Doula Medicaid Project: February 2024 State Roundup

NHeLP’s Doula Medicaid Project has been tracking Medicaid coverage for doula care legislation since 2018. Each year since then has seen a steady increase in legislation as well as other efforts. 2023 was a very busy year for expanding access to doula care, as we’ll see, not just in the Medicaid context but in private insurance as well. Last year saw four states rolling out Medicaid coverage for doula care (Michigan, California, Oklahoma, Massachusetts); three states issue standing statewide orders for Medicaid coverage for doula care for all pregnant Medicaid enrollees in the state (Michigan, California, Massachusetts, and a fourth, Minnesota, in January 2024.); and multiple states introduce legislation for private insurance coverage of doula care, with Louisiana being the only state to pass legislation.

Meanwhile, as evidenced by the map below, a record number of states are embarking on various efforts aimed at ultimately rolling out statewide Medicaid coverage for doula care. A total of 43 states and Washington DC have implemented Medicaid coverage for doula care, are in process to implement Medicaid coverage for doula care, or have taken some related or adjacent action. There are now only a handful of states where the Doula Medicaid Project was not able to find any ongoing state-funded or state-organized effort at expanding access to doula care.

As of January 2024, twelve states and Washington DC have implemented Medicaid coverage for doula care. In chronological order they are:

