Prevention of congenital syphilis requires identification and treatment of syphilis in pregnancy. The CDC¹⁵ and the American College of Obstetricians and Gynecologists (ACOG) recommend routine syphilis screening in the first trimester,¹⁶ and until recently, both also recommended that screening in the third trimester and at delivery be based on risk. Meanwhile, state laws regarding syphilis testing in pregnancy vary.¹⁷

The lack of a national recommendation (or Healthcare Effectiveness Data and Information Set [HEDIS] measure) has not entirely precluded action at the state or plan level. For example, in 2020, AmeriHealth Caritas Louisiana created a perinatal quality enhancement program that included syphilis screening in the third trimester.¹⁸ Louisiana Medicaid then developed a required Performance Improvement Project (PIP) with specific targets for increasing syphilis screening at all 3 stages, which offers a compelling model for other states and plans.¹⁹ Louisiana recently launched the PIP with all 6 of its state MCOs; they focus on both patient and provider engagement.

However, in interviews with Medicaid MCOs and in earlier interviews with health care providers,¹⁸ we heard repeatedly that the lack of a national recommendation made it difficult to shift providers to routine third-trimester and delivery screening.

This landscape recently changed. In April 2024, citing nationally rising rates of congenital syphilis and persistent disparities, ACOG revised its recommendation to endorse routine screening in the first and third trimesters and at delivery.²⁰ Accordingly, Medicaid MCOs, in partnership with state Medicaid agencies, may consider recommendations for their providers to conduct routine syphilis screenings in the first and third trimesters and at delivery, whether through reporting requirements, performance incentives, or both.

Many Medicaid contracts already require a range of activities around pregnancy, including specific quality improvement efforts or care management,²¹ and every plan we interviewed discussed focused efforts to improve perinatal health. Syphilis testing can be integrated into these efforts. Where states or MCOs use bundled payments for prenatal care, they could consider either a carved-out reimbursement or a bonus for syphilis screening.

Most of the plan representatives we interviewed described extensive provider and enrollee education around pregnancy and providing case management to higher-risk enrollees. All such initiatives could include information about syphilis screening in pregnancy and use existing enrollee incentives to support education and uptake of syphilis screenings.

All but 1 state have either extended, or plan to extend, postpartum Medicaid coverage from the minimum 60 days to 12 months.²² The health plans we looked at are starting to consider how to best use this opportunity to strengthen their postpartum health efforts. During the postpartum period, MCOs could encourage or incentivize providers to provide counseling regarding sexual health and STIs; plans could also offer enrollee education on STIs and sexual health.

Syphilis rates among heterosexual men and among women, pregnant women in particular, are strongly associated with substance use, including methamphetamine, heroin, and other injection drugs.^23,24 All Medicaid MCO efforts serving enrollees with substance use disorder could include low-barrier testing and treatment for syphilis and other STIs. Notably, Indiana’s model contract requires plans to cover opioid treatment programs that include syphilis, HIV, and hepatitis testing.²⁵

Most plans fund community-based organizations through grants and other mechanisms.²⁶ The plan representatives we interviewed were enthusiastic about these opportunities to bolster the capacity of clinical safety net providers and address social determinants of health through nonclinical organizations.

To support meaningful access to STI services, MCOs can identify trusted local organizations that serve communities highly affected by STIs, such as organizations focused on lesbian, gay, bisexual, transgender, and queer or questioning populations or those serving birthing communities of color. Funding education or outreach opportunities through such organizations could support public health by fostering greater trust in the health care system and utilization of sexual health and other services. MCOs could also sponsor on-site STI testing opportunities, which could help bolster chlamydia HEDIS screening rates while promoting community health.

Many MCOs, including those we looked at, employ or reimburse community health workers, prenatal and postpartum doulas, and other frontline workers who conduct outreach, education, and linkages to care.¹⁹ All of these workers could be trained to inform enrollees on where to seek STI screening and treatment services and where partners, whether insured or not, can receive free or low-cost services. These workers should also be trained to counsel enrollees that STI testing and treatment are “family planning–related” services for which Medicaid enrollees may see any Medicaid provider regardless of whether they are in their plan’s network under federal law.

Local health departments serve a central role in addressing STIs by conducting surveillance, partner notification, contact tracing, and education services. Most STI clinics in the US are run by health departments,²⁷ and many bill both Medicaid and private insurance.²⁸ Notably, 12 states’ model contracts require plans to reimburse local health departments for STI testing and other services. Some states specifically direct plans to coordinate with local health departments regarding STI screening, partner notification, and follow-up. Whether or not contractually required, MCOs can reach out to local health departments in their service areas to coordinate with community-level STI efforts. MCOs can also give local health departments funding to support disease intervention specialists who address individual health and minimize community transmission.

Condoms and home STI tests are over-the-counter (OTC) products that play important roles in STI prevention. Some state Medicaid programs are already covering OTC contraceptive products including condoms,²⁹ and the 2023 approval of the first OTC birth control pill has further heightened interest in OTC coverage.³⁰ The approaches that states and plans develop to provide OTC birth control and other products to Medicaid enrollees could also be applied to increase access to condoms and home STI tests.

Although some of these opportunities, such as the extended postpartum eligibility period, are specific to Medicaid, many of these approaches could be taken up by other public and commercial health plans. Consistent multipayer efforts—in parallel or, ideally, in collaboration—would not only improve enrollee health but also standardize payment models to facilitate consistent care by providers. Regardless of sector, managed care plans have an important role to play in reversing the tide of congenital syphilis and other STIs.