manual: Preventive Services 

The Alliance ensures initiation of prenatal care as soon as possible and covers all medically necessary services for pregnant and postpartum members, with ACOG and CPSP standards as the minimum measure of quality. 

The Alliance does not require prior authorization for basic prenatal, maternal and preventive services and care, as defined by current ACOG and CPSP standards. 

Key Coverage Requirements 

• Folic acid: Covered by Medi-Cal Rx for members trying to become pregnant, pregnant members and postpartum members who are breastfeeding.  
• Prenatal vitamins: Covered by Medi-Cal Rx for pregnant members and postpartum members who are breastfeeding. 
• Dental screenings: Coordinated for all pregnant and postpartum members per ACOG guidelines. 
• CPSP enrollment not required: Maternity network providers, including licensed midwives (LMs) and certified nurse-midwives (CNMs), are not required to enroll as certified CPSP providers. 
• High-risk referrals: Pregnant members at high risk of poor pregnancy outcomes are referred to appropriate specialists or hospitals equipped for high-risk pregnancies. 

Prior Authorization Turnaround (Effective January 1, 2026) 

Per Centers for Medicare and Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F), when PA is required, determinations must be made within: 

• 7 calendar days from the date the request is made for standard cases. 
• 72 hours from the date and time the request is made for urgent cases. 

Culturally Competent Care 

The Alliance provides culturally and linguistically competent/humble health care and services to all pregnant and postpartum members. 

See Alliance Policy #401-3106: Perinatal Services for prenatal and postpartum care services. 

The Alliance offers language assistance services to members at no cost. 

Resources 

• DHCS Birthing Care Pathway 
• Local Health Department (LHD) Memoranda of Understanding (MOU) by County 

California Prenatal Screening (CA PNS) Program 

Prenatal network providers must offer information about the CA PNS Program to all pregnant members who engage in care before 21 weeks 0 days gestation. The program screens for chromosomal abnormalities, sex chromosome aneuploidies and neural tube defects via cell-free DNA (cfDNA) and Maternal serum alpha-fetoprotein (MSAFP) blood tests. 

CA PNS Program services are carved out of MCP contracts and billed through Medi-Cal Fee-For-Service. No PA is required when the services are performed by participating providers.  

Members pay nothing for screenings, phlebotomy, shipping or authorized follow-up diagnostic testing.Participation is voluntary andmember consent must be documented. 

If results are positive or inconclusive, the regional CA PNS coordinator contacts the prenatal provider for referral to a state-approved prenatal diagnosis center (PDC). 

Out-of-program screening 

If a member declines the CA PNS Program, screening through Medi-Cal-enrolled licensed clinical labs is covered through managed care. 

California Newborn Screening (NBS) Program 

All newborns must be screened for over 80 serious but treatable genetic and congenital disorders through the CA NBS Program. Members may opt out for religious beliefs or practices. 

Specimen collection must occur between 12 and 48 hours after birth unless otherwise medically indicated. If the screening is not performed within 48 hours, specimen may be collected up to 1 year of age without PA. 

• If results are positive, then the newborn is eligible for California Children's Services (CCS) and should be referred to the county CCS office. Find more information about CCS on the DHCS website. 

California Newborn Hearing Screening Program (NHSP) 

Through the NHSP, voluntary screenings are offered in general acute care hospitals with licensed maternity care units. Screenings are required (not voluntary) for infants receiving care in a NICU prior to discharge. Newborns who do not pass are referred for additional testing. Confirmed positive results trigger CCS eligibility. Find more information about the NHSP in the DHCS Medi-Cal Provider Manual. 

Critical Congenital Heart Disease (CCHD) Screening 

CCHD screenings are covered for newborns at least 24 hours of age. They are conducted with a pulse oximeter and are optional at the parents'/guardians' discretion. CCHD screenings are recommended via the American Academy of Pediatrics (AAP) Bright Futures Periodicity Schedule. Newborns who do not pass receive comprehensive medical evaluation by their primary care provider (PCP) and may be CCS-eligible. 