• Oregon is one of the two early adopters of Medicaid coverage for doula care. The state passed legislation in 2011 requiring the Oregon Health Authority to begin exploring doula benefits. The state began Medicaid coverage for doula care in 2014. The state has increased its reimbursement rate twice, from $75 to $350 in 2017, and then from $350 to $1500 in 2022. The impetus for the increased reimbursement rate was in part an acknowledgement of the low uptake during the first several years of the benefit. Oregon is notable for having doula hubs that have formed across the state to assist doulas with many of the administratively burdensome tasks that it entails to be a Medicaid provider, such as billing and contracting.
• Minnesota is another of the two early adopters of Medicaid coverage for doula care. Minnesota passed legislation to add doula care as a covered Medicaid benefit in 2013, and the doula Medicaid benefit formally began in 2014. The original reimbursement rate was $411, which in 2019 was increased to $770. As in Oregon, there have been significant obstacles in Minnesota for Medicaid enrollees trying to access the doula benefit, as well as doulas trying to enroll as Medicaid providers and obtain reimbursement, including barriers to enrollment, the clinician supervision requirement, and lack of adequate outreach and awareness about doula care. In March 2023, a bill was introduced to increase reimbursement to a total of $2000, for six prenatal or postpartum visits of $100 each, and $1400 for support at birth. The bill did not pass, but Minnesota Medical Assistance nonetheless independently submitted a State Plan Amendment (SPA) to the Center for Medicare and Medicaid Services (CMS) to increase the reimbursement rate to $2000. The new reimbursement rate became effective January 1, 2024. On the same date, the requirement for doulas to have to bill through a supervising medical provision was lifted. On January 9, 2024, a statewide standing recommendation was put in place for the state.
• Florida began covering doula care for Medicaid enrollees in 2019, after doula services were included as an optional expanded benefit in Medicaid managed care. This means only Medicaid managed care enrollees in the state have access to doulas (87% of Florida’s Medicaid enrollees are in managed care). Since services are up to the individual state managed care plans, the Agency for Health Care Administration does not have broader authority or control over implementation of the benefit. As a result, each Medicaid managed care plan in the state is able to determine the scope and administration of the benefit, as well as credentialing requirements and reimbursement.
• New Jersey passed S1784 into law in May 2019, which added doula care to the state list of Medicaid covered maternity care services. The State Plan Amendment was approved in February 2021 with a retroactive start date of January 1, 2021 for the doula Medicaid benefit. Doulas have found the Medicaid enrollment and credentialing process challenging, and in response the Department of Health has convened the New Jersey Doula Learning Collaborative to provide training, support, and technical assistance to Medicaid doula providers in the state. In 2022, the doula Medicaid reimbursement rate was increased to $1165.
• Virginia passed legislation in 2020 to create a process for state certification of doulas and to convene a workgroup to make recommendations on doula Medicaid benefits. Based on the recommendations of the workgroup, the Department of Medical Assistance Services submitted a State Plan Amendment to CMS, which was approved in October 2021. The benefit began on April 1, 2022.
• Nevada passed AB 256 in June 2021, which required Medicaid coverage for doula care. The State Plan Amendment was approved on July 7, 2022 with the benefit starting retroactively as of April 1, 2022. Also in July 2022, a group of doulas formed the DOULA CO-OP, with the goal of cultivating a thriving and diverse community for birthworkers and parents in Nevada, with a specific focus on underserved birthing families, including Medicaid enrollees. In June 2023, AB 283 was signed into law to increase the state’s Medicaid reimbursement rate. The current Medicaid reimbursement rate is up to $450. The state has submitted a State Plan Amendment for approval with a new reimbursement rate of $1500 in urban counties and $1650 in rural counties, and is awaiting a response from CMS.
• Maryland initially began Medicaid coverage for doula care in February 2022 with funding authorization for four years, but legislation passed later that year made coverage permanent. The State Plan Amendment was approved in June 2022. The reimbursement rate is up to $930.
• Rhode Island remains the only state thus far to have implemented a requirement for doula care in both Medicaid and private insurance, which they did following passage of H5929A in July 2021. The State Plan Amendment was approved in May 2022 and the benefit went into effect on July 1, 2022. The doula Medicaid reimbursement rate is $1500.
• Washington DC initially created a pilot for Medicaid coverage for doula care in January 2021, which was made into permanent Medicaid coverage for doulas in the DC 2022 Budget Support Act of 2021. The State Plan Amendment was approved by CMS in September 2022 and the Department of Health Care Finance began enrolling and reimbursing doulas in October 2022. The doula Medicaid reimbursement rate is up to $1950.71.
• Michigan in 2020 introduced legislation for Medicaid coverage for doula care, SB 965. The bill did not pass, but it did launch discussions within the Department of Health and Human Services on including doula services as a Medicaid benefit. In April 2022, the Department announced it would be working to include doula care as a new benefit for Medicaid enrollees, and subsequently created the Michigan Doula Advisory Council. The State Plan Amendment was approved in June 2022 and the doula Medicaid benefit began on January 1, 2023. The same date the benefit began, the state’s Chief Medical Executive issued a standing recommendation for doula services, making it the first state to do so. Michigan’s doula Medicaid reimbursement rate is $1150.
• California’s doula Medicaid benefit began on January 1, 2023. The state’s doula Medicaid benefit is available to all pregnant and postpartum people regardless of immigration status. Coverage is also full spectrum, providing doula care for all the ways in which a pregnancy ends, including labor/delivery, abortion, miscarriage, and stillbirth. In November 2023, California became the second state (after Michigan) to issue a statewide standing recommendation for doula services. In December 2023, CMS approved a State Plan Amendment increasing California’s doula Medicaid reimbursement rates to up to $3100, making it the highest in the country.
• Oklahoma’s Health Care Authority began internal discussions on including doula services in SoonerCare as early as 2021. In 2023, the Health Care Authority requested funding in the state budget to cover doula services. The State Plan Amendment was approved in June 2023 with an effective start date of July 1, 2023.
• Massachusetts’ doula Medicaid benefit began on December 8, 2023. On the same date that the benefit began, the state also issued a standing recommendation for doula services, making it the third state to do so. The state has an active Massachusetts Doula Coalition which has been organizing meetings, town halls, and other advocacy and education efforts in the state since at least 2020. The doula Medicaid reimbursement rate is up to $1700.

Nine states are in the process of implementation, many of which will begin their doula Medicaid benefits at some point in 2024. Another two are implementing some level of private coverage of doula care. Interestingly, 2023 saw a handful of State Medicaid Agencies exploring Medicaid coverage of doula services, either parallel with legislative efforts or independently.

