Doula Medicaid Project

• For the purpose of requiring the Maryland Medical Assistance Program, subject to certain limitations, to provide certified doula services; authorizing the Secretary of Health to contract with certified doulas for the provision of care under the Maryland Medical Assistance Program; providing that certified doulas need not be under the supervision of a physician for purposes of certain provisions of this Act; defining a certain term; and generally relating to the Maryland Medical Assistance Program and doulas.
• ""CERTIFIED DOULA"" MEANS AN INDIVIDUAL WHO HAS RECEIVED A CERTIFICATION TO PERFORM DOULA SERVICES FROM THE INTERNATIONAL CHILDBIRTH EDUCATION ASSOCIATION, THE DOULAS OF NORTH AMERICA, THE ASSOCIATION OF LABOR ASSISTANTS AND CHILDBIRTH EDUCATORS, OR THE CHILDBIRTH AND POSTPARTUM PROFESSIONAL ASSOCIATION
• The Secretary may contract with insurance companies or nonprofit health service plans or with individuals, associations, partnerships, incorporated or unincorporated groups of physicians, chiropractors, dentists, podiatrists, optometrists, pharmacists, hospitals, nursing homes, nurses, including nurse anesthetists, nurse midwives and certified nurse practitioners, opticians, CERTIFIED DOULAS, and other health practitioners who are licensed or certified in this State and perform services on the prescription or referral of a physician.
• For the purposes of this section, the nurse midwife OR CERTIFIED DOULA need not be under the supervision of a physician.

•Application for certificate; certification; renewal; fingerprint clearance card; continuing education

A. A person may apply to the director for a certificate to practice as a certified community doula on a form prescribed by the director and shall furnish the information required by the director.

B. The director shall grant a community doula certificate to a person who:

1. Meets the qualifications prescribed by this article and rules adopted pursuant to this article.

2. Pays the applicable fees.

3. Possesses a valid fingerprint clearance card issued pursuant to title 41, chapter 12, 3.1.

C. A community doula certificate is valid for three years and may be renewed every three years by applying to the director and paying the applicable fees.

D. A person shall file an application for renewal at least thirty days and not more than sixty days before the date the current community doula certificate expires. A community doula must complete fifteen hours of continuing education before the community doula's certificate may be renewed.

36-766.02. Powers and duties of director; rules; waiver

A. The director, by rule, shall:

1. Prescribe the scope of practice and the core competencies of certified community doulas, including skills and areas of knowledge that are essential to expand health and wellness in diverse communities and to reduce health disparities.

2. Describe and define reasonable and necessary minimum qualifications, including education and training requirements, for certified community doulas. Training for certified community doulas must include all of the following:

(a ) At least thirty hours of in-person classroom instruction on the following topics:

(i ) Anatomy and physiology of pregnancy, labor and delivery.

(ii ) The role of certified community doulas and standard services.

(iii ) Cultural diversity regarding pregnancy and childbirth.

(iv ) Business practices and requirements of certified community doulas.

(v ) Professional courtesy and best practices of certified community doulas.

(vi ) Prenatal contact and obligations.

(vii ) Comfort techniques for labor and delivery.

(viii ) Working with the father and other family members.

(ix ) Needs of at-risk women and families.

(x ) Social services.

(xi ) Interventions during childbirth.

(xii ) Current hospital policies.

(xiii ) Complications of childbirth.

(xiv ) Cesarean section and vaginal birth after a cesarean section.

(xv ) Universal precautions.

(xvi ) Unexpected outcomes.

(xvii ) Breastfeeding.

(xviii ) Newborn care.

(xix ) Postpartum care.

(xx ) Standards of practice and the code of ethics of certified community doulas.

(b ) At least one documented observation of a birth after training is completed.

(c ) Attending at least three births while serving as the primary doula support person.

(d ) Passing a written examination as prescribed by the department.

(e ) Instruction on first aid and cardiopulmonary resuscitation.

3. Adopt standards and requirements to establish certified community doula education and training programs in this state.

4. Adopt standards to approve or accept continuing education courses and programs for renewing community doula certificates.

5. Establish minimum education, training, experience and other qualifications that a certified community doula must possess to qualify as a trainer in any education, training or continuing education program for certified community doulas.