Resources 

DHCS Medi-Cal Provider Manual: Genetic Counseling and Screening

Freestanding Birth Centers (FBCs) 

The Alliance provides access to FBC services and contracts with a sufficient number based on level of need in each county, with at least one FBC in each county where available. If unavailable in-network, the Alliance covers out-of-network FBC services. FBCs are sometimes referred to as Alternative Birthing Centers (ABCs) in California. 

Certified Nurse-Midwives (CNMs) and Licensed Midwives (LMs) 

The Alliance provides members access to both CNMs and LMs for services permitted within each practitioner's scope of practice. 

Both CNMs and LMs practice independently. No physician supervision is required for contracting, payment or service provision. High-risk pregnancy definitions may not be used to restrict which pregnancies a CNM or LM can support. 

• CNMs: Licensed by the California Board of Registered Nursing; may maintain national certification through the American Midwifery Certification Board (AMCB) (not required). 
• LMs: Licensed by the Medical Board of California; may maintain national certification through the North American Registry of Midwives (NARM) (not required). 

Prior authorization is prohibited for in-network and out-of-network CNM and LM coverage of basic prenatal, maternal and preventive services per ACOG and CPSP standards. 

When members seek out-of-network CNM/LM care due to in-network unavailability, provider payment is no less than applicable FFS rate.APL 23-022 protects continuity of care for members with established CNM/LM care prior to Medi-Cal eligibility or enrollment. For more information, see Alliance Policy 404-1114: Continuity of Care. 

Learn more on the DHCS Midwifery Services webpage 

American Indian (AI)/Alaska Native (AN) Member Protections 

The Alliance maintains Tribal Liaisons dedicated to working with contracted and non-contracted Indian health care providers (IHCPs).  

AI/AN members can choose an IHCP as PCP, in or out of network. No referral or prior authorization is required for IHCP services. 

Resources 

• ACOG Levels of Maternal Care 
• DHCS Medi-Cal Provider Manual: Non-Physician Medical Practitioners 

Pregnant and postpartum members may access behavioral health services through the Alliance. This page highlights behavioral health services and requirements specific to the prenatal and postpartum periods. 

Looking for general behavioral health information? 

For information about non-specialty mental health services (NSMHS), specialty mental health services (SMHS), behavioral health referrals, crisis services, provider responsibilities and additional behavioral health resources, visit the Behavioral Health provider webpage. 

Depression Screening and NSMHS 

Network providers must offer prenatal and postpartum depression screenings. DHCS monitors plan performance through two Managed Care Accountability Set (MCAS) measures: Prenatal Depression Screening and Follow-Up (PND-E) and Postpartum Depression Screening and Follow-Up (PDS-E). 

Providers are encouraged to submit MCAS measure compliance through our Data Submission Tool located on the Alliance Provider Portal. For more information, please review these resources:  

• HEDIS 
• HEDIS FAQ Guide 
• HEDIS Code Set 

NSMHS counseling via individual and/or group sessions is covered for pregnant and postpartum members with risk factors for prenatal/postpartum depression. These services are covered during pregnancy and through 12 months postpartum. 

It is a USPSTF Grade B recommendation to connect members with counseling interventions to prevent prenatal and postpartum depression if they are at increased risk (low socioeconomic status, lack of support, recent IPV, etc.). 

For SMHS, the Alliance refers to and coordinates with Behavioral Health Plans (BHPs), formerly known as Mental Health Plans (MHPs), for SMHS delivery when members meet access criteria. 

No Wrong Door for Behavioral Health Services 

Members receive timely mental health services regardless of delivery system where they seek care. The Alliance must: 

• Provide substance use disorder (SUD) services (screening, assessment, brief intervention, referral) for pregnant members in primary care settings. Universal urine drug screening is not required. 
• Cover medications for addiction treatment (Medication Assisted Treatment, or “MAT”) in primary care offices, emergency departments, inpatient hospitals and other contracted medical settings. 
• Authorize payment for NSMHS delivered to members who concurrently meet criteria for or are receiving SMHS, provided services are clinically appropriate, coordinated and non-duplicative. 

