analysis of doula programs - payment and certification

by First 5 alameda; April 2019

Doula Services through Medicaid 

·       Currently, only two states, Minnesota andOregon, allow for reimbursement for doula services through Medicaid [2]

o  Minnesota increased the reimbursement rates for doulasin the 2018 budget[1]

o  A law enacted in 2017 (HB 2015) requires the Oregon Health Authority (OHA) to review and revise reimbursement rates, if necessary, every two years and provide an annual report to the legislature on the status of doulas in the state [1]

§  Requires Oregon’s coordinated care organizations, which deliver Medicaid services, to provide information about how to access doula services online and printed explanations of benefits

§  Tasks OHA with facilitating direct payments to doulas, which was addressed through rulemaking (OAR 410-130-0015).

·       Legislators in New Jersey, New York, and Vermont introduced bills in 2018 to add doula services as a covered benefit for Medicaid, as well as private insurance [1]

·       In New York, Gov. Andrew Cuomo announced a comprehensive initiative to improve maternal mortality and address disparities, which included a pilot program to provide for doulas services in Medicaid [1]

Certification and Registration Requirements for Reimbursement

Federal Rules Empowering the States

·      On July 15, 2013, CMS published its final rule (CMS-2334-F) expanding the definition of who can provide preventive services covered by Medicaid; this enable preventive services to be provided, at state option, by practitioners other than physicians or other licensed practitioners [2]

o  This change granted individual states the option to reimburse for preventive services that

have been recommended by a physician or other licensed medical provider (such as a midwife), but provided by a non-licensed practitioner

·      To be approved to cover non-licensed preventive service providers, states must submit an amendment to their state Medicaid plan that includes the scope of services to be covered and who may provide them; the amendment must define practitioner qualifications, education, credentialing and any registration that the state will require [2]

·      The rule change opened a new pathway for state Medicaid agencies to reimburse community-based preventive services that could include doula support before, during and following birth [2]

·      Resources have been developed to help states and organizations develop a state plan amendment: [2]

o  CDC has created a technical assistance guide to support states seeking to utilize community health workers to provide preventive services 

o  Two non-profit organizations, the Trust for America’s Health and Nemours Health and Prevention Services, have developed a questionnaire to guide states or organizations through the process of working with state Medicaid offices to develop state plan amendments to include community health workers [2]

State Action  

·      Oregon and Minnesota have worked to identify/create certifying bodies, registration procedures, core competencies, scope of services, supervision arrangements and reimbursement procedures [2]

·      In 2012, Oregon’s Medicaid program began coverage of birth doulas through the same “non-traditional health workers” reimbursement category used for community health workers [4]

·      In Oregon doulas must register with the state to be eligible for reimbursement, but must also work with a health care provider (physician or certified nurse-midwife) who submits a request for their reimbursement, receives the reimbursement and then pays doulas [2]

o  This requires close collaboration between the doula and the health care provider, which may not always be possible and may limit available services

·      Minnesota passed legislation in May 2013 establishing Medicaid reimbursement for doulas starting after federal approval of their Medicaid waiver, which occurred in September 2014 [4]

·      Few doulas, if any, have received reimbursement in either Oregon or Minnesota [2]

o  Challenges have included identifying the mechanism for a non-licensed service provider to receive payment and locating and making arrangements with licensed providers who are required to serve as a conduit for reimbursement

·      Washington, D.C. and Oregonestablished maternal mortality review committees that bring together multi-disciplinary experts and stakeholders to review instances of maternal death and examine the factors and processes that may have contributed to the fatal outcome [1]

o  Committees can often make recommendations, as well as promote and implement population-level prevention activities in their jurisdictions

o  Both Washington, D.C. and Oregon included doulas in committee membership 

Challenges and Concerns 

Workforce and Contracting Concerns 

·      Concernexistsaround a doula’s ability to advocate for a birthing person’s needs while simultaneously respecting medical practice [1]

·      There is a lack of diversity in the doula population as compared to the potential Medicaid patient population [3]

·      The Medicaid supported doula program will require communication within complex networks of patients, doulas, medical providers, delivery systems and managed care organizations [4]

Certification, Registration and Enrollment Issues

·      There is a lack of centralized certification or credentialing requirements for doulas in the US [3]

·      There is an inconsistency of certification [1]

o  Not all doulas are certified, nor do they need to be to call themselves a doula

o  Verifying certification is challenging [4]

·      In the year after doula coverage went into effect in Minnesota, evaluations documented implementation challenges, including difficulties with becoming an enrolled provider [2]

o  Need to ensure that doulas are registered as enrolled providers with the state and with managed care organizations to provide the services protected in statute [4]

Reimbursement for Services 

·      Doulas and agencies were unclear as to the documentation required for payment of claims for doula services, which differed from one Medicaid managed care organization to another [2]

o  Minnesota doulas noted the need for a formal coordination structure to allow various parties to work together to resolve issues related to the registry/credentialing (Minnesota Department of Health) and payment, including for sustainable levels of reimbursement (Minnesota Department of Health Services) 

·      Billing mechanisms require doulas to seek reimbursement by working under a licensed Medicaid provider [3]

·      Reimbursement rates are currently set well below the costs for doulas to provide services [4]

o  Without private health insurance coverage to balance a payer-mix portfolio, doula work has limited financial viability

·      It is challenging to establish payment codes and to set reimbursement rates for these codes under fee-for-service Medicaid [4]