6. Establish the criteria for granting, denying, suspending and revoking community doula certificates in order to protect the public health and safety.

B. The director may adopt rules:

1. That are necessary to administer and enforce this article.

2. That allow for reciprocity agreements, including with the Indian health service.

C. The director shall waive the minimum training and education requirements for certification for applicants who provide documentation of current certification with a nationally recognized doula organization.

36-766.03. Denial, suspension or revocation of certificate; hearings; disciplinary action; appeal

A. The director may deny, suspend or revoke the certificate of any community doula who:

1. Violates any provision of this article or rule adopted pursuant to this article.

2. Is convicted of a felony or a misdemeanor involving moral turpitude.

3. Indulges in conduct or a practice that is detrimental to the public health or safety.

B. The department may deny, suspend or revoke a community doula certificate without holding a hearing. After receiving notification of the denial, suspension or revocation, the applicant or community doula may request a hearing to review the denial, suspension or revocation and, if requested, the department shall conduct the hearing pursuant to title 41, chapter 6, article 10.

C. If the director determines pursuant to a hearing that grounds exist to deny, suspend or revoke a community doula certificate, the director may do so permanently or for a fixed period of time and may impose conditions as prescribed by rule.

D. A Certified community doula who is employed by an Indian tribe and who violates this section shall be under tribal government jurisdiction. If the certified community doula is determined to have violated this section, the information provided to the director may result in the denial, suspension or revocation of the community doula's certification. Internal hearings, appeals or penalties resulting from disciplinary actions by a tribal government are deemed to be the final decision in accordance with this section.

This act would provide for medical assistance health care for expectant mothers and would establish medical assistance coverage and reimbursement rates for perinatal doula services.

(32) Within the amounts appropriated in this section, the authority shall reimburse for maternity services provided by doulas.

This bill would require the department to establish, commencing July 1, 2021, a full-spectrum doula care pilot program to operate for 3 years for pregnant and postpartum Medi-Cal beneficiaries residing in 14 counties, including the Counties of Alameda, Sacramento, San Diego, and Solano, that experience the highest burden of birth disparities in the state, and would provide that any Medi-Cal beneficiary who is pregnant as of July 1, 2021, and residing in a pilot program county, is entitled to doula care. The bill would require the department to develop multiple payment and billing options for doula care, and to ensure specified payment and billing practices, including that any doula and community-based doula group participating in the pilot program be guaranteed payment within 30 days of submitting any claim for reimbursement. The bill would require the department to establish a centralized registry listing any doula who is available to take on new clients in each county participating in the pilot program, and would provide several requirements for the registry, such as the information on the registry being accessible by various means, including the internet website. The bill would require each Medi-Cal managed care health plan in any county participating in the pilot program to provide information in its materials, and specified notices, on identified topics related to doula care, including reproductive and sexual health, and to inform pregnant and postpartum enrollees at prenatal and postpartum appointments about doula care, such as the availability of doula care and how to obtain a doula.
The bill would require the department to convene a doula advisory board that would be responsible for deciding on a list of core competencies, such as the capacity to employ different strategies for providing emotional support, education, and resources during the perinatal period, required for doulas who are authorized by the department to be reimbursed under the Medi-Cal program. The bill would require a doula to provide documentation that they have met the core competencies specified by the board as a prerequisite to be reimbursed under the Medi-Cal program. The bill would require the department to work with outside entities, such as foundations, to make trainings available at no cost that meet the core competencies to people who are from communities experiencing the highest burden of birth disparities in the state.
The bill would require the department to allocate funding and resources for data collection, reporting, and analysis for purposes of conducting an evaluation of the pilot program, to ensure that an evaluation of the pilot program begins no later than July 1, 2023, and that it be completed by January 1, 2024, to submit a report to the appropriate policy and fiscal committees of the Legislature, and to include the board and relevant stakeholders, including practicing doulas, in the department’s evaluation design. The bill would authorize the department to consider the feasibility of a statewide doula benefit for Medi-Cal beneficiaries during the perinatal period if, after the first 3 years of the pilot program, the pilot program is achieving improved birth outcomes for people using doulas and their babies, and to terminate the pilot program if the pilot program is not achieving those outcomes during that period.

