2024 Update: Medicaid Coverage for Doula Care Requires Sustainable and Equitable Reimbursement to be Successful

2024 Update: Medicaid Coverage for Doula Care Requires Sustainable and Equitable Reimbursement to be Successful

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. 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 is affordability. Private doulas typically charge their clients out-of-pocket, upwards of $2,000 or more per pregnancy. Doula care can therefore be unaffordable for low-income families — who are disproportionately Black, Indigenous, and families of color — that need these services the most. 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. As such, a growing number of states are implementing doula care for Medicaid enrollees. As of this writing, a total of 15 states plus Washington D.C. have enacted access to doula care for Medicaid enrollees, up from five states in early 2022 (Table 1).

Table 1. 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[4] (July 2022)
MN July 2014 $411 $3,200[5] (May 2024)
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 for clients with up to 8 visits (standard care)

$1,166 for clients with 12 visits (enhanced care)

 

Standard care: $1,165[6]

Enhanced care: $1,431[7]

(July 2022)

RI July 2021

(approved May 2022)

$1,500[8] No change
VA Jan. 2022 $959[9] No change
MD Jan. 2022

(approved June 2022)

$929.84[10] $1,379.84[11] (July 2023)
NV Apr. 2022

(approved July 2022)

$350[12] Urban counties: $1,500[13]

Rural counties: $1,650[14]

(Oct. 2023)

DC Oct. 2022 $1,950.71[15] No change
MI Jan. 2023 $1,150[16] $2,700[17] (Oct. 2024)
CA Jan. 2023 $1,154

 

Vaginal delivery: $3,152.65[18]

Cesarean birth: $3,263.31[19]

(Jan. 2024)

OK July 2023 Vaginal delivery: $1,043.38[20]

Cesarean birth: $1,062.10[21]

No change
MA Dec. 2023 $1,700[22] No change
NY Jan. 2024

(approved Mar. 2024)

NYC: $1,500[23]

Rest of state: $1,350[24]

No change

 

However, in order for implementation of a doula Medicaid benefit to be successful, states must prioritize sustainable and equitable reimbursement rates for doulas. Doulas dedicate a substantial amount of time to their clients, both on direct client care and on tasks beyond scheduled appointments, such as administration and documentation, research, communication, and training. One study found that community-based doulas work an average of 30 hours per week, with about half that time spent on direct client care and support, 20% on administrative documentation tasks, 10% on training and career development, 6% on client-care focused meetings with colleagues, 6% on organization-wide work, 4% on community work, and 2% on research and evaluation tasks. This means that for every hour that a doula spends on delivering direct client care through scheduled appointments, they also spend an additional forty minutes on administrative and documentation tasks, thirty-nine minutes on gathering resources for clients, 21 minutes on communicating with clients, twenty minutes on training and career development, and twelve minutes on 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 an essential part of increasing and sustaining access to doula services. Doulas should not have to work several jobs to sustain themselves. As states continue to recognize the value of doula care for low-income birthing people, it is critical that equitable reimbursement rates are implemented from the start. States such as Oregon and Minnesota that began their doula Medicaid benefits with inadequate compensation faced initially low participation rates by doulas. Part of the reason for the low participation rates of doulas in these early adopter states is the initial low-reimbursement rate. One survey of doulas in Washington found that doulas are unlikely to support low reimbursement rates like those offered in Oregon and 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 according to scheduled appointments that doulas have with their clients: prenatal visits, attendance at labor and delivery, and postpartum visits. For example, Rhode Island’s $1,500 maximum reimbursement consists of $100 per prenatal or postpartum visit (with a maximum of six visits covered), plus $900 for support during labor and delivery. Even assuming that this method provides adequate compensation for these particular services, it does not reimburse doulas at all for the time spent traveling, researching and gathering resources for clients, completing administrative tasks, training, attending meetings, and more. This is especially important as doulas are often not salaried or hourly employees and thus this work is not covered. According to the time use study discussed above, this rate determination method does not take into account at least half of the services that doulas provide. Doula compensation should be calculated with consideration to several factors: cost of living, administrative labor, actual time spent with clients, travel, and additional activities, like training, that allow them to effectively care for their clients in addition to the labor performed during appointments and labor and delivery.

