Best Practices for Medicaid
Coverage of Doula Care

As mentioned above, some of the Best Practices may by necessity belong in more than one chronological category, or may shift from one category to another depending on the particular circumstances in the state. The image above is meant to illustrate this potential flow from one category to the next. Advocates are advised to keep this fluidity in mind when reviewing these Best Practices.

Where relevant, under the enumerated Best Practice, I have a drop-down menu that lists specific examples of states that have put in place that best practice. To the extent possible, I have included hyperlinks for these examples so that those utilizing the Best Practices for Medicaid Coverage of Doula Care can conduct their own research and track back to the original sources. I have also tried to put in short descriptions where such would be helpful, but in some cases have simply included lists.

While this document stands on its own as of the date of its publication in Spring 2025, I also want to acknowledge that by necessity this is also a living document. As more states move through implementation of Medicaid coverage of doula care, there will be additional examples to include in the list, and indeed likely additional Best Practices to add. I also anticipate that as time goes on, some of the entries in this Best Practices document will become outdated. With that in mind, if you have any edits, corrections, or suggestions, please send them to [email protected].

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The Pre-Implementation Phase encompasses the period in which, ideally, doulas, advocates, state agency staff, and other stakeholders sit down to design the details of what the Medicaid coverage of doula care program will look like in that state. You will see that this phase has the most Best Practices of any of the three chronological phases. There is good reason for that. It behooves states to be strategic and thoughtful in their program design, and to obtain buy-in from relevant stakeholders early and often. States that do so can avoid having to later engage in time-consuming, costly, and resource-intensive legislative and/or regulatory clean up.

Many state efforts that explore Medicaid coverage for doula care begin through doula pilot programs that provide doula care to smaller groups of individuals, typically limited by population, type of insurance coverage, and/or geography. These pilot programs allow local, regional, and state actors to test out different types of doula projects, and can help troubleshoot issues before broader statewide expansion.

In some cases, doulas and state advocates push for the creation of Doula Advisory Boards, Committees, or other such entities to partner with state agencies on implementation of Medicaid coverage for doula care. These Boards or Committees are groups of, ideally, mostly doulas, that provide expert guidance to state agencies during the implementation process. It is important that they be set up to have explicit decision making power, and not merely serve as a toothless vehicle for advice or input which can permissibly be ignored.

Doulas and state advocates should come together and self-organize around advocacy for legislation or administrative efforts to advance expanding access to doula care, including in Medicaid. A statewide doula coalition of this type can help ensure that doulas and state advocates have a voice in the process, and provide them a vehicle to lift up their priorities and demand that their concerns be addressed.

Doulas and advocates working together to advocate for expanding access to doula care should consider creating a survey, series of focus groups or town halls, or other mechanisms to gather collective input from doulas in the state and publish their findings. Reports and issue briefs of this type are helpful because they allow doulas and advocates to publicly share their recommendations as well as concerns. Legislators, state agencies, and other stakeholders can then later use these publications to help guide legislation or implementation action.

Any training or certification requirements that doulas must meet in order to be eligible for reimbursement must be flexible and not constitute an undue burden for doulas or serve as an excessive barrier to entry.

• Rather than provide a list of certification organizations and require that a doula be certified by one of the organizations on the list, states can consider instead, or also, allowing doulas to meet a set of core training competencies that are not tied to a specific organization. Such competencies typically consist of a list of core training topics that are considered crucial for competency as a doula, such as childbirth education, anatomy of pregnancy and childbirth, labor support techniques including non-medical comfort measures, lactation support, and other topics. The states below all include core competencies in their training or certification requirements.

• In order to allow more experienced doulas to be able to participate in the benefit, states should create “experience” or “legacy” pathways that are alternatives to having to present new training or certification criteria. Such pathways allow doulas to enroll as Medicaid providers based on their more extensive years of experience as practicing doulas. This experience is typically confirmed through testimonial letters or letters of recommendation. The states below all have an experience or legacy pathway.

• Allow reciprocal certification for doulas that are already certified as Medicaid providers in other states. This will allow doulas that have already successfully enrolled as Medicaid providers and been providing services to Medicaid enrollees in one state, to more easily transition their practice to another state. My guess is that such reciprocal certifications will become more common as more states implement Medicaid coverage of doula care.

Doulas that serve Medicaid enrollees must receive equitable and sustainable reimbursement for their services at a rate at or above market rate. In most communities this should be at least $2000 for the complete package of services, and in many cases should be upwards of $3000+. This is particularly true for states that are covering postpartum doula care for up to 12 months after the end of pregnancy. Reimbursement rates should be reviewed periodically every few years, and such review should include input from stakeholders including practicing doulas.

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Expansions in access to doula care should prioritize those communities most at need, such as Medicaid enrollees; immigrants; Black, Indigenous, and other People of Color (BIPOC) who are most impacted by racial disparities in care; members of the LGBTQ+ community; people with disabilities; and people with opioid and/or substance use disorders.

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Medical professionals in leadership positions in the state government can pass statewide standing recommendations recommending doula care as beneficial for all pregnant, postpartum, and post-pregnancy Medicaid enrollees in the state. Such statewide standing recommendations will go a long way to reducing a key barrier to doula access. Virtually all states that have implemented Medicaid coverage of doula care have included doula care in their Medicaid State Plan as a preventive service. As a preventive service, doula care must meet the requirements of 440.130(c) of title 42 of the Code of Federal Regulations, which include that the service be “recommended by a physician or other licensed practitioner of the healing arts.” Typically this means that Medicaid enrollees must have a licensed Medicaid provider recommend that doula care would be beneficial for their health. Needless to say, obtaining such a recommendation, which often must be in writing, can be onerous and Medicaid enrollees and impede access to doula services. A statewide standing recommendation obviates the need for Medicaid enrollees to obtain such individual recommendations.