This "Certified doula" means an individual who has received a certification to perform doula services from the International Childbirth Education Association, the Doulas of North America (DONA), the Association of Labor Assistants and Childbirth Educators (ALACE), Birthworks, the Childbirth and Postpartum Professional Association (CAPPA), Childbirth International, the International Center for Traditional Childbearing, or Commonsense Childbirth, Inc., or Modern Doula Education (MDE).

Establishing the Doula Technical Assistance Advisory Group; providing for the composition, chair, and staffing of the Advisory Group; requiring the Advisory Group to study certain programs, review certain studies and reports, invite certain stakeholders to meetings, and make certain recommendations; requiring the Advisory Group to submit a final report to the Maryland Department of Health and certain committees of the General Assembly by January 1, 2022; etc.

The Department of Health shall develop a standardized perinatal health curriculum for training community health workers in the provision of education and support services to women of childbearing age. The curriculum shall include basic educational information and materials concerning factors and behaviors that affect maternal and infant health and childbirth, including, but not limited to: alcohol and substance use during pregnancy; maternal medical conditions that affect pregnancy; premature births and low birthweight babies; cesarean sections and labor induction; labor and delivery; infant mortality; breastfeeding; shaken baby syndrome; perinatal mood disorders ; and the signs, symptoms, and risk factors most commonly associated with maternal and infant mortality and mobidity. The curriculum shall further include information on: shared decision making; informed consent; and resources available in the State for women, including, but not limited to, the resources and referrals available through the county central intake agencies.
As it related to doulas: the department shall promote and share the curriculum as best practices for community doulas.

An Act to enact R.S. 22:1057, relative to health insurance coverage for doula services; to require health insurance coverage for maternity services provided by doulas; to provide for legislative findings; to prohibit discrimination; to define key terms; to provide for applicability; to establish an effective date; and to provide for related matters.

State plan for medical assistance; perinatal birth workers. Directs the Department of Medical Assistance Services to convene a work group to (i) evaluate the potential costs and benefits, including potential reductions in maternal and infant mortality rates, of amending the state plan for medical assistance services to include a provision for the payment of medical assistance for antepartum, intrapartum, or postpartum services provided to a pregnant person or to a person who is up to one year postpartum for labor and delivery support by a certified doula and at least four visits during the antenatal period and at least seven visits during the postpartum period with a certified doula and (ii) develop recommendations related to an appropriate reimbursement rate for such services provided by certified doulas

• Defines doula certification organizations with 6 named organizations.
• Defines doula services as "physical, emotional, or educational support provided during the prenatal, childbirth, and postpartum periods, other than such support that is considered to be medical, midwifery, or clinical in nature. "Doula services" include all of the following:
(a) Prenatal and postpartum visits;
(b) Birth support and time spent on call in reasonable anticipation of a birth;
(c) Communications between a doula and a pregnant woman or a pregnant woman's support person, including through telephone, electronic, or other means;
(d) Connecting a pregnant woman or woman capable of becoming pregnant with nonprofit organizations that provide assistance in locating available health and social services;
(e) Time spent on related administrative tasks such as documentation."
These services shall be covered by Medicaid when provided by a doula who meets the following qualifications:
(1) Proof that the doula has a current, valid certificate issued by a doula certification organization;
(2) An attestation that the doula has completed at least sixty hours of in-person classroom instruction and training that includes any combination of childbirth education, birth doula training, antepartum doula training, and postpartum doula training;

(3) Proof of attendance at a minimum of all of the following: One breastfeeding class, two childbirth classes, two births
(4) At least one positive reference from a birth mother and at least one positive reference from a licenced health professional practicing in public health or a community-based public health organization
(5) Proof of completion of instruction in all of the following that meet the standards of the recommendations of the Ohio doula advisory board:
(a) Cultural competency;
(b) Cardiopulmonary resuscitation;
(c) Health information confidentiality, including the privacy standards established under HIPAA
- Establishes a Doula Advisory Board

A bill to amend 1939 PA 280, entitled "The social welfare act," (MCL 400.1 to 400.119b) by adding section 109n. The people of the state of Michigan enact:

Sec. 109n. (1) An individual who is eligible for medical assistance and who is an expectant mother may receive doula services before, during, and after childbirth for up to 60 days postpartum. If a federal waiver is necessary to modify the medical assistance state plan and implement the provisions of this section, the department shall promptly seek the federal waiver.

