Current State of Doula Medicaid Implementation Efforts in November 2022

The National Health Law Program’s Doula Medicaid Project has been tracking doula Medicaid implementation efforts since 2019. Each year since then, the number of states introducing bills related to Medicaid coverage for doula care, or working to expand access to doula care in other ways, has steadily increased.

As of November 2022, there are now more than half of all states that are either actively providing Medicaid coverage for doula care, in the process of implementing such coverage, or that are taking some statewide action related or adjacent to Medicaid coverage for doula care. Similarly, in late October 2022, the Biden-Harris Administration announced that more than half of all states had expanded access to 12 months of Medicaid and CHIP (Children’s Health Insurance Program) coverage after pregnancy. Expanding access to doula care for Medicaid enrollees, along with the extension of Medicaid postpartum coverage, are both key strategies for improving maternal health and addressing racial disparities in maternal health, mortality, and morbidity. Indeed, both strategies were highlighted in the White House Blueprint for Addressing the Maternal Health Crisis, released in June 2022.

This blog, adapted from a recent issue brief, will share an update of current state implementation efforts around Medicaid coverage for doula care, including some key implementation challenges as well as notable states. The blog will conclude with recommendations for doulas, legislators, state agencies, and other stakeholders interested in implementing sustainable, equitable, and inclusive programs for Medicaid coverage for doula care.

Where We’re At: 2022 State Roundup

Below is a map of the United States indicating where states are in terms of implementation of Medicaid coverage for doula care. States with the red stars, including Washington D.C., are currently actively providing Medicaid coverage for doula care. States with yellow stars are currently in the process of implementing Medicaid coverage for doula care. States with blue stars have taken some statewide action related or adjacent to Medicaid coverage for doula care. All of this information is taken from the Doula Medicaid Project’s Current State Doula Medicaid Efforts chart.

As of November 2022, eight states and Washington D.C. are actively providing coverage, indicated on the map by the red stars.

• Florida began covering doula care for Medicaid enrollees in 2019, after doula services were included as optional expanded benefits in Medicaid managed care. This means only Medicaid managed care enrollees in the state have access to doulas (83% of Florida’s Medicaid enrollees are in managed care organizations). Since services are being implemented by the individual state managed care plans, Florida’s Agency for Health Care Administration has no overarching control over implementation.
• Maryland began Medicaid coverage for doula care in February 2022 as part of a broader statewide Maternal and Child Health Care Initiative launched in 2021 by Governor Larry Hogan in partnership with the Maryland Department of Health. The state’s Medicaid Doula Program was initially given funding authorization for four years, but legislation passed in May 2022 made the program permanent. Maryland’s State Plan Amendment to add doula services was approved by the Centers for Medicare and Medicaid Services in June 2022.
• Minnesota is one of the two early adopters of Medicaid coverage for doula care (the other is Oregon). The state passed initial legislation to add doula care as a covered Medicaid benefit in 2013, and the benefit began in 2014. Minnesota’s State Plan Amendment was approved by CMS in September 2014.
• New Jersey passed legislation in May 2019 to add doula care to its list of Medicaid-covered comprehensive maternity care services. However, the doula care benefit did not become effective until January 1, 2021. New Jersey’s State Plan Amendment was approved in February 2021.
• Nevada passed legislation in June 2021, and began enrolling doulas as Medicaid providers starting in April 2022. Nevada’s State Plan Amendment was approved in July 2022.
• Oregon is one of the two early adopters of Medicaid coverage for doula care (the other is Minnesota). The state passed legislation in 2011 requiring the Oregon Health Authority to explore doula benefits. This led to the state beginning to cover doula benefits in 2014. Oregon’s State Plan Amendment adding non-traditional healthcare workers as Medicaid providers was approved in 2012. A subsequent State Plan Amendment for doula services was approved in 2017. The state has increased its reimbursement rate twice, from $75 to $350 in 2017, and then from $350 to $1500 in 2022.
• Rhode Island is so far the only state to have passed legislation requiring doula coverage in both Medicaid and private insurance. Doula benefits began for Medicaid enrollees on July 1, 2022. Rhode Island’s State Plan Amendment was approved in May 2022.
• Virginia first passed legislation in 2020 to create a workgroup on doula Medicaid benefits. The workgroup subsequently issued a report in December 2020. The state’s 2021 budget bill instructed the Department of Medical Assistance Services to submit a State Plan Amendment to include coverage of doula care, consistent with the recommendations of the workgroup report. Virginia’s State Plan Amendment was approved in October 2021. The benefit was set to begin in April 2022, and the state is currently working on getting doulas enrolled as Medicaid providers.
• Washington, D.C. included coverage of doula care in its Budget Support Act of 2021. The benefit was set to begin in October 2022, and as of that date the Department of Health Care Finance had begun enrolling doulas as Medicaid providers. The Washington, D.C. State Plan Amendment was approved in September 2022.

