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Expanding the Perinatal Workforce through Medicaid Coverage of Doula and Midwifery Services

Introduction

The perinatal period — defined as the period before, during, and after childbirth — is a critical time for supporting pregnant people and infants to promote positive short- and long-term health outcomes. The United States has the highest maternal mortality rate compared to peer nations. In 2020, 861 individuals died while pregnant or within 42 days of the end of a pregnancy, an increase over the previous two years. As a result of historical inequities, Black and Indigenous communities are disproportionately impacted, as these communities experience higher rates of maternal and infant mortality.

In June 2022, the White House released a blueprint to address the maternal health crisis. It includes five priorities, including a goal to expand and diversify the perinatal health workforce. With more than 40 percent of births financed by Medicaid, the Centers for Medicare & Medicaid Services (CMS) has developed an action plan that corresponds with goals outlined in the White House blueprint. Medicaid coverage of doulas and midwives is not a sole solution to address high rates of maternal mortality; however, it is a lever states have available to expand the perinatal workforce. Community-based models of care, including care delivered by doulas and midwives, is shown to improve health outcomes, patient experience, and potentially reduce costs.

This toolkit is designed to assist state health officials in improving maternal and infant health outcomes and the health systems that support care delivery for pregnant and postpartum people and their infants. Medicaid coverage of doula and midwifery services has the potential to improve birth outcomes especially for low-income individuals and people of color. The toolkit outlines key Medicaid policy considerations for implementing doula and midwifery services perinatally and postpartum.

Considerations for supporting and expanding the perinatal workforce

  • Raise awareness of the role of doulas and midwives in advancing maternal and infant health outcomes.
  • Identify community assets, engage the provider community, and build infrastructure.
  • Develop training, licensing, and certification guidelines and build provider capacity.
  • Determine structure of benefit.
  • Implement Medicaid benefit.
  • Monitor and evaluate quality improvement and outcomes and address barriers to care.

Raise Awareness of the Role of Doulas and Midwives in Advancing Health Outcomes

Educate policymakers and other key partners

Not everyone is familiar with the terms “doula” and “midwife” and the support they provide families. States can adapt this one-pager for key audiences.

To learn more about doulas and midwives, visit our explainer

Conduct outreach and engagement

Simply having statewide reimbursement of doulas or midwives does not guarantee utilization of perinatal health services. States can work with other partners, including Medicaid managed care organizations (MCOs), providers, and community-based organizations, to make sure all parties involved in the perinatal health continuum are aware of benefits available to Medicaid members. States can also educate members about newly available benefits through communication campaigns.

Virginia: Virginia created flyers in English and Spanish to recruit community doulas.

Identify Community Assets, Engage the Provider Community, and Build Infrastructure

Engage the existing provider community

States can engage, consult with, and compensate doulas, midwives, community-based provider organizations, and associations in an environmental scan of existing services and provider availability. Collaboration with providers of color is a best practice for addressing racial disparities in maternal and infant health outcomes.

  • California: The California Department of Health Care Services convenes a Doula Stakeholder Workgroup to inform the creation of a doula benefit in the state’s Medicaid program. Supported by the California Health Care Foundation, the state works with RACE for Equity to serve as a third-party facilitator between state officials and members of the doula community.
  • Oregon: The Oregon Office of Equity and Inclusion provided a grant to the Oregon Doula Association to complete a doula workforce needs assessment. The assessment included listening sessions, online surveys, and key information interviews that included traditional health worker program members and coordinated care organizations.

Form or support a doula commission or workgroup

With an increase in Medicaid coverage of doula services, several states have formed doula commissions or workgroups to inform the creation of doula training, certification, and Medicaid coverage. Engaging community providers throughout the Medicaid benefit process assists in addressing provider questions and concerns before the benefit is created. As noted by Dila Perera, executive director of Open Arms Perinatal Services, this process provides the opportunity to re-enfranchise groups that have historically been left out of policy conversations.

  • Pennsylvania: In late 2021, the Pennsylvania Doula Commission became an independent nonprofit with a goal of promoting equitable access to doula services through workforce development for the doula profession. The commission focuses on the following priorities:
    • Identifying fair reimbursement strategies for doulas.
    • Creating state certification and standards with the Pennsylvania Certification Board.
    • Developing a provider type for Medicaid reimbursement with the Pennsylvania Department of Human Services.
    • Establishing the Pennsylvania Doula Commission Advisory Board.
  • Virginia: Virginia’s Office of the Secretary of Health and Human Services engaged a diverse set of partners in a series of workgroup meetings prior to establishing a Medicaid benefit. The group discussed certification, reimbursement rates, and training materials prior to issuing recommendations to the governor and House Appropriations and Senate Finance committees.