In 2022, NHeLP’s Doula Medicaid Project published a blog post discussing California’s state budget allocating funding for a doula Medicaid benefit. Since then, over a dozen states have joined California in implementing Medicaid coverage for doula services. NHeLP published a state roundup in February 2024 summarizing these updates. From that roundup and further developments since February 2024, an important trend has emerged: reimbursement rates are beginning to increase (Table 1). This is true both for the very first states that began doula Medicaid coverage (Oregon and Minnesota), and for states that only began coverage in the past few years (such as California and Nevada). This upward trend is crucial progress towards more sustainable and equitable reimbursement rates for doula services. Several states are notable in that they increased their reimbursement rate in response to doula and advocate feedback. This includes states like California, Maryland, Minnesota, Nevada, New Jersey, Oregon, and a prospective increase in Washington State. 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 reimbursement rate is about $685 for vaginal deliveries; $796 for cesareans; and $251 for miscarriages and abortions. After taking into account coverage of prenatal and postpartum visits, the maximum reimbursement amounts for doula services in California are currently around $3,153 for vaginal deliveries and $3,263 for cesareans. 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 for delivery services is $900, and the base amount for prenatal and postpartum visits is $100 per visit (with up to six visits covered); this results in a maximum reimbursement of $1,500. Nevada then offers a 10% increase in these rates for services provided to clients residing outside of the specified urban counties, meaning the maximum reimbursement in those areas is $1,650. This rural provider incentive is aimed at addressing Nevada’s “vast maternal health care deserts,” as more than half of the state’s counties do not have a hospital or birth center with obstetric care.

 

  • New Jersey’s maximum reimbursement rate is different depending on the beneficiary’s age. For patients older than 19 (“standard care”), the maximum amount is $1,165. For patients aged 19 or younger, the state covers “enhanced care”—which includes an extra four doula visits—for a maximum reimbursement of $1,431. New Jersey designed this reimbursement structure based on doulas’ reports that they needed additional visits with younger clients.

 

  • New York sets its doula reimbursement rates based on geographical location, but unlike Nevada, the bump in reimbursement is for services provided to clients residing in an urban area rather than rural areas, likely due to a higher cost of living in New York City. Doulas providing services in New York City can be reimbursed at a maximum rate of $1,500: $750 for labor and delivery, plus about $94 per prenatal or postpartum visit for 8 visits. Outside of New York City, the maximum reimbursement is a little lower at about $1,350: $675 for labor and delivery, and around $84 per prenatal or postpartum 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. In addition to providing extra income for doulas, incentive payments are intended to maximize doulas’ role in improving health quality for birthing people, targeting the unique needs of different communities, and addressing equity gaps in birth outcomes. Still, incentive payments may not be an ideal solution for encouraging doulas to participate in Medicaid programs. As doulas are advocates who empower their clients to make informed decisions on their health care, incentivizing visits may put a doula in a difficult position, especially if reimbursement rates are low. Doulas may feel pressure to seek incentive funding and this can affect the relationships that doulas build with their clients. Doulas must be able to remain strong advocates for their clients and support their decisions to engage with the health care system even in such situations where it may be more financially beneficial for a doula to encourage additional care.

  • Nevada will reimburse up to two extra doula visits (six total visits) as an incentive for doulas to connect their clients to additional prenatal health care. One additional doula visit may be reimbursed when the client has had two prenatal visits with a licensed physician, nurse midwife, Advanced Practice Registered Nurse, or physician assistant. 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.

Conclusion

Doula 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. Equitable reimbursement rates are critical for sustaining a stable doula workforce. States have made great strides in recent years to expand access to doula care for Medicaid enrollees, and an upward trend in compensation is emerging. States should continue to collaborate with community doulas and other stakeholders to establish equitable and sustainable reimbursement rates and design doula benefit programs that are accessible to all.