• Colorado Governor Jared Polis included doula care in the state budget in April 2023. In May 2024, he signed SB23-288, which requires the state to begin a stakeholder process for Medicaid coverage for doula care, create a report of findings from the stakeholder process, seek CMS approval for Medicaid coverage for doula care by July 1, 2024, create a scholarship program for doulas seeking to serve Medicaid enrollees, and evaluate the cost-benefit of covering doula care in private insurance. The reimbursement rate is expected to be $1500.
• Connecticut has passed multiple pieces of legislation over the past three years on its path to implementation of Medicaid coverage for doula care. In 2021, part of Public Act No. 21-35 required the Commissioner of Public Health to conduct a scope of practice review on establishing a state certification process for doulas, resulting in a committee report that was published in March 2022. Also in 2022, HB 5500 was signed into law, which created a Doula Advisory Committee to develop recommendations for training and continuing education requirements required for doula certification, and the Doula Training Program Review Committee to conduct a continuous review of training that would meet the requirements laid out by the Doula Advisory Committee. In June 2023, HB 986 was signed into law, which laid out specific requirements for doula certification and affirmed the role of the Doula Advisory Committee and Doula Training Program Review Committee. Parallel to these efforts, the Department of Social Services is incorporating doula care as part of its planned HUSKY Maternity Bundle Payment Program, which will shift maternity care payment from fee-for-service to a bundled payment. The state’s doula Medicaid benefit is expected to roll out in September 2024.
• Delaware passed HB 343 in July 2022, which required the Division of Medicaid and Medical Assistance to create a plan for Medicaid coverage for doula care. In August 2023, HB 80 was signed into law, which required the Division to create a process for doulas to be certified and to enroll as Medicaid providers, and specified that the doula Medicaid reimbursement rate be established “that supports a livable annual income for full-time practicing doulas.” The Division is holding regular meetings with a Doula Ad Hoc Committee on implementation of the doula Medicaid benefit, and anticipates rolling out the benefit in 2024.
• Illinois passed HB 158 in April 2021, which included coverage of perinatal doula services alongside coverage of home visiting services. The doula benefit was originally set to begin in July 2022, but implementation efforts were delayed and are ongoing.
• Louisiana in 2021 passed HB 190, which created a Louisiana Doula Registry Board charged with developing criteria for doula registration and reviewing and approving applications. In June 2023, HB 272 was passed into law, which requires private health plans in the state that cover maternity services to include coverage for doula care, with reimbursement reportedly set at up to $1500. Louisiana would be the second state to require coverage of doula care for those in private insurance, and the first state to do so in the absence of Medicaid coverage for doula care.
• New Hampshire included Medicaid coverage for doula care in its 2023 state budget. The benefit was part of a broader state Mom-nibus package of bills that also included lactation services, extension of Medicaid coverage to 12 months postpartum, and relevant appropriations.
• New York has had a number of doula pilots, including a statewide pilot that began in 2018 and a New York City pilot that began in March 2022. In November 2023, S1867A was signed into law, which will establish a community doula directory for doulas in the state serving Medicaid enrollees. The state submitted a State Plan Amendment to CMS in December 2023, and is awaiting a response.
• Ohio is implementing Medicaid coverage for doula care as part of a broader statewide 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 as part of the fourth and final phase. The 2023 state budget included funding for Medicaid coverage for doula care. The Board of Nursing has been charged with regulating doulas and appointed a Doula Advisory Board which began to meet in January 2024.
• Pennsylvania has created a pathway for doulas to be certified by the state, and the Pennsylvania Certification Board maintains a list of approved Certified Perinatal Doulas. Pennsylvania Medical Assistance is in ongoing discussions with doulas and advocacy groups, including the Pennsylvania Doula Commission, on doula Medicaid implementation efforts.
• South Dakota introduced HB 1081 in January 2024, which would have implemented Medicaid coverage for doula care. However, less than two weeks later, the South Dakota Department of Social Services announced that it would be including Medicaid coverage for doula care as part of its Pregnancy Health Home effort, which aims to improve care and management of prenatal, postpartum and well-child care services for pregnant and parenting Medicaid enrollees. HB 1081 has thus been tabled while the Department proceeds with administratively implementing Medicaid coverage for doula care.
• Utah passed HB 415 in March 2023, which requires coverage of doula services in Utah’s Public Employees’ Benefit and Insurance Program.