There are six states at various states of implementing coverage, indicated on the map by the yellow stars.

• California is set to begin covering doula care for Medicaid enrollees on January 1, 2023. Doula services were included in Governor Gavin Newsom’s 2021-2022 state budget, and additional details around implementation of care were included in SB 65, the California Momnibus. The Department of Health Care Services has been holding regular meetings with doulas and other stakeholders across the state around implementation of the benefit.
• Connecticut passed legislation in May 2022 to create a formal Doula Advisory Committee to make recommendations on doula certification and training, with the aim of incorporating such recommendations into formal statewide implementation of Medicaid coverage for doula care. Meanwhile, the Department of Social Services is also looking at incorporating doula care in a HUSKY Maternity Bundle of care.
• Illinois passed legislation in 2021 to include coverage of doula services in Medicaid, along with coverage of home visiting services. The state requested public input on implementation of Medicaid coverage for doula care in late 2021. Benefits were supposed to begin on July 1, 2022, but implementation details are still being worked out.
• Massachusetts is engaged in various simultaneous implementation efforts including pending legislation, MassHealth efforts to include doula services for Medicaid enrollees, doula pilot programs run by the Department of Public Health, and even exploratory efforts by the State Marketplace.
• Michigan’s Department of Health and Human Services is implementing doula Medicaid coverage. The state has released two proposed policy drafts for public comment, first in April 2022 and again in October 2022. The benefit will begin on January 1, 2023. Michigan’s State Plan Amendment was approved in June 2022.
• Ohio’s Department of Medicaid is implementing Medicaid coverage for doula care as part of a broader Maternal and Infant Support Program aimed at improving infant and maternal outcomes, with a focus on reducing racial disparities. The Program is being implemented in phases over the next few years, with the doula program scheduled to roll out likely sometime in 2023.

Fifteen states are taking some related or adjacent statewide action pertaining to Medicaid coverage for doula care, indicated on the map by the blue stars.

