Medicaid Reimbursement for Doulas Overview, Considerations, and Status Report
Excerpted from The Doula Business Guide, 4th Edition
(Forthcoming December 2023)
By Patty Brennan
Third Party Reimbursement Overview
While the work of the doula is timeless, the concept of the professional doula first came into existence in the early 1990s with the emergence of training and certification programs for birth doulas. Postpartum doulas were added shortly after, followed by end-of-life doulas (also known as “death doulas”). Twenty years ago, in my early years as a doula trainer, it was not uncommon for doula class participants to report being questioned “what is a doula?” in response to sharing with others their plans to attend a training. Today in the U.S. and around the world, doulas are coming into mainstream consciousness.
As the doula movement grows, the push for third-party reimbursement for doula services is picking up steam. Today, more than thirty states either cover or are pursuing Medicaid reimbursement for birth doula services to eligible families. It is clear this trend will continue, and I believe we will see a growing number of states and private insurers embrace the medical cost savings that doulas represent. Birth doulas are leading the way because an extensive body of research has established risk reduction, lower rates of medical intervention (including cesarean delivery), and improved health outcomes associated with their use. The data clearly indicate that birth doulas reduce costs and save tax dollars while improving outcomes for moms and babies.
It is important to note that, in states where birth doulas are approved for Medicaid reimbursement, covered services typically include a limited number of relatively short postpartum home visits. This provision is not the same as ensuring coverage for postpartum doulas and the more extensive support services they provide. At this time, we are not seeing reimbursement for postpartum doulas, though there may be some private-pay exceptions. Finally, there is no reimbursement available for end-of-life doula services.
Research is needed on postpartum and end-of-life doulas to make the case for comparable benefit. While qualitative studies have been published (for example, research seeking to explore how death doulas define themselves, the types of services provided, training offered, and so on), quantitative studies focused on outcomes are needed to move the needle. See the table below for ideas on quantifiable factors that might be measured to demonstrate potential cost savings for postpartum and end-of-life doulas. Any researchers reading this?
Medicaid Reimbursement for Doulas: A Complex Landscape
The U.S. Medicaid budget (government funded health care for low-income Americans) is a federal program managed by each state, while Medicare (government funded health care for elderly Americans) is a federal program. The result is that under Medicaid, covered services vary from state to state, whereas under Medicare, coverage is the same regardless of location. Efforts to cover doula services under Medicaid, therefore, must be undertaken by each state legislature. An increasing number of states are seeking federal authorization to provide doula services to pregnant beneficiaries as a Medicaid covered benefit. As these efforts unfold, we are seeing variable approaches to the issue.
In addition to each state doing its own thing (or nothing) regarding Medicaid reimbursement for doulas, the lack of a comprehensive, national clearinghouse where doulas can get reliable information on the status of third-party reimbursement efforts adds to the confusion. The situation is very fluid right now due to a flurry of recent legislative activity across many states. See “Sources” below for websites that proved helpful in my investigation. Hopefully, these sources will be maintained and updated. At the least, you will find contacts and links for state-specific details to aid in your investigation.
There are five phases involved in implementing Medicaid coverage for doulas in a state:
Overall, legislative efforts tend to be driven by coalitions formed in the public health and nonprofit sector rather than the doula community directly. This means that well-meaning people who see the end benefit of doulas, but lack understanding of the doula’s perspective, end up calling the shots for our profession. Therefore, it is critical that doulas participate in this process.
The approval and implementation process takes time, and there can be delays and setbacks at each stage. States will fall into one of the following categories:
What can you do?
Doulas are advised to research what, if anything, is happening in the state(s) where they provide services. Even if you don’t intend to participate in the reimbursement system, it is important to know what is available for lower-income folks in your area who might reach out.
Network with Other Doulas!
Overview of Requirements for Doula Participation
Where reimbursement is in effect, states have established conditions of participation for the doulas. Requirements vary from state to state and typically include completion of a doula training program. In some states, specific doula training organizations are pre-approved, while in others, specific content is mandated. Certification may or may not be required. A range of other state requirements may include any of the following:
- Complete adult and infant cardiopulmonary resuscitation (CPR) certification from the American Red Cross or American Heart Association
- Complete HIPAA training
- Complete community-based cultural competency training
- Complete SafeServ meal preparation training
- Submit to a background check and fingerprinting
- Be at least 18 years of age
- Possess a high school diploma or equivalent (GED)
- Carry professional liability insurance
- Apply for a National Provider Identification (NPI) number
- Reside in the state
- Pay application and renewal fees
- Provide documentation of attendance at a minimum number of births
- Complete continuing education requirements
Rates of Reimbursement for Birth Doulas
Reimbursement amounts are far-ranging. The lowest rate reported is $350 per client (resulting in low participation from the doula community) and the highest is $1950 per client. Reimbursement amounts in between the two extremes range from around $800 to $1500. Doulas must advocate for reasonable rates of reimbursement, or they will be dis-incentivized to participate in the program. Your voice matters so be sure and provide input on these conversations as they occur in your state.
Common Challenges to Implementation of Medicaid Reimbursement for Doulas
The training or certification requirements being proposed by the State Medicaid agencies are too restrictive and create unnecessary barriers to entry. Some states list the names of specific organizations from which doulas must receive training and certification, an approach that critics believe is overly rigid and inflexible to change over time. Programs not included on the list are not accepted. In addition, many states have neglected to create a legacy pathway for community doulas who have been practicing for years but lack formal training and/or proof of certification.