State advocacy and expansion efforts should lift up the importance of community based doulas and doula care, but need not actually require that doulas be trained as community based doulas in order to be eligible for reimbursement. Community based doulas provide culturally and linguistically appropriate support to pregnant, postpartum, and post-pregnancy people. Community based doulas often hail from the communities in which they serve. This is in contrast to doulas more broadly defined, who provide support to pregnant, postpartum, and post-pregnancy people, but who may not be culturally or linguistically aligned with their clients. That being said, while community based doulas and community based doula care is important, it is equally critical that states be flexible in their training or certification requirements. As such, while we promote states championing the importance of community based doula care, we do not advise that states require doulas to obtain specific community based doula training.

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Doula care should be full spectrum, meaning doula care provided for all the ways in which a pregnancy can end. This means not just doula care for prenatal care, postpartum care, and presence at labor and delivery, but also doula care for abortion, ectopic pregnancies, miscarriage, and stillbirth. The states below have Medicaid coverage for the full spectrum of doula care, including doula care for abortions.

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The Implementation Phase is the period when the Medicaid coverage of doula care program is actually rolling out. This phase may last for much longer than doulas, advocates, and state agencies would like. Indeed, many states can linger in this phase for years. The timing of this phase is a little tricky to nail down. In most states, this phase begins when the actual Medicaid doula benefit begins. However, in some states the phase may begin even earlier, such as in the case of states that begin enrolling doulas as Medicaid providers prior to the actual start date of the benefit. It is also not entirely clear when this phase ends. For example, would the implementation phase end when a sufficient number of doulas are enrolled as Medicaid providers, and a sufficient number of Medicaid enrollees are able to successfully access services? Yet what is or is not “sufficient” will likely vary from state to state, and indeed vary based on who is making the evaluation.

The most successful programs for Medicaid coverage for doula care will be implemented in close and direct partnership with doulas and doula groups, especially community-based doulas and doula groups, Black doulas and Black-led doula groups, and doulas and doula groups already serving Medicaid enrollees and low-income clients. State Medicaid Agencies must devote staff, time, and resources to creating, building, and sustaining partnerships with the doulas and doula groups that will help them implement the doula Medicaid benefit, and give them valuable information and insight into the new doula Medicaid workforce.

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Doulas may want to join together in a more formal arrangement to form groups, organizations, and/or co-ops to serve as a go-between third party agency between the doulas and the State Medicaid Agency and/or Medicaid managed care plans. Such groups can provide doulas with administrative support in enrollment, billing, and reimbursement, as well as mentorship and other critical support.

Create centralized doula registries so that Medicaid enrollees, health plans, advocates, doulas and doula groups, agencies, and other stakeholders know what doulas are enrolled as Medicaid providers. Break down the registry by geography, race/ethnicity, languages spoken, specialties (such as providing services to youth, people with substance use disorder, or survivors of domestic violence), and where relevant, enrollment in Medicaid managed care plans.

For states that have Medicaid managed care plans, standardize application forms, billing paperwork, and other processes to the extent possible so that doulas enrolling with both the State Medicaid Agency and individual managed care plans do not need to jump through multiple hoops. In the alternative, states can also opt for the State Medicaid Agency to centralize the provision of doula services as a “wrap,” “wrap-around,” or “carved out” service. These are different terms that refer to a State Medicaid Agency providing doula care directly fee-for-service for all Medicaid enrollees, even for those Medicaid enrollees who receive their other health care services through their Medicaid managed care plan. (See for example temporary carve-out in New York, and permanent wrap service in Massachusetts.)

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Provide the names and contact information of specific individuals at the State Medicaid Agency and health plans that doulas can contact if they have questions or encounter challenges or barriers.

When partnering with doula groups, state agencies and health plans should prioritize funding doula groups that are already on the ground doing the work with low- income clients and/or with BIPOC clients.

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Doulas, state agencies, health plans, and other stakeholders should bear in mind that the ramp up time for doula Medicaid programs can be long. There is often a period when the benefit is technically live, but not yet truly accessible, as a sufficient number of doulas will not yet have successfully enrolled as Medicaid providers.

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The Ongoing Implementation Phase focuses on ensuring that the Medicaid doula programs have long term sustainability. States need to ensure that they are dedicating the resources necessary to both provide access to doula care for Medicaid enrollees, and also support a stable doula workforce. This phase in some sense is dependent on the continued implementation of many of the Best Practices in the earlier phases, but also has its own specific Best Practices.

State agencies, legislators, funders, doula groups, and other stakeholders, must dedicate funding for outreach about the doula benefit, including educating medical providers, agency and health plan staff, and members of the general public about what a doula is and the benefit of doula care, as well as informing Medicaid enrollees that doulas services are available to them.

Dedicate funding to creating and subsidizing training and certification programs for doulas who want to serve Medicaid enrollees. Consider offering fee waivers, grants, and other support for individuals from low-income and underserved communities.

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State agencies, health plans, hospital associations, and other relevant stakeholders, must ensure that doulas have access to their clients, and that clients have access to their doulas, during prenatal and postpartum appointments, as well as during labor and delivery. Some states have addressed the issue by creating recommendations, guidelines, and best practices for doula and hospital interactions. In other states, doulas and advocates have passed legislation requiring hospitals allow doulas access to their patients, and vice versa.

States should expand universal access to doula care, in both Medicaid and other public programs, as well as private insurance.

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