• Arizona passed legislation in 2021 to create a voluntary process of state certification for doulas. The legislation did not provide for Medicaid coverage for doula care.
• Colorado passed a Birth Equity Bill Package in July 2021 which included a specific requirement for doulas to be present during labor, in addition to a partner or spouse. The Package is part of broader efforts to support birth equity and birth justice efforts across the state.
• Delaware passed legislation in July 2022 requiring that the State Medicaid Agency present a plan to the legislature by November 2022 for doula Medicaid coverage.
• Georgia has two ongoing doula pilot programs being run by Medicaid managed care plans in the state. Healthy Mothers, Healthy Babies Georgia has been running a Doula Access Working Group to advance legislation related to Medicaid coverage for doula care. In October 2022, the group published the Georgia Doula Study, in partnership with Emory University’s Center for Reproductive Health Research in the Southeast
• Hawaii adopted a resolution in April 2022 requiring the state auditor to assess potential impacts, costs, and benefits to certify and regulate community health workers, including doulas.
• Indiana passed legislation in 2019, but it was permissive rather than required, and as no budget was allocated to the effort, there was no implementation. Doulas and other advocates in the state continue to push for implementation of Medicaid coverage for doula care. Meanwhile, legislation passed in August 2022 to create a doula advisory board.
• Iowa’s Department of Public Health is running a multi-year doula pilot program to serve Black families and improve maternal and infant health outcomes. The pilot is being funded through the state’s Title V Maternal and Child Services Block Grant. The Department hopes the doula pilot project can help them explore and establish the case for expanding access to doula care more broadly.
• Louisiana passed legislation in 2021 to create a state Doula Registry Board, with the goal of creating a workforce of doulas to serve Medicaid enrollees once a benefit is in place.
• Missouri passed part of an appropriations bill in June 2022 which included funding for a statewide community doula training program. Meanwhile, one Medicaid managed care organization has started a doula pilot program for its members in select areas across the state.
• New York Governor Andrew Cuomo announced a statewide doula pilot program in April 2019. Separately, New York City Mayor Eric Adams announced a citywide doula pilot program in March 2022. The New York Coalition for Doula Access and other advocates continue to work to expand access to doula care.
• Pennsylvania’s Department of Human Services is creating a Doula Advisory Group to make recommendations on expanding doula access in the state, including creating recommendations around doula education requirements, a potential doula registry, and the financing of doula services.
• Tennessee passed legislation in 2022 requiring the Department of Health to collaborate with TennCare to study doula certification programs and make recommendations on doula services to the legislature by the end of 2022. Meanwhile, in October 2022, Healthy and Free Tennessee released a report on Tennessee Doulas: Practical and Policy Recommendations.
• Texas has at least one Medicaid managed care plan in the state offering doula support as a value added service to Medicaid enrollees.
• Washington passed legislation in 2022 to create a new health profession for birth doulas, which will include a process for state certification of doulas, but not a path for Medicaid coverage for doula care. The Doulas For All Coalition also continues to meet regularly with the Washington Health Care Authority and plans to propose legislation for 2023.
• Wisconsin Governor Tony Evers included Medicaid coverage for doula care in the state budget in February 2021, but the amount allocated for doula care was  subsequently stripped from the budget by the Republican controlled legislature. The State Medicaid Agency is currently doula pilot programs in Madison and Milwaukee.

Common Challenges

In our tracking of the state legislation and other efforts, and in our conversations with doulas and policy advocates in many states with proposed legislation, there are a handful of challenges that regularly come up.

The training or certification requirements being proposed by the State Medicaid Agencies are too restrictive and create unnecessary barriers to entry. Some states go so far as to list the names of specific certifying organizations from which doulas must receive certification before they can be authorized to receive reimbursement for serving Medicaid enrollees, an approach that is overly rigid and inflexible to change over time. Many doulas, particularly community-based doulas and doulas who are Black, Indigenous, or people of color, say that the most nationally known doula training and certification organizations are not necessarily responsive to the needs of underserved communities, and do not adequately train doulas to serve Medicaid enrollees. Many state training and certification requirements also do not create any legacy pathways for doulas that have been practicing for quite some time. Such doulas are valuable to include in Medicaid coverage for doula care programs as they are often already doula mentors and trainers themselves, but they may no longer have proof of certification, or may not even have been formally trained or certified but instead learned through shadowing or apprenticeship. For more information about this topic, please see Building A Successful Program for Medi-Cal Coverage For Doula Care: Findings From A Survey of Doulas in California.

Doulas need more support and guidance navigating the process to become Medicaid providers. Most doulas practicing outside of the Medicaid context are independent contractors who provide services on an individual basis to their clients. Sometimes private pay doulas enter into formal contracts with their clients and sometimes not. They are rarely tracking data and outcomes of their clients on an ongoing basis, and nor are they required to interface with health plans or billing entities in order to get paid. All of these additional administrative requirements come to play for doulas who serve Medicaid enrollees. Doulas who wish to become Medicaid providers must figure out how to become authorized by their state to be eligible for reimbursement for serving Medicaid enrollees, must enter into contracts with Medicaid managed care plans, must translate billing codes in order to submit billing claims for payment, and must in some cases track and report data to the health plan and/or State Medicaid Agency. Moreover, doulas are often having to navigate this process with very little guidance from state agencies, while at the same time also providing a significant amount of free labor in helping state agencies to construct and implement the benefit. For more information about this topic, please see California Doula Pilots Lessons Learned Project.