(2) As used in this section, "doula" means a professional trained in childbirth who provides continuous physical, emotional, and informational support to an expectant mother.

SECTION 10M: Medicaid Coverage for Doula Services.

(a) For purposes of this section, the following words shall have the following meanings:

“A perinatal doula” or referred to hereafter as "doula”, is a trained professional who provides physical, emotional, and informational support, but not medical care, for pregnant individuals, surrogates, foster care parents and adoptive parents during and after pregnancy, labor, childbirth, miscarriage, stillbirth or loss. Doulas provide services, including but not limited to:

(1) providing continuous labor support to pregnant individuals, families, surrogates, and

adoptive parents;

(2) conducting prenatal, postpartum, and bereavement home or in-person visits

throughout the perinatal period, lasting until 1 year after birth, pregnancy loss,

stillbirth, or miscarriage;

(3) accompanying pregnant individuals to health care and social services appointments;

(4) providing support to individuals for loss of pregnancy or infant from conception

through age 1;

(5) connecting individuals to community-based and state- and federally-funded

resources, including those which address needs within the social determinants of health;

(6) engaging in administrative tasks related to these services; and

(7) making oneself available (being on-call) around the time of birth or loss as well as providing support for any concerns of pregnant individuals throughout pregnancy and until 1 year after birth, pregnancy loss, stillbirth, or miscarriage.

(b) (1) Coverage of Doula Services:

The division shall provide coverage for doula services throughout the Commonwealth of Massachusetts for pregnant individuals, surrogates, foster parents and adoptive parents.

(2) In partnership with the doula care commission, MassHealth and the department of public health shall establish and maintain a registry of doulas who are eligible for reimbursement; establish processes for billing and reimbursement of doula services; and determine competencies a doula must demonstrate in order for their services to be reimbursed by MassHealth; and establish processes for doulas to demonstrate proof of competencies.

(i) Competencies shall include, but are not limited to:

(A) understanding of basic anatomy and physiology as related to pregnancy, the

childbearing process, the postpartum period, breast-milk feeding, breastfeeding and

chestfeeding;

(B) capacity to employ different strategies for providing emotional support, education

and resources during the perinatal period;

(C) knowledge of and ability to assist families with a wide variety of non-clinical labor coping strategies;

(D) strategies to foster effective communication between clients, their families, support services and health care providers;

(E) awareness of and ability to provide information on integrative health care systems and various specialties of care to address client needs beyond the scope of practice of the doula;

(F) knowledge of community-based, state- and federally-funded, and clinical resources

available to address client needs beyond the scope of practice of the doula; and

(G) knowledge of HIPAA compliance and client confidentiality.

(ii) In addition to the above competencies, doulas serving members of MassHealth shall also show competency or demonstrate actively seeking training or engagement in the areas of:

(A) health equity;

(B) implicit bias;

(C) racism, including structural, interpersonal, and institutionalized racism;

(D) reproductive and birth justice;

(E) cultural sensitivity and humility;

(F) trauma-informed care, including for survivors of sexual assault or birth trauma;

(G) parental mental health needs;

(H) needs of persons with disabilities or disabled persons;

(I) sexual and gender identities; and

(J) social determinants of health.

(c) Creation of Doula Care Commission

There is hereby created a doula care commission. The commission shall provide recommendations on the implementation and evaluation of doula care reimbursement.

(1) The commission shall consist of no more than 15 members, including the commissioner of public health, or designee; the commissioner of insurance, or designee; the commissioner of the department of children and families, or designee; the director of Medicaid, or designee; at least 5 doulas to be appointed by the commissioner of public health, or designee; and no more than 6 other members to be appointed by the commissioner of public health, or designee.

