Medicaid Coverage of Doula Care in 2024 Will Require Sustainable and Equitable Compensation
Since 2019, the Doula Medicaid Project of the National Health Law Program has tracked doula Medicaid implementation. This blog post updates and expands on a previous blog post titled, Medi-Cal Coverage for Doula Care Requires Sustainable and Equitable Reimbursement to be Successful. This blog post updates and expands on a previous blog post titled, Medi-Cal Coverage for Doula Care Requires Sustainable and Equitable Reimbursement to be Successful.
The importance of sustainable and equitable reimbursement rates
A wealth of evidence shows that doula care during pregnancy, birth, and the postpartum period improves birth outcomes, increases childbirth care quality and patient satisfaction, and reduces overall spending. Doula services are a particularly promising approach to addressing racial disparities in maternal and infant health outcomes.
Despite the extensive, well-researched benefits of doula care, many barriers prevent pregnant and birthing people from accessing this support. One of these barriers to doula care is affordability. Private doulas charge their clients up to $2,000 per pregnancy. Doula services can be out of reach for low-income families, disproportionately Blacks, Indigenous peoples, and families with children of color. Meanwhile, some doulas provide their services for free or on a sliding scale, which can limit the sustainability of doula care as a paid profession.
States are increasingly recognizing the benefits of doula care as well as the affordability of doula care as a problem. A growing number of states now offer doula services to Medicaid enrollees. Table 1.
States that have implemented Medicaid coverage for doula care. States that have implemented Medicaid coverage for doula care.
[1][2][3]
State
| Implementation Date | Reimbursement Rate at Initial Implementation | Current Reimbursement Rate | OR |
| 2014 | $75 | $1,505 | (July 2022)[4]MN |
| July 2014 | $411 | $3,100 | (May 2024)[5]FL |
| 2019 | Varies by plan | Varies by plan; tends to be ~$800-$1,110, but at least one plan is ~$450 | NJ |
| Jan. 2021 | $900 per client with up to eight visits (standard care). | $1,166 for clients with 12 visits (enhanced care)
Standard care: $1,165 |
Enhanced care: $1,431[6]
(July 2022)[7] RI |
| July 2021 | (approved May 2022)
$1,500 |
No change[8] | VA |
| Jan. 2022 | $959 | No change[9] | MD |
| Jan. 2022 | (approved June 2022)
$929.84 |
$1,379.84[10] | (July 2023)[11]NV |
| Apr. 2022 | (approved July 2022)
$350 |
Urban counties: $1,500[12] | Rural counties: $1,650[13]
(Oct. 2023)[14] DC |
| Oct. 2022 | $1,950.71 | No change[15] | MI |
| Jan. 2023 | $1,150 | No change[16] | CA |
| Jan. 2023 | $1,154 |
Vaginal delivery: $3,152.65 |
Cesarean birth: $3,263.31[17]
(Jan. 2024)[18] OK |
| July 2023 | Vaginal delivery: $1,043.38 | Cesarean birth: $1,062.10[19]
No change[20] |
MA |
| Dec. 2023 | $1,700 | No change[21] | NY |
| Jan. 2024 | (approved Mar. No change
NYC $1,500 |
Rest state $1,350[22]
No changes[23] |
– |
However to ensure the success of a doula Medicaid program, states must prioritize sustainable, equitable reimbursement rates for these professionals. Doulas devote a significant amount of time to clients, including direct client care, as well as tasks outside of scheduled appointments such research, communication and training, administration and documentation. In one study, community-based doulas spend an average of 30 hrs per week on client care. About half the time is spent on direct client support and care, 20% on administrative tasks, 10% on career development and training, 6% for client-care focused meetings, 6% for organization-wide tasks, 4% for community work and 2% research and evaluation tasks. For every hour a doula spends providing direct client care via scheduled appointments, she spends an additional forty-five minutes on administrative and documenting tasks, 39 minutes gathering resources for clients and 21 minutes communicating with them, 20 minutes training and career development and 12 minutes client-care focused meetings. Another report shows that doulas spend an average of thirty-six hours with each client, excluding transportation and the wide range of tasks that doulas work outside of scheduled appointments.
In order to support doulas in providing these extensive services, states need to recognize doulas’ multifaceted role in supporting birthing people, and Medicaid reimbursement rates should reflect the demanding nature of their work. Fair compensation is essential to increasing and maintaining access to doula service. Doulas shouldn’t have to work multiple jobs to support themselves. As states continue recognizing the value of doulas for low-income birthing women, it is important that equitable reimbursement rates be implemented from the beginning. Doulas in states like Oregon and Minnesota, which began doula Medicaid benefits without adequate compensation, experienced low participation rates at first. The initial low reimbursement rate is one of the reasons for the low participation of doulas. Doulas in Washington were surveyed and found to be unlikely to support low reimbursements rates, such as those offered in Oregon or Minnesota. Moreover, it can take years for a state to increase the reimbursement rate once it has been established; for example, it took a decade for Minnesota to increase its doula compensation from the initial $411 to the current rate of $3,200.