The largest category of states, twenty, have undertaken other or adjacent efforts related to expanding access to doula care.

• Alaska is running a state-funded community doula program through an Anchorage-based organization called Due North Support Services. The program provides free doula care to pregnant and postpartum people, with a priority on specific vulnerable populations.
• Alabama’s Department of Mental Health is funding a group called BirthWell Partners, which runs a Community Doula Project providing support to pregnant people with substance use disorder. Also, in 2023 a group including March of Dimes, Women’s Foundation of Alabama, and BirthWell Partners Community Doula Project, came together to form a committee to begin exploring Medicaid coverage for doula care in the state.
• Arizona passed legislation in 2021 to create a voluntary state certification for doulas. What the state calls its ”voluntary licensing program for doula,” rolled out in August 2023. The certification is voluntary, and is not required in order to practice as a doula in the state. Also in 2023, UnitedHealthcare, one of the state’s Medicaid managed care plans, began offering doula services.
• Georgia has a doula pilot program being run by two Medicaid managed care plans in the state. The pilots are viewed as stepping stones to eventually broader statewide implementation. Healthy Mothers, Healthy Babies Georgia also runs a Doula Access Working Group to advance legislation and advocate for Medicaid coverage for doula care.
• Hawaii passed resolution SCR2 SD1 in April 2022, which required the state auditor to create a sunrise review on the certification and regulation of community health workers (a category in which doulas were included). Sunrise Analysis: Regulation of Community Health Workers was published in September 2022.
• Iowa’s Department of Health and Human Services is piloting a Maternal Health Doula Project through the state’s Title V Maternal and Child Health Service Block Grant, aimed at providing culturally congruent, community-based care to address disparities in Black maternal and infant health outcomes. The Department hopes to use the pilot as a stepping stone to make the case to expand access to doula care more broadly. One of the state’s Medicaid managed care plans, Iowa Total Care, is also providing doula services for their pregnant enrollees in Polk, Johnson or Muscatine counties.
• Indiana passed SB 416 in 2019, which allowed doulas to be reimbursed under Medicaid and allowed for the submission of a State Plan Amendment or waiver to effect coverage. However, funding for the bill was stripped from the budget. As the language in SB 416 was permissive rather than required, the doula Medicaid benefit was never implemented. In August 2022, SB 2 was signed into law, which created a Doula Reimbursement Advisory Board. However, over a year later it is unclear how much progress has been made in establishing the Board or making the doula Medicaid benefit a reality. The Indiana Minority Health Coalition maintains an Indiana for Doulas movement that continues to work with doulas and other stakeholders in the state on public education campaigns, information gathering, advocacy efforts, and potential legislation.
• Kansas doulas formed the Kansas Doula Alliance in November 2023, aimed at advocating for equitable reimbursement for doula services, promoting doula-friendly policies in the medical setting, providing professional development and training to doulas, and improving public education on doula care. Additionally, UnitedHealthcare, one of the state’s three Medicaid managed care plans, in 2023 began offering doula services to its pregnant and postpartum Medicaid enrollees.
• Kentucky has multiple Medicaid managed care plans in the state piloting doula care for some portion of their Medicaid enrollees, including Humana, Anthem, and UnitedHealthcare.
• Maine has a statewide group, the Maine Doula Coalition, which launched in 2022. The group is working towards doula access for birthing people, equitable reimbursement for doulas, and improving birth experiences and perinatal outcomes in Maine.
• Missouri passed part of an appropriations bill in June 2022, which included funding for a statewide community doula training program. One Medicaid managed care organization has started a doula pilot program for its members in select areas across the state. There is also a statewide organization called the Missouri Community Doula Council, which advocates for access and coverage to community-based doula services for pregnant women and birthing families, as well as sustainable pay for community doulas.
• North Carolina has introduced multiple bills since 2020 pertaining to Medicaid coverage for doula care. Those bills have not passed. However, the Department of Health and Human Services is exploring Medicaid coverage for doula care, and in 2022 provided funding to help hire and train doulas in select counties across the state. There is also a statewide organization called the North Carolina Doula Organization which is working to organize doulas in the state and promote educational development and financial support for doulas.
• Nebraska has a doula pilot program to provide doulas for high-risk Black, Indigenous, and other birthing people of color. The pilot – which is a partnership between I Be Black Girl, A Mother’s Love, United Healthcare, Nebraska Medicine, and the Nebraska Perinatal Quality Improvement Collaborative – will run for five years and launch first in two counties, which are home to over half of the state’s non-white residents.
• New Mexico has a Medicaid managed care plan, UnitedHealthCare, which has donated $150,000 to the New Mexico Doula Association to fund scholarships for a doula certification and training program. Also, in April 2020, Tewa Women United’s Indigenous Women’s Health and Reproductive Justice Program published a report on Expanding Access to Doula Care: Birth Equity and Economic Justice in New Mexico, which uplifts a community-based doula model, shares details about doula care from the organization’s Doula Project, and offers recommendations to promote birth equity and economic justice in New Mexico and beyond.
• South Carolina has a collaborative, statewide effort called the South Carolina Doula Steering Committee, which launched in November 2022. The Committee is working to study how other states have built their doula reimbursement policies in order to make policy recommendations for equitable compensation for doulas in South Carolina.
• Tennessee passed SB 2150 in June 2022, which required the Department of Health to collaborate with TennCare to study existing doula certification programs. In May 2023, SB 394 passed, which creates a doula services advisory committee to advise the Department of Health on core competencies and reimbursement rates for Medicaid coverage for doula care. Following passage of SB 394, the Dept of Health set up the TN Doula Services Advisory Committee, which began meeting in Sep 2023.
• Texas has two Medicaid managed care plans piloting doula care: Dell Children’s Health Plan and UnitedHealthCare. In 2023, doulas across the state came together to form the Texas Doula Association, which is working to ensure that doulas in Texas are centered in any work for doula reimbursement legislation, that their voices are heard in the process, and that they are able to regulate and govern themselves.
• Washington in March 2022 passed HB 1881 into law, which created state-certified birth doulas as a new health profession. A group called the Doulas For All Coalition drafted and worked to pass HB 1881, and continues to work towards Medicaid coverage for doula care. In 2023, UnitedHealthcare, one of the state’s Medicaid managed care plans, began offering doula services.
• 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 stripped from the budget by the Republican-controlled legislature. The Wisconsin Department of Health Services has been running doula pilot programs in Madison and Milwaukee, with positive results.
• West Virginia’s Perinatal Partnership is running a doula pilot, in partnership with the West Virginia Office of Maternal, Child and Family Health and the West Virginia Rural Maternity and Obstetric Management Services.