The reimbursement rate for doulas providing care to Medicaid enrollees is often insufficient. Too often reimbursement rates are being created without an understanding of the type of work that a doula does, and in particular how that work is different in time, scope, and approach from that of medical providers such as doctors, midwives, and nurses. Doulas deserve to be fairly and equitably compensated for their work with Medicaid enrollees. The reimbursement rate must offer doulas a thriving wage, and account for the type of care doulas provide to their clients, as well as the realities of the number of clients that a doula can serve in any given period of time. To adequately support pregnant, birthing, and postpartum Medicaid enrollees, Medicaid coverage for doula care programs must be sustainable, equitable, and inclusive, not just for the Medicaid enrollees but also for the doulas providing the care. For more information about this topic, please see Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities and Medicaid Coverage for Doula Care Requires Sustainable and Equitable Reimbursement to be Successful.

Notable States

There are some states that have implemented or are implementing Medicaid coverage for doula care that deserve further mention.

Both Oregon and Minnesota have had Medicaid coverage for doula care for some time, but there have been challenges with implementation in both states that have a bearing on considerations of workforce and reimbursement rate, among other issues. In a series of articles published in 2021 in The Lily/Washington Post, low reimbursement rates and bureaucratic challenges with billing and reimbursement, have led to a low uptake of the doula Medicaid benefit in both states.

In Minnesota, the initial reimbursement rate was $411 for prenatal, postpartum, and continuous support during labor and delivery, far below the amount doulas in the state would typically receive for clients who pay out of pocket. In 2019, legislators increased the reimbursement rate to $770.  However even this amount did not adequately compensate doulas for the amount of time they spend with each pregnant and postpartum client.  Meanwhile, data from the Minnesota Department of Human Services showed that between 2014 and 2020, doulas provided support for Medicaid enrollees at roughly 850 births (26,000 people a year give birth in Minnesota while enrolled in Medicaid).

In Oregon, the original reimbursement rate was only $75, a figure that was later raised to the still very low figure of $350. Data from the Oregon Health Authority show that between 2016 and 2020, doulas were paid for supporting clients at roughly 204 births (19,000 people a year give birth in Oregon while enrolled in Medicaid). Yet one notable silver lining is that in May 2022, after years of advocacy by doulas in the state, the Oregon Health Authority announced it would be increasing its fee-for-service Medicaid reimbursement rate to $1500. The obvious lesson learned here for other states implementing coverage is about the importance of a sustainable reimbursement rate to achieving a successful benefit that can actually be utilized by Medicaid enrollees. Doula care may indeed save the lives of mothers and babies, but it cannot do so if Medicaid enrollees are not actually able to access the benefit, and if there are not enough doulas available to provide the care.

Rhode Island is notable for being the first state thus far to require doula care in both Medicaid and private insurance. Doula leaders in the state have also been successful in pushing for other goals with the aim of an equitable and sustainable program. The Medicaid reimbursement rate is $1500 for three prenatal and three postpartum visits ($100 each) and presence at labor and delivery ($900). The benefit began on July 1, 2022, and before the end of the month, doulas had already reported successfully receiving payment for doula services. Doulas in Rhode Island, in particular Black doula leaders, have been active partners with the State Medicaid Agency in implementation from the beginning through an active and organized coalition. To address the administrative and bureaucratic challenges that they knew becoming Medicaid providers would pose, doulas in the state also self-organized to form a Rhode Island Birthworker Co-op.

Here in California where the Doula Medicaid Project is based, the doula Medicaid benefit was originally scheduled to begin on January 1, 2022, but was pushed back twice, first to July 1, 2022 and then again to its current start date of January 1, 2023. The doula Medicaid benefit in California will be full spectrum, including doula care for prenatal care, labor/delivery, and postpartum care, as well as for all the ways in which a pregnancy ends including abortion, miscarriage, and stillbirth. The National Health Law Program has been part of the Department of Health Care Services Doula Stakeholder Workgroup, which has been meeting with doulas, maternal health advocates, and other stakeholders since September 2021. Many of these conversations have been challenging, as documented by The Sacramento Bee in November 2021. To the chagrin of doula benefit stakeholders, the amount originally allocated for reimbursement in Governor Gavin Newsom’s 2021 budget was $450, which doulas said was simply unsustainable. Ongoing advocacy efforts ultimately paid off, with the proposed reimbursement rate more than doubling in the Governor’s 2022 budget. Even so, the new rate of $1154 is still not close to market rate in most regions of the state, and conversations around ensuring a more sustainable reimbursement rate continue.