Dyadic Services and Family Therapy 

Dyadic services and family therapy are covered for pregnant and postpartum members with a newborn and/or older child. Includes dyadic behavioral health well-child visits, dyadic comprehensive community supports services, dyadic psychoeducational services, and dyadic family training and counseling for child development. Family therapy is covered under the NSMHS benefit. 

Adverse Childhood Experiences (ACEs) screening 

ACEs screenings are covered for pregnant and postpartum members. Positive screens trigger care coordination and medically necessary follow-up referrals. 

For more information, review the ACEs Aware Provider Toolkit. 

Alliance Policy Reference 

See Alliance policies: 

• 408-1308 – Behavioral Health Crisis and Triage  
• 405-1320 – Medi-Cal Screening and Transition of Care Tool 

Resources 

• Alliance MOUs 
• Behavioral Health Information Notices (BHINs) 

Breastfeeding Information and Education 

Network providers (including maternity providers, PCPs and pediatric providers) must provide information regarding techniques for successful initiation of breastfeeding at an appropriate time after delivery. 

• Prenatal period: Provide nutrition and health education assessments and interventions including breastfeeding education and counseling. Communicating the benefits of breastfeeding and strategies to overcome barriers are integral to prenatal counseling. 
• Postpartum period: Provide health education, counseling and medically necessary interventions immediately after delivery and throughout the postpartum period. 

Lactation Consultant Services 

Prior authorization or referral is not required for pregnant or postpartum member to access lactation consultation services. There is no limit on medically necessary lactation visits while pregnant and through 12 months postpartum. These visits are covered for in-person, home-based and telehealth settings. 

• Qualified providers: Physicians, RNs (including CNMs and NPs), dietitians under physician direction. LMs paid via E&M codes. 
• International Board Certified Lactation Consultants (IBCLCs) and Certified Lactation Counselors (CLCs): Not eligible to enroll as Medi-Cal providers, but may provide services under a supervising licensed provider who bills on their behalf. 
• Women, Infants and Children (WIC) program referrals: All pregnant and breastfeeding members must be offered referrals to WIC. Find more information about WIC eligibility on the U.S. Department of Agriculture (USDA) website. WIC also offers other services for eligible families, including help buying healthy food. 

Lactation Durable Medical Equipment (DME) 

Effective January 2026, the Alliance does not require prior authorization for non-hospital-grade (manual and electric) breast pumps. It is recommended that pregnant members are provided with abreast pump at 32 weeks 0 days gestation (or earlier for high-risk pregnancies). Providers can submit a request for a breast pump to a durable medical equipment (DME) provider that accepts Medi-Cal. 

Cordless and wireless wearable breast pumps are covered.Covered supplies include tubing, adapters, bottles and caps, breast shields, splash protectors, locking rings and nipple shields. 

Member choice is protected. Providers cannot restrict members to one type, model or manufacturer for breast pumps.Lactation DME cannot be authorized solely based on lowest price if it doesn't meet medical needs. Find relevant DME guidance in the DHCS Medi-Cal Provider Manual.  

Human Milk Banks 

Pasteurized donor human breast milk is covered for newborns whose mother is unable to breastfeed for medical reasons and whose infant cannot tolerate or has medical contraindications to any formula. California has two human milk banks: Mother's Milk Bank California (San Jose) and the University of California Health Milk Bank (San Diego). 

Alliance Policy Reference: 

• See Alliance Policy 404-1136 - Enteral Nutrition Products 

Breastfeeding Promotion at Hospitals 

Per state law effective January 1, 2025, all general acute care hospitals and special hospitals in California must adopt either the "Ten Steps to Successful Breastfeeding" (Baby-Friendly USA), the CDPH Model Hospital Policy Recommendations or an alternate evidence-based process. 