There are a few important trends that are worth pointing out as we head into 2024 legislative sessions.

Reimbursement continues to be a salient topic. Multiple states with Medicaid coverage for doula care have already introduced bills or engaged in other actions to increase reimbursement rates.

• In 2022, Oregon increased its reimbursement rate from $350 to $1500.
• In 2023, Nevada submitted a State Plan Amendment to increase its reimbursement rate from $450 to $1500 for urban areas and $1650 for rural areas. They are still awaiting a response from CMS.
• In 2023, Minnesota increased its reimbursement rate from $770 to $2000.
• In 2024, California increased its reimbursement rate from $1500 to $3100 following broader state increases to Medicaid provider rates.

Meanwhile, the trend for states that are newly implementing Medicaid coverage for doula care seems to be skewing towards higher reimbursement rates than the earlier implementing states.

• Massachusetts rolled out Medicaid coverage for doula care in December 2023 with a reimbursement rate of $1700.
• Colorado is anticipating rolling out its benefit in July 2024 and has confirmed that its reimbursement rate will be $1500.
• Louisiana in 2023 passed legislation requiring private insurance coverage of doula care, and a reimbursement rate of “up to $1500.”

Other states are explicitly trying to ensure sustainable and equitable reimbursement rates in the language of their legislation. For example, in August 2023 Delaware passed HB 80, which requires Medicaid coverage for doula care. The bill specifies that the state has to establish “a reimbursement rate for doula services that supports a livable annual income for full-time practicing doulas.”