Although there has been an upward trend in compensation in states that have more recently implemented Medicaid coverage of doula services, the method by which reimbursement rates are calculated remains deeply flawed. States calculate their rates based on the scheduled appointments doulas make with their clients, including prenatal visits, attendance during labor and delivery and postpartum. Rhode Island, for example, has a maximum reimbursement of $1,500, which includes $100 per visit, either prenatal or afterpartum (up to six visits are covered), plus $900 in support during labor and birth. Even if this method compensates adequately for these services, it doesn’t reimburse doulas for time spent on travel, research and gathering resources for their clients, administrative tasks, attending meetings and more. This is important because doulas often aren’t salaried employees or hourly workers, and so this work isn’t covered. According to the above time use study, this method of determining rates does not include at least half the services provided by doulas. Doula compensation must be calculated taking into account several factors, including cost of living, administrative work, time spent with clients, travel and other activities, such as training, which allow them to care for their clients effectively in addition to labor performed during appointments and birth. Since then, more than a dozen other states have implemented Medicaid coverage for doulas. NHeLP published a roundup of these updates in February 2024. A trend is emerging from that roundup, and the subsequent developments since February 2024: reimbursement rates have begun to increase (Table 1). This is true for both the states that were the first to offer Medicaid coverage for doulas (Oregon, Minnesota) and those that have only recently begun coverage (such as California, Nevada). This upward trend is a crucial step towards more equitable and sustainable reimbursement rates for doulas. In response to feedback from doulas and advocates, several states have increased their reimbursement rates. California, Maryland, Minnesota Nevada, New Jersey, Oregon and Washington State are among the states that have increased their reimbursement rate. Overall, even if a state has not increased their reimbursement rate, it is important to note the different strategies that states have taken in their reimbursement rate strategies.
Different reimbursement rates within states
A few states have tailored their doula reimbursement rates to vary based on the client’s circumstances, such as birthing method (e.g., vaginal versus cesarean) or geographical location (e.g., urban versus rural).
California’s
reimbursement rates for doula services vary by the type of support provided. The California reimbursement rates for doula services vary depending on the type of support provided. California’s maximum reimbursement for doula service amounts are around $3,153 per vaginal delivery and $3,263 per cesarean. Furthermore, up to nine additional postpartum visits may be covered at the recommendation of a licensed health care provider.
- Nevada calculates its doula reimbursement rates based on where in the state the services are being provided. In certain urban counties the base amount is $900 for delivery services, and the base for prenatal and afterpartum visits is 100 per visit. Nevada offers a 10% increase on these rates for clients who reside outside the specified urban counties. This means that the maximum reimbursement is $1,650 in those areas. This rural provider incentive was created to address Nevada’s “vast maternal health care deserts” as more than half the counties in the state do not have access to a hospital with obstetrical care. The maximum amount for patients older than 19 (“standard” care) is $1,165. The state pays for “enhanced” care, which includes four additional doula visits, for patients under 19 years old. Maximum reimbursement is $1,431. New York
- bases its doula reimbursement rate on geographic location. However, unlike Nevada, it only gives a bump to clients who live in urban areas. This is likely due to the higher cost of living in New York City. Doulas in New York City are reimbursed up to $1,500 for their services: $750 for the labor and delivery as well as $94 for each prenatal or postpartum appointment. Outside of New York City the maximum reimbursement is about $1,350. This includes $675 for labor, delivery, and approximately $84 per visit. The New York City Department of Health and Mental Hygiene and the New York Coalition for Doula Access are advocating for a statewide rate of $1,930.Oklahoma’s
- reimbursement rates differ based on the type of labor and delivery service the client needs. In addition to the payment received for prenatal and postpartum visits, doulas are reimbursed about $469 for vaginal-only deliveries; $325 for cesarean-only deliveries; $547 for cesareans following a vaginal delivery attempt; and $528 for vaginal deliveries after a previous cesarean.States with additional incentive payments
- One method that some states use to try to improve health outcomes for doula clients is adding incentive payments on top of the base reimbursement rates for doulas to connect their clients to supplemental obstetric care. State with additional incentive paymentsSome states use incentives to improve health outcomes for doula clients by adding them to the base reimbursement rates for doulas to connect their clients to supplemental obstetric care. Incentive payments may not be the best way to encourage doulas participate in Medicaid programs. Doulas are advocates that empower their clients to make informed health care decisions. Incentivizing visits can put them in a difficult situation, especially if the reimbursement rates are low. Doulas can feel pressured to seek funding for incentives, which can negatively impact the relationships they build with their clients. Doulas should be able to support their clients’ decisions to engage in the health care system, even when it is financially more beneficial for them to do so. A client may be eligible for an additional doula when they have had two prenatal appointments with a licensed doctor, nurse midwife or Advanced Practice Registered Nurse. Another additional doula visit may be reimbursed when the client receives any dental service during the prenatal period.