 

[1] Chen, A. National Health Law Program. Doula Medicaid Project: February 2024 state roundup. February 21, 2024. https://healthlaw.org/doula-medicaid-project-february-2024-state-roundup/

[2] National Health Law Program Doula Medicaid Project. Current Efforts at Expanding Access to Doula Care: Current State Efforts. Accessed September 2024 https://healthlaw.org/doulamedicaidproject/#current-efforts-at-expanding-access-to-doula-care

[3] Hasan, A. National Academy for State Health Policy. State Medicaid Approaches to Doula Service Benefits. April 16, 2024. https://nashp.org/state-tracker/state-medicaid-approaches-to-doula-service-benefits/

[4] $215/ea for prenatal and postpartum visits + $645 for birth and delivery. Up to 2 prenatal visits and 2 postpartum visits.

[5] $100/ea for prenatal and postpartum visits + $1,400 for labor and delivery. Up 18 total sessions, including labor and delivery.

[6] $99.72 for initial 90-min visit + $66.48/ea for 60-min prenatal and postpartum visits + $500 for delivery + $100 incentive payment. Up to 8 total prenatal and postpartum visits. Maximum of $1,065.

[7] For beneficiaries age 19 or younger. $99.66 for initial 90-min visit + $66.44/ea for 60-min prenatal and postpartum visits + $500 for delivery + $100 incentive payment. Up to 12 total prenatal and postpartum visits. Maximum of $1,331.

[8] $100/ea for prenatal and postpartum visits + $900 for labor and delivery. Up to 3 prenatal visits and 3 postpartum visits.

[9] $859 total + up to $100 incentive payment. Up to 8 total prenatal and postpartum visits.

[10] $66.48/ea for prenatal visits + $78.48/ea for postpartum visits + $350 for labor and delivery. Up to 8 total prenatal and postpartum visits. Total of $929.84 assumes 4 prenatal and 4 postpartum visits.

[11] $66.48/ea for prenatal visits + $78.48/ea for postpartum visits + $800 for labor and delivery. Up to 8 total prenatal and postpartum visits. Total of $1,379.84 assumes 4 prenatal and 4 postpartum visits.

[12] $50/ea for prenatal and postpartum visits + $150 for labor and delivery. Up to 4 total prenatal and postpartum visits.

[13] $100/ea for prenatal and postpartum visits + $900 for labor and delivery + up to $200 incentive payment. Up to 4 total prenatal and postpartum visits.

[14] Same as for urban counties, supra note 10, but with an additional 10% incentive.

[15] $97.04/ea for perinatal and postpartum visits + $686.23 for labor and delivery + $100 incentive payment. Up to 12 perinatal and postpartum visits.

[16] $75/ea for prenatal and postpartum visits + $700 for labor and delivery. Up to 6 total prenatal and postpartum visits.

[17] $100/ea for prenatal and postpartum visits + $1,500 for labor support. Up to 12 prenatal and postpartum visits.

[18] $197.98 for initial 90-min visit + $162.11/ea for prenatal and postpartum visits + $486.36 for extended 3-hr postpartum visit + $685.07 for vaginal delivery. Up to 8 prenatal or postpartum visits after the initial visit. Up to 2 extended 3-hr postpartum visits. With an additional recommendation from a licensed Medicaid provider, up to 9 additional postpartum visits can be provided.

[19] Same as for vaginal delivery, supra note 14, but $795.73 for support during cesarean birth.

[20] $64.45/ea for prenatal and postpartum visits + up to $527.78 for vaginal delivery. Up to 8 total prenatal and postpartum visits.

[21] Same as for vaginal delivery, supra note 16, but $546.50 for support during cesarean birth.

[22] $100/ea for 60-min perinatal visits + $150/ea for 60–90-min perinatal visits + $900 for labor and delivery. Up to $800 for perinatal visits.

[23] $93.75/ea for prenatal and postpartum visits + $750 for labor/delivery. Up to 8 total prenatal and postpartum visits.

[24] $84.37/ea for prenatal and postpartum visits + $675 for labor/delivery. Up to 8 total prenatal and postpartum visits.

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