Four states have issued statewide standing orders for doula care. In these states, doula care is primarily being implemented as a preventive service, and pursuant to 440.130(c) of title 42 of the Code of Federal Regulations, such services typically require a written recommendation from “a physician or other licensed practitioner of the health arts acting within their scope of practice.” A statewide standing recommendation for doula care allows Medicaid enrollees to secure their doula without having to first obtain an individual recommendation from a licensed Medicaid provider for doula services. Four states thus far have issued statewide standing recommendations: Michigan, California, Massachusetts, and Minnesota.

With more states implementing Medicaid coverage for doula care, attention is also moving to mandating doula care in private insurance as well. Thus far, Rhode Island is the only state that has implemented private insurance coverage for doula care, which they did in 2021 alongside Medicaid coverage for doula care. In 2023, Louisiana passed legislation requiring private insurance coverage for doula care, and Utah passed legislation. It is likely that more states will continue introducing legislation or undertake other efforts to expand doula access in the private insurance context in 2024 and beyond. Doulas in Rhode Island have expressed that a primary goal in including the categories of both Medicaid and private insurance in their legislation was addressing racial disparities in maternal health for Black pregnant and birthing people, which we know remain steady regardless of factors such as income and socioeconomic status. As the saying goes, a high tide lifts all boats. Accordingly, expanding access to doula care for Medicaid enrollees as well as consumers in private insurance, with the goal of addressing racial disparities in care for Black pregnant and birthing people, will ultimately lead to improving health outcomes for all pregnant and birthing people and their babies across the country.

As was the case in 2022, expanding access to doula care and improving maternal and infant health outcomes remains a bipartisan issue, in spite of the extreme polarization in other areas of sexual and reproductive health, namely abortion and contraception. It remains to be seen if bipartisan support for maternal health more broadly, and expanding access to doula care more specifically, will continue to be the case as we head into a presidential election season. Certainly, legislators in conservative states that have banned or restriction abortion care have often claimed to be pouring increased resources into supporting maternal health and families, a tacit nod to the fact that in states where abortion is banned, more babies will be born than otherwise would have been. Yet initial reports have found this to be often mere lip service. We also know that, historically, states with abortion restrictions experience worse maternal mortality rates. Doulas and state advocates must work to hold these politicians to their word and ensure that they actually provide the investment and resources in maternal health and family supports that they promise.

Meanwhile, abortion restrictions have made the landscape for miscarriage and pregnancy management fraught for both doctors and patients. Medical procedures for managing a miscarriage are identical to those for managing an abortion – accordingly, medical providers have provided improper miscarriage treatment or even denied care for fear of being criminally prosecuted for performing an illegal abortion. Meanwhile, patients who have had a stillbirth or who have miscarried have faced criminal charges for so-called “fetal harm.” Eliminating a person’s ability to end their pregnancy is, predictably, having a deleterious effect on the quality of pregnancy care more broadly. Doulas continue to have a role to play here in supporting their clients through all the ways in which pregnancies can end, and ensuring that their clients receive evidence-based medical standard of care, rather than care dictated by malicious laws aimed at eradicating bodily autonomy for pregnant people.

The Doula Medicaid Project continues to see doula care within the context of broader sexual and reproductive health access, as an opportunity for alignment across the landscapes of birth justice and reproductive justice. Advocates for expanding access to doula care can and should push back against efforts to eliminate access to abortion and contraception, and where possible, support access to these services. For example, some states are explicitly providing doula care during abortion, including California and Massachusetts. Meanwhile, in Georgia, a state that has prohibited abortion after six weeks, Healthy Mothers Healthy Babies Coalition of Georgia, Emory Schools of Public Health and Medicine, and the Georgia Doula Access Working Group, came together to conduct a community-engaged project called the Georgia Doula Study, aimed at building support for full spectrum doula care in the state, to date publishing six peer-reviewed articles on topics including stigma and other challenges for full spectrum doula care in Georgia. The Doula Medicaid Project has also advocated for full spectrum doula care. We will continue to do so, and invite all our doula and state advocate partners across the country to join us in this work.

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