·      Most community-based doulas work for agencies rather than as individuals, but as of 2016, there was no provision to allow agencies to contract with Medicaid, only individual providers 

·      There is a need for establishing contractual agreements between doulas and clinicians for payment purposes [4]


Centralizing and Standardizing Certification Process 

·      While all doula services can be beneficial, creating a standard for the training and certification of doulas may improve understanding and acceptance of doula care [1]

o  Several organizations, such as DONA International, provide doula training and certification 

o  Individuals can also choose to become certified as community-based doulas through HealthConnect One; This community-based doula program model, which has been replicated nationwide to serve unique populations, trains doulas to provide culturally sensitive pregnancy and childbirth education to the underserved in their own community

o  Governing bodies and policy makers should consider these models and identify standard resources and requirements for doula training and certification for Medicaid reimbursement

Collect and Implement Doula Input 

·      Ensure doula representation on maternal mortality review committees such as those Implemented by Washington, D.C. and Oregonto review instances of maternal death and examine the factors and processes that may have contributed to the fatal outcome [1]

·      When designing legislation and resulting coverage programs, understand doula concerns about how training and certification programs can be used to diversify the workforce, and creating billing and payment mechanisms that enable more sustainable reimbursement rates [3]

·      The National Health Law Program conducted a survey from October – November 2018 collecting input from doulas across California on their thoughts, concerns, and feedback around potential Medicaid coverage for doula care, including their perspectives on sustainability, training, certification, and reimbursement; NHLP is currently analyzing survey responses from 243 doulas across the state and will produce policy recommendations in 2019 [3]

Adjust Healthcare Financing 

·      Include doula programs in the Delivery System Reform Incentive (DSRIP initiatives), a category of Section 1115 waiver programs that enable states to test innovative practices through demonstration or pilot projects to transform the Medicaid payment and delivery system by linking funding with improvements meeting specific metrics [2]

o  States should pursue the inclusion of projects to expand access to doulas under existing and new DSRIP programs to strategically improve maternal and infant health outcomes while reducing associated costs 

·      Allow doulas to claim reimbursement for travel mileage to facilitate access for people in rural and remote areas by ensuring that travel expenditures alone do not outweigh earnings for prenatal visits to distant clients in rural areas [4]

Address Geographic and Cultural Barriers to Care 

·      Increase the diversity of the doula workforce to reflect the population of Medicaid beneficiaries giving birth and to expand the workforce to rural areas by introducing state grant programs to subsidize doula training for people from culturally diverse backgrounds and from rural communities [4]

o  Doula training, certification, and registration are costly, generally ranging from $800–$1200, and many low-income women and people from communities of color have limited financial access to the training required to become a doula

·      Establish a fee waiver process for fees for doula certification and registration for low-income applicants to diversify the doula workforce [4]

Increase Uptake of Doula Support Among Low-Income People and Document Effects 

·      Maternity care clinicians (midwives, obstetricians, family physicians, and others) should receive education and information about the role of doulas and how to work with them in the prenatal period [4]

o  Facilitates increased knowledge among pregnant people and their providers about the potential benefits of a doula in their pregnancy and childbirth

o  Helps solidify doula’s role as part of the care team 

·      Implement a formal coordination structure that manages issues related to doula registry/credentialing (possibly housed in state Department of Health) and payment through Medicaid (managed through Department of Human Services) 

o  This infrastructure is necessary to embed doulas into the system 

o  The joint coordination of these departments may also be tasked with providing clear guidance for doulas on how to become enrolled providers and bill for services 

Federal Level 

·      CMS should make continuous labor support from a trained doula a reimbursable service by: clarifying the appropriate current procedural terminology code for obtaining reimbursement for doula services; identifying doula support as a reimbursable preventive service provided by non-licensed service providers who should be reimbursed through agencies of community health centers under 42 CFR §440.130(c); Exploring and advancing strategies to integrate doulas into innovative payment and delivery systems; and Advancing reimbursement for continuous labor support by a trained doula within its ongoing Maternal and Infant Health Initiative [2]

·      The USPSTF should determine whether continuous labor support by a trained doula falls under the scope of its work and, if so, should undertake a scientific evidence review to determine if such care meets its criteria for recommended preventive services [2]

·      HRSA and CMS should explore and define clear pathways for community-based doulas to be reimbursed for home visits that provide preventive services including, but not limited to, health education, nutrition counseling and breastfeeding counseling [2]

·      The Agency for Healthcare Research and Quality should collaborate with stakeholders to develop, implement and seek National Quality Forum endorsement of an adaptation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey suitable for measuring the experience of facility care of birthing people and newborns, including the dimension of access to supportive care during labor [2]

·      Congress should include high-value birth doula services, inclusive of prenatal and postpartum home visits, among services mandated for Medicaid coverage [2]

State Level 

·      States should seek CMS approval of state plan amendments to cover continuous labor support and home visits as reimbursable preventive services provided by non-licensed service providers under 42 CFR §440.130(c) [2]

·      States should seek to include coverage of doula support under new and existing DSRIP programs [2]

·      Medicaid managed care organizations and other health plans should offer doula services as a covered benefit, and states should enact legislation requiring plans to do so [2]

·      States should require health plans to include doula services within their covered benefits [2]

·      Local governments, public and other safety net hospital systems, Medicaid managed care organizations, community health centers and other agencies and organizations should establish interdisciplinary teams to continue to explore and develop innovative approaches to making doula support available to people enrolled in Medicaid [2]