Doulas need more support and guidance navigating the process to become Medicaid providers. The Medicaid credentialing, enrollment, and contracting processes are new and unfamiliar territory for doulas. Most doulas work as independent contractors who provide services on an individual basis to their clients. They rarely track data and outcomes of their clients systematically on an ongoing basis. Nor do they interface with health plans or billing entities to get paid. Doulas who wish to become Medicaid providers must figure out how to:
- Become authorized by their state to be eligible for reimbursement for serving Medicaid enrollees
- Enter in contracts with Medicaid managed care plans
- Translate billing codes to submit billing claims for payment
- Track and report data to the health plan and/or State Medicaid Agency
In most cases, doulas must navigate this process with little guidance from state agencies. Support can be provided in diverse ways including through training, one-on-one support, toolkits, and peer-to-peer learning collaboratives. In Oregon, the state supports “doula hubs” that help doulas get the necessary credentialing, enroll to be a Medicaid provider, and contract with Community Care Organizations (CCOs).
The reimbursement rate for doulas providing care to Medicaid enrollees is often insufficient. Too often reimbursement rates are being established without an understanding of the type of work a doula does, and how that work is different in time, scope, and approach from that of medical providers such as doctors, midwives, and nurses. Reimbursement rates must offer doulas a thriving wage that considers the realities of doula work, including being on-call, as well as limitations on the number of clients that a doula can serve in any given time period.
The Blessings and Pitfalls of Legislation
Arguments in favor of enabling government reimbursement for doula services revolve around access to care and reduction of disparities, certainly worthy causes. In the absence of Medicaid/Medicare reimbursement, doulas are essentially a luxury service, leaving out marginalized populations who have limited resources and an increased risk of poor outcomes. Everyone can benefit from doula support!
Ethical mandates regarding the doula’s responsibility to the primacy of clients’ interests could be compromised.
Doulas who come from lower-income or at-risk communities and wish to serve families in their community face severe sustainability challenges. How can they attend births or death vigils if they must maintain another job to pay their bills and keep their gas tank full? Outcomes can be improved, disparities reduced, and health care dollars saved if dedicated, trained community doulas are paid a living wage for their efforts. Proponents argue that third-party reimbursement is the only way to achieve this goal.
While the effort to expand doula care to low-income families is praiseworthy, the devil is in the details. In addition to unsustainable doula reimbursement fees, watch for limitations on approved doula training programs, micro-managing mandates, excessive or complicated documentation requirements, challenges navigating the system, and more.
Whenever there is a push for legislation of this kind, there will always be pushback, from within the profession itself, by folks with legitimate concerns. Primary among these is the fear that doulas will become co-opted by the medical system, thereby compromising the client advocacy role, and that we will be inviting all-powerful vested interests to exert control over the profession. Ethical mandates regarding the doula’s responsibility to the primacy of her client’s interests could be compromised as regulation opens a pathway for the promotion of other agendas. For example, postpartum doulas might be mandated to push vaccines or safe sleep orthodoxy rather than presenting unbiased information to promote informed decision making and client autonomy (our true bailiwick).
For 35 years, I offered community-based childbirth education programs, purposefully steering clear of hospital-based settings that might have proved more lucrative. The reason? If the hospital has authority over me and my job is on the line, then I can be held accountable to their agenda (selling epidurals or routine induction of labor, for example). As a community-based educator, I faced repeated confrontations from medical care providers regarding my encouragement for informed choice on routine active management of third stage of labor, as just one example. Had I worked for the hospital and continued to present both pros and cons to this practice, I surely would have been fired. As it is, I suffered a reduction in referrals to my classes from some providers—a price I am willing to pay to keep my purpose and integrity intact.
Another pitfall involves the administrative burden of dealing with government bureaucracies and other third-party insurers. This is not a small concern. I frequently hear from hospice nurses who are moving to doula work because their time with families is increasingly eaten up by Medicare documentation and administrative minutiae. There is little time left over for family education and emotional support, robbing nurses of their sense of purpose for engaging in end-of-life work in the first place. I don’t believe these retired nurses, now practicing doulas, want to see their time constrained once again by excessive bureaucratic requirements.
To balance the blessings and pitfalls, efforts to advance the cause of third-party reimbursement for doula services must seek to rigorously protect the core principles of the Doula Model of Care and doulas must advocate for their own interests.
What about licensing for doulas?
While many professions are regulated and licensed by the states (e.g., daycare providers, hair salons), doulas are unregulated service providers in all states. So far, we are not seeing mandatory state licensing for doulas being put into place in conjunction with Medicaid reimbursement efforts. Nor do we see legislation mandating that doulas must participate in reimbursement programs. This means that doulas who intend to serve Medicaid-eligible families in their communities are free to choose whether to participate in the reimbursement program (and get in bed with the government) or not. In my view, this is ideal—maintaining maximum freedom of choice for families and professional doulas alike.
National Academy for State Health Policy (NASHP)
NASHP’s tracker only includes information and updates on statewide, federally authorized doula Medicaid benefits. It does not include information on states that allow doula services to be covered by Medicaid managed care entities. (A managed care entity is a general term for HMOs and all health plans that contract with the state to provide a comprehensive package of services, coordinated through a specific network of primary care physicians and hospitals, in return for pre-set monthly payments.)
According to this table, as of November 2022, more than half the states are either actively providing Medicaid coverage for doula care, are in the process of implementing such coverage, or are taking statewide action related or adjacent to Medicaid coverage for doula care.
Center for Health Care Strategies
This brief provides a practical guide for states that are pursuing doula coverage under Medicaid. It explores how six Medicaid agencies approached doula coverage decisions, including a detailed analysis of (1) services covered; (2) rate setting and reimbursement; (3) credentialing and enrollment; (4) training and certification; (5) managed care contracting; (6) practitioner recommendation requirements; and (7) workforce development and sustainability.