Introduction
The United States has the highest mortality rate for pregnant and birthing people among higher-income countries, with especially high mortality rates for Black pregnant and birthing people. Increasing access to doula care is a cost-effective, evidence-backed strategy to decrease the overall mortality rate among pregnant and birthing people and address racial disparities in perinatal outcomes. Doula care can also improve health outcomes throughout the pregnancy and postpartum period, and save billions of dollars by reducing the number of cesarean births and infant hospitalizations due to preterm birth.
Over the past several years, dozens of states have started covering doula care for Medicaid enrollees. However, racial disparities in maternal health persist even for the wealthiest pregnant people of color. Accordingly, access to doula care through both Medicaid as well as private insurance plans is critical to addressing the mortality rates associated with pregnancy and childbirth. This blog post will discuss the growing number of states that are also beginning to require coverage for doula care in private health plans.
Private Insurance Coverage for Doula Services
While 27 states and Washington DC either currently include or are in the process of implementing Medicaid coverage for doula care, only two states (Rhode Island and Louisiana, shown in red below) currently require coverage of doula care in private insurance plans.Four states (shown in orange) are in the process of implementing the requirement. California and Utah (shown in purple) have passed legislation that incorporates some coverage for doula care but stops short of requiring coverage for people enrolled in state-regulated private plans.
States that have Implemented Doula Care Coverage Requirements for Private Plans
Rhode Island was the first state to have passed and fully implemented a doula coverage requirement for state-regulated private plans. The state passed H 5929 in 2021, which required that both private plans and Medicaid cover doula services according to each insurer’s “respective principles and mechanisms of reimbursement, credentialing, and contracting.” The bill was the result of a successful campaign led by a coalition of BIPOC doulas and birth advocates. Consultation with practicing doulas shaped the bill’s provisions, including the decision not to require that doulas be supervised by a licensed practitioner. Following implementation, Rhode Island doulas participating in listening sessions with the Department of Labor’s Women’s Bureau reported receiving more inquiries from potential clients, but that low pay and reimbursement rates remain a challenge and the financial and administrative burden of participating in private insurance and Medicaid can be prohibitive.
Louisiana, the state with the highest percentage of births covered by Medicaid at 61%, is the only state that has passed legislation mandating coverage of doula care for privately insured pregnant and birthing people but not Medicaid enrollees. After Rhode Island, Louisiana was the second state to enact a private insurance coverage requirement, with the passage of HB 272 in June 2023. The bill did not specify the scope of services that must be covered and allows insurers to impose a per-pregnancy limit of $1,500. State-regulated private health plans in Louisiana were required to incorporate doula coverage by January 1, 2025.
States in the Process of Implementing Doula Care Coverage Requirements for Private Plans
Colorado, Virginia, Illinois, and Delaware have all passed legislation mandating doula care coverage in state-regulated private plans, though none of the laws have yet been implemented.
Colorado’s SB24-175 was signed into law in June 2024 and will require state-regulated private plans to cover three hours of prenatal doula care, three hours of postpartum care, and support during labor and delivery. The requirement will not go into effect until July 1, 2025 at the earliest.
The Virginia legislature passed SB 1118 in April 2024, requiring that state-regulated private insurers cover a minimum of eight doula visits plus labor and delivery support across the perinatal period for policies issued on or after January 1, 2025. However, the State Corporation Commission, which regulates health insurance plans issued in Virginia, has not included doula care on its list of mandated benefits and offers as of this writing.
Both Colorado and Virginia have experienced challenges in implementing their Medicaid doula benefits, which private plans should take into account when designing their own doula benefits. Colorado’s experience highlights the importance of engaging directly with doulas when creating provider registration systems. Meanwhile, Medicaid payment rates for doulas in Virginia have not been sufficient to cover the cost of care. Although Colorado will require that state-regulated private plans cover the same number of hours of doula care as the Medicaid benefit, Virginians enrolled in state-regulated private plans will have access to at least eight pre- and postpartum doula visits while people enrolled in the state’s Medicaid program are limited to a maximum of eight perinatal doula visits.
The Illinois legislature enacted HB 5142 in July 2024, requiring that, beginning in 2026, state-regulated private plans cover at least sixteen prenatal visits, labor and delivery support, and sixteen postpartum home visits with a perinatal doula. Illinois’s Medicaid doula benefit went into effect in December 2024, and has a slightly different coverage scheme, covering the perinatal period plus up to twelve months, regardless of how the pregnancy ends.
Delaware has passed legislation requiring coverage of doula care in both Medicaid and state-regulated private health plans, but neither law has yet been fully implemented. HB 362, Delaware’s private insurance coverage requirement, passed in September 2024 and will go into effect in 2026. Both Medicaid and state-regulated private plans must cover three prenatal and three postpartum doula visits, as well as doula support during labor and delivery, though private plans will also be required under HB 362 to cover additional postpartum visits at the recommendation of a licensed clinical provider.
States with Limited Expansion of Doula Care Coverage
Recently, two states passed laws extending doula care coverage to state employees.
Utah’s HB 415, signed into law in March 2023, makes doula care available to state employees and their families through the Public Employees’ Benefit and Insurance Program. The benefit applies to plans that begin on or after July 1, 2023 and before July 1, 2026. Nearly 160,000 people, or 4.7% of Utah’s population, participate in the Public Employee Health Program. The bill carried a negative fiscal note, meaning expanded access to doula care is projected to save the state money. However, like Louisiana, Utah does not yet require Medicaid coverage for doula care.
California’s Public Employees’ Retirement System (CalPERS), the largest state pension plan in the country, began including coverage for doula services for members and their families in the 2025 health plans. Unlike in Utah, California Medi-Cal enrollees (the state’s Medicaid program) do have access to coverage for doula care as of January 2023. Additionally, in October 2023, AB 904 was signed into law. AB 904 requires that, starting on January 1, 2025, state-regulated public and private health plans develop a health equity plan for combating racial disparities in outcomes for infants and birthing people through the use of doula care. While AB 904 does not explicitly require that all state-regulated plans cover doula services, the bill lists several ways to incorporate doula care into plans that meet the law’s requirements.
Conclusion
Efforts to expand state doula coverage requirements in private insurance are gaining momentum, with six states introducing doula coverage requirement legislation in the first two months of 2025 alone. If passed, Arkansas (HB1252) and South Carolina (S0042 and H3108) would require doula care coverage in both Medicaid and private insurance plans, while Massachusetts (H.2576), Nevada (SB 192), and New York (A5140) would add private insurance coverage requirements to already active Medicaid requirements. Like Utah, Texas’ HB 2477 would require that certain group benefit plans for government employees and retirees cover doula care.
It is likely that in the years to come, more states will follow suit in requiring doula benefits for people enrolled in private insurance plans. In doing so, the challenges and successes that states have experienced when implementing doula benefits through Medicaid can inform how states design similar benefits for people enrolled in private insurance plans. Ultimately, coverage for doula services through Medicaid and private insurance is an important step towards building a safe and affirming health landscape for all pregnant and birthing people.