(2) At least 5 of the members of the commission shall be doulas; provided, that a majority of the doula members shall be from racial or ethnic populations most affected by inequities in birth outcomes in the Commonwealth, as evidenced by the most current

perinatal data supplied by the MA Department of Public Health. Other members of the commission shall include at least:

(i) 2 persons who have experienced pregnancy as a MassHealth member or are currently recipients of MassHealth;

(ii) 1 person who identifies as belonging to the LBTQIA+ community;

(iii) 1 person who is a survivor who has experienced sexual assault and/or birth trauma;

(iv) 1 person who is a survivor who has experienced a severe maternal morbidity, a perinatal

mental health or mood disorder, or a near-death experience while pregnant or in maternity care;

(v) 1 person who is a family member affected by infant loss, miscarriage, or infertility;

(vi) 1 person who identifies as a person with disabilities or disabled person;

(vii)1 person who has an advanced degree in health economics or public health;

(viii) 1 person who is qualified in actuarial sciences;

(ix) 1 person who is a representative from the Massachusetts Association of Health Plans;

(x) 1 person who is an obstetrician, family physician or midwife; and

(xi) 1 person who has experience in workforce development, supervision, training and mentoring of community doulas.

Representatives on the Doula Care Commission shall strive to include representation from

areas within the Commonwealth where maternal and infant outcomes are worse than the state

average, as evidenced by the most current perinatal data supplied by the MA Department of

Public Health.

(4) The purposes of the commission shall include, but not be limited to:

(a) developing recommendations for required doula competencies;

(b) developing recommendations for standards of proof or demonstration of competency or equivalency for required doula competencies;

(c) developing recommendations for a diverse doula and doula trainer workforce development strategy, including, but not limited to, a focus on accessible continuing education/training activities, mentorship and career growth opportunities;

(d) developing recommendations for standards and processes around billing for and reimbursement of services;

(e) ensuring the racial, ethnic, cultural, geographic, and professional diversity of standing membership of the commission;

(f) representing the interests of doulas in communication with state entities and the health care system;

(g) receiving any grievances from doulas, doula clients, healthcare providers, and health systems and making recommendations to resolve those grievances;

(h) overseeing communications to the public and various stakeholders about access to doula care and reimbursement;

(i) advising on the evaluation of outcomes, access to, and satisfaction with doula care services;

(j) approving a reimbursement amount for doula services and related activities listed in subsection (a) that constitutes a living and fair wage for doulas who reside in all areas of the commonwealth, as well as establishing a recurring timeframe to review the established wage in light of recent data on living and fair wages in the commonwealth;

(k) establishing a plan for the scaling of provision doula services and growing the workforce of doulas, in order to increase access to MassHealth members; and

(l) ensuring all aims of the commission, the establishment of reimbursement for doula services, the growth of a diverse workforce of doulas, and all other aims are directed towards the goal of reducing inequities in maternal and birth outcomes among racial, ethnic, and cultural populations who reside in all areas within the commonwealth, as evidenced by the most current perinatal data supplied by the department of public health.

(5) The commission may conduct public hearings, forums or meetings to gather information and to raise awareness of access to doula care, including the sponsorship of or participation in statewide or regional conferences.

(6) The commission shall file a report within 12 months of initiation to the Governor, the

commissioner of public health, and the director of Medicaid detailing the activities of the commission; a strategic or implementation plan for each of the purposes listed in paragraph (4); a process evaluation plan for implementation objectives; and an outcome evaluation plan for maternal and infant outcomes, once reimbursement of doula care is implemented, with a goal of initiating reimbursement of doula services within 18 months of filing

the report.

(d) Payment for Doula Services:

(1) MassHealth shall make an initial recommendation of the reimbursement amount for doula services no later than 3 months from the initiation of the doula care commission. The recommendation shall reflect evidenced consideration of a livable and fair wage for doulas who reside within all areas of the commonwealth, and shall include an amount for support during labor and childbirth; an amount for visits during and after pregnancy, childbirth, miscarriage, stillbirth, or loss that relate to activities listed in subsection (a); a schedule by which doula services can be reimbursed up to 1 year after birth, miscarriage, stillbirth, or loss; and travel-related expenses related to the delivery of those services.

(2) The recommended reimbursement amount shall be approved by the doula care commission prior to being enacted.

(3) MassHealth shall aim to initiate reimbursement of doula services within 18 months of the report of the doula care commission.