- New Jersey offers an additional $100 value-based incentive payment for doulas who provide at least one postpartum visit and ensure their client sees an obstetric clinician for at least one postpartum visit.
Virginia
also offers up to $100 in linkage-to-care incentive payments following a full episode of care. Doulas receive $50 for successfully referring the client to a postpartum visit with an obstetric clinician, and another $50 for successfully referring the client to a visit with a pediatric clinician for the newborn.
- Washington, D.C. provides an additional value-based incentive payment of $100 for doulas who provide at least one postpartum visit and connect their client to an obstetric clinician for at least one postpartum visit.
- ConclusionDoula care has proven to be an invaluable way of addressing poor maternal and infant health outcomes, particularly among low-income families of color. But doula work is also demanding–emotionally, physically, and socially. For a doula workforce to remain stable, it is important that they receive fair reimbursement rates. In recent years, states have made great progress in expanding access to doula services for Medicaid enrollees. A trend of increasing compensation is also emerging. States should continue to work with community doulas, and other stakeholders, to establish equitable and sustainable rates of reimbursement and design doula benefits programs that are available to all. National Health Law Program. Doula Medicaid Project : February 2024 State roundup February 21, 2024. Doula Medicaid Project – National Health Law Program
- . Current State Efforts to Expand Access to Doula care. Accessed September 20, 2024 Hasan A. National Academy for State Health Policy. State Medicaid Approaches for Doula Service Benefits April 16, 2024. Up to 2 prenatal visits and 2 postpartum appointments. Prenatal and postpartum visit at $100 each + $1400 for labor and delivery. Up to 18 sessions including labor and delivery.
- $99,72 for the initial 90-minute visit + $66,48/each for 60-minute prenatal and postpartum appointments + $500 for delivery plus $100 incentive payment. Up to 8 prenatal and/or postpartum visits. Maximum of $1 065. for beneficiaries aged 19 or younger. $99.66 for the initial 90-min appointment + $66.44/each for prenatal and postpartum appointments of 60-mins + $500 for delivery plus $100 incentive payment. You can have up to 12 total visits, including prenatal and postpartum. Maximum of $1331.
$100/each for prenatal and Postpartum visits + $900 labor and delivery. Up to three prenatal and postpartum visits.
Total $859 + up to $100 in incentive payment. Up to 8 prenatal and/or postpartum appointments. Up to eight total prenatal and/or postpartum visits. Total $929.84 is based on 4 prenatal visits and 4 postpartum. Up to eight total prenatal and/or postpartum visits. Total of $1,379.84 is based on 4 prenatal visits and 4 postpartum.
$50 for each prenatal and postpartum visit + $150 for labor & delivery. Up to four total prenatal visits.
[1] $100/each for prenatal visits and postpartum appointments + $900 for delivery and labor + up to $200 in incentive payment. Up to four total visits.
[2] Same incentive as for urban counties supra note 10, plus an additional 10%.
[3] $97.04/each for perinatal visits and postpartums + $686.23 labor and delivery + $100 bonus payment. Up to 12 perinatal visits.
[4] $75/ea prenatal and perinatal visits + $700 labor and delivery. Up to six total prenatal/postpartum visits.
[5] $197.98 initial 90-min visit plus $162.11/each for prenatal/postpartum visits + $586.36 extended 3-hr visit + $685.07 vaginal birth. After the initial visit, you can have up to 8 postpartum or prenatal visits. With an additional recommendation from a licensed Medicaid provider, up to 9 additional postpartum visits can be provided. Up to 527.78 dollars for vaginal birth + $64.45 per visit for prenatal and/or postpartum. Up to 8 prenatal and/or postpartum visits. Up to $800 in perinatal visits.
[6] $93 each for prenatal and perinatal visits + $750 labor/delivery. Up to eight total prenatal/postpartum visits.
[7] $93.75/ea for postpartum and prenatal visits + $750 for labor/delivery. Up to 8 total visits for prenatal and postpartum care.
