Doulas and other birth workers have continued to rise in popularity as a potential intervention for addressing maternal health and mortality issues in the United States. While doulas cannot solve the underlying structural inequities and systemic racism in our health care systems, their presence during pregnancy, birth, and the postpartum period has resulted in decreases in negative health outcomes. 2021 has seen an abundance of state bills for Medicaid coverage for doula care across the U.S. NHeLP has begun specifically tracking implementation efforts of states that have passed legislation, submitted State Plan Amendments (SPAs), or employed other routes to ensure coverage of doula services.
Our current efforts to track doula Medicaid coverage implementation shows that as of November 2021, four states are actively reimbursing doula services through Medicaid: Florida, Minnesota, New Jersey, and Oregon. In addition, eight states are starting to implement doula coverage laws: California, Washington, D.C., Illinois, Indiana, Maryland, Nevada, Rhode Island, and Virginia. Five states are engaging in efforts adjacent to doula coverage, like creating a doula certification process, with the hope that it will lead them on the path to ultimately implementing Medicaid coverage for doula care: Arizona, Connecticut, Georgia, Louisiana, and Washington.
Those states actively reimbursing doulas for services provided to Medicaid enrollees are accomplishing this differently. Minnesota and Oregon have been covering doula care through Medicaid the longest, and both states first passed legislation and now have coverage through SPAs. New Jersey has also joined Minnesota and Oregon with an approved SPA in 2021.
A state plan is an agreement between the state and the federal government on how the state will run their Medicaid program. It gives assurance that a state will abide by federal rules and can claim federal matching funds. States must submit their state plan amendments to Centers for Medicaid and Medicare Services (CMS) for approval when they want to substantially change how they operate their Medicaid program.
While they all are covering doula Medicaid services through an approved SPA, Minnesota, Oregon, and New Jersey still have differences in their coverage. As of 2019, Minnesota covers up to six prenatal and postpartum appointments with a reimbursement rate of $47 per session and labor and delivery services reimbursed at a rate of $488, for a total reimbursement of $770. Oregon requires doulas register as traditional health workers, whereupon they can be reimbursed for two prenatal visits, two postpartum visits, and labor and delivery, for a total rate of $350. New Jersey reimburses for up to eight visits, and labor and delivery for a rate of $900 per birth. New Jersey also offers enhanced care for patients ages 19 and younger that includes an increased reimbursement rate and additional visits.
Florida has taken a different approach to covering doula services. The state’s Agency for Healthcare Administration (AHCA) included doula care as an expanded benefit that Medicaid Managed Care plans could include. This means that only Medicaid enrollees on managed care plans have access to the benefit. It also means that each plan has the ability to implement the benefit itself rather than follow state guidance. In Florida, managed care plans have negotiated reimbursement, which has led to reimbursement rates ranging from $450 to $1,110. This has also led to a range in service availability, with some plans opting to only provide doula services for high-risk pregnancies.
Along with the states that have fully implemented doula coverage, there are exciting developments in other states that are in the process of implementing doula care in Medicaid. In California, the Department of Health Care Services (DHCS) is currently in conversation with a robust and experienced group of stakeholders on the implementation of full-spectrum doula care for all pregnant and postpartum people. California’s doula care benefit is set to start in July 2022 Meanwhile, in Washington, D.C., the doula Medicaid benefit is set to start in October 2022. Both states plan to submit SPAs.
Illinois is also in discussion with stakeholders and has convened a Task Force to implement services. Similarly, Nevada’s state Medicaid agency is in discussion with stakeholders and hosting public meetings to receive feedback. They too are planning to submit a SPA. Rhode Island is an especially exciting state to watch, as they are the first to require coverage of doula care through both Medicaid and private insurance. The state plans to cover three prenatal visits, three postpartum visits, and labor and delivery for a total reimbursement amount of up to $1,500.
There is no doubt that we are seeing exciting developments in Medicaid coverage doula care. It is still important to note that as states develop implementation plans or look to introduce new legislation they look to what has worked and what has not worked in pilot programs and early iterations of coverage. Doulas deserve to be paid a living wage, have autonomy over their work, and practice without unnecessary barriers to certification and reimbursement.