Resources 

• 9 Steps to Breastfeeding-Friendly Clinics 
• AAP Breastfeeding Patient Care 
• Academy of Breastfeeding Medicine Resources 
• ACOG Breastfeeding Resources 
• Baby-Friendly USA Facility Directory 
• CDPH Regional Breastfeeding Liaisons 

Through the Healthy Moms, Healthy Babies program, pregnant and postpartum members may receive health education and support related to prenatal and postpartum care, breastfeeding, pediatric care and parenting. The program also connects members to community resources, including Women, Infants and Children (WIC) and other free or low-cost services. 

The Alliance provides access to doula services for pregnant and postpartum members. Doula services include health education; advocacy; and physical, emotional and non-medical support before, during and after birth. Doulas also offer health navigation, lactation support, birth plan development and linkages to community-based resources. Covered services include support for miscarriage, stillbirth and abortion. 

Statewide Standing Recommendation 

DHCS has issued a statewide standing recommendation that all members who are pregnant or up to 12 months postpartum would benefit from receiving doula services from a Medi-Cal-enrolled doula provider. This recommendation fulfills the federal requirement for a written recommendation for preventive services. 

Authorized Visits Under the Standing Recommendations 

• 1 initial visit. 
• Up to 8 additional visits in any combination of prenatal and postpartum. 
• Support during labor and delivery (including labor and delivery resulting in stillbirth), abortion or miscarriage. 
• Up to 2 extended three-hour postpartum visits. 
• Up to 9 additional postpartum visits available with a recommendation from a physician or other licensed practitioner. 

DHCS Resources 

• Doula Services Webpage 
• Medi-Cal Provider Manual: Doula Services 

CHW services include health education and navigation, screening and assessment, individual support or advocacy, and violence prevention services. CHWs may be known by various titles including community health representatives or promotores. CHW services may be provided virtually via telehealth with member consent. 

Standing Recommendation 

DHCS has issued a statewide standing recommendation that eligible members—including pregnant and postpartum members—would benefit from up to 6 hours annually of Medi-Cal covered CHW services from a CHW operating under the supervision of an enrolled CHW supervising provider. 

Eligibility Triggers for Pregnant/Postpartum Members 

• One or more chronic health conditions (including a behavioral health condition). 
• Exposure to violence and trauma. 
• At risk for a chronic health condition or environmental health exposure. 
• Barriers to meeting health or health-related social needs. 
• Positive IPV screening result. 
• Positive ACE, prenatal/postpartum depression or SUD screening result. 

Examples of CHW Support for Maternity 

• Connecting pregnant members with non-emergency medical transportation (NEMT) for prenatal visits. 
• Helping postpartum members enroll in WIC. 
• Supporting members during the prenatal/postpartum period in clinical and home settings. 

For more information, review the DHCS Medi-Cal Provider Manual. 

Group perinatal care brings pregnant members who are due at the same time together for their prenatal care. These models typically follow the clinically recommended schedule of prenatal visits, but allow members more time with providers, privately and in group settings, to discuss topics including nutrition, stress management, labor and delivery, breastfeeding, safety and newborn care.  

• Benefits: Empowers members to engage in their own care and build community. 
• Outcomes: Shown to improve maternal and infant health outcomes, particularly for pregnant and postpartum members of color.  

More information is available in the Pregnancy: CPSP section of the DHCS Medi-Cal Provider Manual. 

Community Supports are medically appropriate and cost-effective alternatives to services or settings covered under the California Medicaid State Plan.  

Community Supports of Special Relevance to Pregnancy/Postpartum 

• Medically Tailored Meals/Medically Supportive Food: Includes high-risk pregnancy nutrition plans and gestational diabetes meal or grocery plans. 
• Housing Transition Navigation Services, Housing Deposits, Housing Tenancy and Sustaining Services: Pregnancy and up to 12 months postpartum is an eligible clinical risk factor for members who are homeless or at risk of homelessness.  
• Other Community Supports: Members may access or qualify for other supports if they meet relevant requirements. Refer to the Community Supports (CS) Provider Information webpage for more information. 