• Defines “Certified community doulas” as those that were given certification by the Department of Health Services in Arizona
• Defines ""doula"" as a trained nonmedical health worker who provides continous physical, emotional, and informational support to a mother before, during, and after childbirth and who serves as a liaison between the birthing parent and medical and social services staff to improve the quality of medical, social, and behavioral outcomes.
• Director of the Department of Health Services must identify criteria necessary to become a certified doula and has the power to revoke a certificate, director will define minimum qualifications for training and education.
• Core competencies include skills and areas of knowledge to bring expanded health access and wellness in diverse communities and to reduce health disparities.
• Details the application process for becoming certified which includes an application fee and renewal every two years
• Establish minimum education, training, experience, and other qualifications for trainers.
• Clarifies that certificates are not necessary to practice as a community doula in the state

• Provides doula coverage under medical assistance program.
• Sets forth certain certification and training requirements for doulas in order to be reimbursed.
• To be eligible for reimbursement doulas must be certified by an organization that is nationally recognized for training and certification of doulas, complete a cultural competency course, complete a course on HIPAA compliance, be certified to provide cardiopulmonary resuscitation, and submit to a federal and state background check.

• Medicaid coverage of doula care.
• May apply for a SPA or waiver to implement

• Establish a learning network to develop parameters for a 3 year perinatal episode care pilot program in Medicaid to improve outcomes and reduce cost.
• Identifies communities doulas as a wraparound patient support service and to be potentially covered.

Medicaid coverage of doula care (Replaced AB 1662)
From the bill summary: This bill provides for the expansion of the State Medicaid program to include coverage for doula care. A doula is a trained professional who provides physical, emotional, and educational support, but not medical care, to mothers before, during, and after childbirth.

• Amends the public health law to require doulas to be certified, over 18 years of age, and of good moral character to be called “certified doulas”
• Defines doula services as continous emotional and physical support throughout labor and birth, and intermittently during the prenatal and postpartum period.
• Outlines process for doula certification which includes 3 major steps: filing an application within the department, satisfying department’s education requirements, and passing an examination
• Requires payment of at least $40 for a license and $10 for a limited permit
• Does not intend to create an exclusive scope of practice but instead the title of "certified doula"

• Medicaid coverage of doula care
• Outlines steps for doulas to be reimbursable by Medicaid. Including getting a provider ID number, provided a certificate from a doula organization, and letter detailing their completion in core competencies, including at least 24 contact hours.
• Creates a state registry of qualified doulas
• Doula services do not include: "practice of medicine"
• Doulas may be reimbursed through Fee-For-Service and up to one year postpartum and not to exceed $1,500
• To take effect 7-1-2020

• Qualified doulas shall be reimbursed for providing childbirth education and support services, including physical and emotional support, to individuals covered by Medicaid during pregnancy, labor and delivery, and postpartum. The Department shall keep a registery of qualified doulas. Doulas will not be reimbursed for travel time or mileage.
• Describes requirements for obtaining Medicaid reimbursement such as receiving additional training designed specifically for serving marginalized populations, having certification from a national approved organization, and having personal liability insurance. Organizations that doulas may received certification at their own cost include: Birthworks, Childbirth International, CAPPA, Commonsense Childbirth Inc., DONA, ICTC, International Childbirth Education Association.
• Restricts reimbursement to no more than $750
• Establishes reimbursement rates - $25 for prenatal visits per hour for up to 4 hours, $550 for support during delivery, $25 per hour for postpartum visits for up to 2 hours, and up to $50 for administrative expenses

• Within 120 days of the effective date, the Department of Health wil disburse grant funds annually to implement a perinatal health worker training program that trains individuals in Wards 5, 7, 8 to provide culturally congruent nonclinical care to individuals during their perinatal period, including didactic training on reproductive health, including physical, mental, and social wellbeing related to the functioning of the reproductive system.

• Governor Evers’ budget proposal includes a total of $618,700 over the biennium to make doula services reimbursable through Medicaid and fund doula training programs. Governor Evers’ budget would require DHS to request any necessary federal approval to allow Medicaid reimbursement for doulas. This budget earmarks $234,700 (in fiscal year 2020-21) for a pilot program to provide Medicaid reimbursement for doula services for eligible individuals who live in Milwaukee, Rock, Dane, Brown and Sheboygan counties and use a certified doula. The Department of Health Services (DHS) would administer certifications. This budget allocates $192,000 per year in training grants for doulas. These grants will be awarded to organizations that provide community-based doula services to identify and train local community workers to mentor pregnant women.