As a growing number of states join the ranks of states implementing Medicaid coverage for doula care, the hope is that newer states can learn from the challenges and missteps, as well as the successes, of states that have implemented coverage before them. While it is true that implementation of Medicaid coverage for doula care will certainly and by necessity differ state by state and region by region, each state need not completely reinvent the wheel, and certainly there are common lessons to be learned and shared between them.

Recommendations

We have some key recommendations for doulas advocates, legislators, agencies, and other stakeholders looking for ways to implement sustainable, equitable, and inclusive programs for Medicaid coverage for doula care in their states.

Doulas must be equal partners in implementation efforts. We encourage the policy advocates, legislators, agencies, health plans, community members, and others who will be implementing Medicaid coverage for doula care, to make sure that at every step in the process, doulas and doula groups who are already serving low-income communities and Medicaid enrollees; who are already serving pregnant and postpartum people who are Black, Indigenous, and people of color; and who are community-based doulas; are front and center in crafting the policy language and determining how it is implemented. Merely providing avenues for feedback and input alone is not enough. Doulas must be equal partners in the endeavor in order for it to be successful. By way of example, the National Health Law Program staff involved with the Doula Medicaid Project are not themselves doulas. As such, the Doula Medicaid Project has always sought to do our work in partnership with, and with the guidance of, community-based doula groups, doula collectives, and individual doulas, especially Black doulas and Black-led doula groups, as well as doulas and doula groups serving low-income clients. We know that our work is substantively more impactful, more relevant, and more effective because of this partnership.

Fund doulas. Practicing doulas are not otherwise paid to do policy advocacy and support with implementation work. In order to achieve a sustainable partnership with doulas, the states, agencies, and other entities must seek out funding to support them to do so. Doulas should be paid to do policy work and policy advocacy. Doulas should be paid to sit on state doula advisory boards and committees. Doulas should be paid to think through how they can meet the administrative challenges of Medicaid reimbursement and whether they want to self-organize. State agencies have an incentive to ensure that their partnerships with doulas are sustainable. There is also significant room for engagement here for foundations and philanthropies interested in health equity, racial disparities in health, maternal and infant health, community development, and workforce development.

States should get it right from the get go. This will obviate their having to go back and do a lot of clean up on the back end. Both Minnesota and Oregon have had to pass numerous legislation over the years to fix or improve upon their original legislation, including changes to the billing structure and increases to the reimbursement rates. Legislative fixes are time-consuming, a drain on resources, and do not always resolve the problem. States clearly have an incentive to be thoughtful and to craft their best Medicaid coverage for doula care programs from the start.

Doulas can’t do it all. As firm as our faith is in the power of doulas to positively impact the lives of their clients, we also know that in the end we cannot put it all on the backs of doulas. Doulas can help mitigate the impacts of racism on their clients of color by advocating for them in the face of individual, institutional, and structural racism. But in the end, that individual, institutional, and structural racism will still be there, harming other people.  In other words, doulas may be necessary, but they alone are not sufficient.  The solution to the underlying racism that plagues America’s maternal health care system cannot be simply throwing doulas at the problem. Thus, as we all do this work, we must remember this, and remembering it, continue to work in other ways to seek out and eradicate racism in all its forms.

A Path Forward Towards Birth Justice

As of this writing in November 2022, we are at a crossroads for reproductive and sexual health law and policy. The logo for the Doula Medicaid Project reads: “All pregnant and postpartum people deserve access to full spectrum doula care.” The National Health Law Program’s Doula Medicaid Project has always been focused on full spectrum doula care, because we understand that our reproductive lives do not take place in a vacuum and that abortion is health care. You cannot separate birth justice from reproductive justice, just as you cannot separate the autonomy in decision-making about our bodies when it comes to pregnancy, from autonomy in decision-making about our bodies when it comes to abortion, contraception, and family planning.

We already know that states that put in place abortion bans have higher rates of maternal mortality. So the broader fights for reproductive access in abortion, following Dobbs v. Jackson Women’s Health Organization and the overturning of Roe v. Wade, must very much be a part of the conversation around doula access and birth justice as well. Our path forward towards birth justice is one and the same with the path forward towards reproductive justice.

story originally seen here