Resources 

• DHCS Community Supports Policy Guide Volume 1 and Volume 2 

Care Management Tiers 

• Basic Population Health Management (BPHM): Available to all members. 
• Complex Care Management (CCM): For members needing extra support but not in the highest risk group. 
• Enhanced Care Management (ECM): Whole-person, interdisciplinary care management for members with the most complex medical and social needs.  

Enhanced Care Management 

Birth equity 

ECM eligibility criteria for the Birth Equity population of focus (POF) includes adults and youth who are pregnant or postpartum (through 12 months) and are subject to racial and ethnic disparities as defined by California public health data on maternal morbidity and mortality. 

Transitional Care Services 

Transitional Care Services (TCS)are care coordination services provided to members during transitions between care settings. Pregnancy and postpartum TCS must be provided during transitional events throughout pregnancy and the postpartum period (12 months following the end of pregnancy). Delivery-related pregnancy and postpartum TCS supports are limited to 60 days following delivery and do not extend for the full postpartum period. Eligible transitional events include any hospital discharge, as well as the end of pregnancy. 

For pregnant and postpartum members, TCS is categorized into two levels: moderate-intensity and high-intensity. “Lower-risk TCS” is not applicable. 

Pregnancy and postpartum TCS align with PHM and CPSP requirements, as well as ACOG and AAP guidelines. For both pregnancy and postpartum TCS categories, the Alliance and its contracted entities must complete the TCS Birthing Supports Checklist. This checklist connects members to medical, behavioral health, and whole-person services and supports including WIC, CalFresh, home visiting programs and paid family leave. 

• High-intensity TCS: Members are assigned a single point of contact TCS Care Manager. Services should begin upon identification of high-intensity criteria, and no later than the beginning of the third trimester. 
• Moderate-intensity TCS: May be fulfilled by a care coordination entity (contracted entity or Alliance staff); responsibilities may be distributed across multiple provider roles. Services should begin no later than the beginning of the third trimester. 

Resources 

• CDPH Women/Maternal Dashboard 
• DHCS ECM Policy Guide 
• DHCS Enhanced Care Management 
• DHCS Population Health Management 
• PHM Policy Guide 

The Alliance covers family planning and related services for members, including pregnant and postpartum members, in or out of network.  

The Alliance does not require prior authorization for family planning and related services, whether obtained in or out of network.

Covered Services 

• Contraceptive services: 
• All FDA-approved methods of contraception. 
• Up to 12-month supply of self-administered hormonal contraceptives at member’s request (carved out to Medi-Cal Rx). 
• Counseling and education on all methods, including natural family planning and abstinence. 
• Male and female sterilization. 
• Emergency services and services for complications. 
• Laboratory, radiology and drugs associated with family planning procedures. 
• Pregnancy testing and counseling services. 
• STI services: Prevention, counseling, screening, testing, diagnosis and treatment per CDC STI Treatment Guidelines. 
• HIV counseling and testing. 
• Cervical cancer screening. 
• HIV pre-exposure prophylaxis (PrEP)/post-exposure prophylaxis (PEP): Carved out to Medi-Cal Rx. 

Member Rights 

The Alliance educates members on family planning importance, options available and member rights to confidential services and unrestricted choice of contraceptive methods.  

DHCS Resources 

• Medi-Cal Provider Manual: Family Planning 
• Office of Family Planning 

The Alliance covers and ensures timely access to abortion services, as well as the medical services and supplies incidental or preliminary to an abortion, consistent with the Abortions section of the Medi-Cal Provider Manual. 

This includes: 

• 12 months postpartum coverage for members following abortion. 
• Care coordination for related behavioral health services, including grief support after stillbirth, miscarriage or abortion.  
• Doula services to support members through abortion, miscarriage and stillbirth.