Explore the potential value of a pilot program

Prior to establishing a statewide benefit, states can support pilot programs for doula or midwifery services to test processes, gauge interest, and assist in identifying any state-level policy changes that might be needed or helpful. The following are examples of funding for pilot programs:

  • Partner with philanthropy: In Pennsylvania, the Tuttleman Foundation funds a doula pilot program at the State Correctional Institute Muncy that provides doula services to pregnant people who are incarcerated.
  • Engage Managed Care Organizations (MCOs). Medicaid-contracted MCOs have the option to cover doula services for members as a value-added service. The service can be for all members or a specific population.
    • Nebraska: In Nebraska, one MCO, WellCare of Nebraska, chose to cover doula services for pregnant members up to 21 years old who are engaged with the foster care system and live in a group home or maternity home and have minimal parent support.
    • Washington: In Washington, Coordinated Care offers doula services for former foster care youth as a value-added benefit.

Identify funding sources

In addition to Medicaid reimbursement, other funding sources can support recruitment, training, and building doula program capacity.
  • Leverage the Title V Maternal and Child Health Block Grant. Iowa is implementing a Title V community-based doula project for African American families. The project will serve at least 40 Black families in the first year and train additional Black doulas in five Title V service areas. The project is supported by the Preventive Health and Health Services Block Grant, the Title V Maternal and Child Health Block Grant, and the Mid-Iowa Health Foundation.
  • Support from MCOs. In Virginia, MCOs help fund doula training programs such as Urban Baby Beginnings in their efforts to build a statewide doula workforce.

Develop Training, Licensing, and Certification Guidelines and Build Provider Capacity

To recognize doulas and midwives as part of the Medicaid provider community, states can develop training, licensure, and certification guidelines. Developing requirements in consultation with existing providers of color can avoid creating additional barriers through the state certification process.

Establish training and certification requirements for doulas

Doulas are unlicensed providers but undergo certain training and certification requirements to be reimbursed by state Medicaid programs. States generally approve specific trainings for doulas or set up pathways for doulas with existing experience to become certified. Different organizations offer trainings and some focus on care for specific communities. The following are some organizations that offer doula trainings nationally:

Doula trainings cover core competencies related to providing physical, emotional, and social support before, during, and after pregnancy.

  • New Jersey: In New Jersey, doula trainings must cover evidence-based perinatal education, birth plan development, continuous support during labor, and infant feeding. Trainings must include community-based and cultural competency for delivering person-centered care and facilitating access to community-based resources. Doulas must also be trained in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and adult and infant CPR.

States also establish credentialing processes for doulas to become Medicaid-eligible providers. Approaches are different in each state but can involve the following components:

  • Completing a state-approved training.
  • Applying for state certification.
  • Applying for and obtaining a National Provider Identifier (in states where doulas can bill independently).
  • Completing a fingerprint/background check.
  • Enrolling as a fee-for-service provider or contracting with MCOs.
  • Paying a fee.
  • Registering with the state as an approved provider.
  • Obtaining liability insurance.
  • Virginia: In Virginia, there are two pathways to become a state-certified doula. Pathway 1 includes completion of training by an approved doula training entity. Pathway 2 is for doulas who have already completed some training. Organizations can also apply to become an approved training entity. Training must cover the following knowledge areas:
    • Maternal and infant health concepts
    • Lactation anticipatory guidance and support
    • Service coordination and system navigation
    • Health promotion and prevention
    • Advocacy, outreach, and engagement
    • Communication
    • Cultural humility and responsiveness
    • Ethical responsibilities and professionalism
  • All doulas must fill out a state-certified application, submit a $100 fee, obtain a National Provider Identifier (NPI), and provide proof of liability insurance to become a Medicaid provider.

Establish education and licensure requirements for midwives

States determine licensure requirements for all types of midwives (e.g., CNMs, CMs, CPMs, traditional midwives). Most states require CNMs to follow the same licensure requirements as advanced practice nurses (APRNs). Licensure requirements for CNMs generally include an active registered nurse license, master’s or higher degree in nursing, and certification as a CNM from the American Midwifery Certification Board (AMCB). CNMs and CMs receive certification from the AMCB, while CPMs receive certification from the North American Registry of Midwives (NARM). In recent years, states are increasingly establishing licensure for midwives without a nursing degree (e.g., CMs and CPMs) to expand the maternal health workforce and increase access to care for pregnant people.

  • Illinois: In 2021, Illinois Governor JB Pritzker signed HB 3401, which allows for the certification and licensure of CPMs. By establishing standards for the qualifications, training, experience, and educational requirements of midwives, this bill aims to help reduce health disparities across the state. The licensure and certification of midwives is administered by the Illinois Department of Financial and Professional Regulation. This law creates the Licensed Certified Professional Midwife Practice Act, which licenses CPMs who perform out-of-hospital births. This law also forms an Illinois Midwifery Board, which has the authority to recommend revisions to the Licensed Certified Professional Midwife Practice Act.
  • Washington: The Midwifery Advisory Committee in Washington serves to protect the public health and safety of the state by regulating the competency and quality of midwives. This committee advises and makes recommendations on continuing educational requirements, mandatory reexamination, and peer review of midwives. The committee is comprised of a practicing obstetrician, physician, certified nurse-midwife, three licensed midwives, and one public member.
  • Maryland: The Direct-Entry Midwife Advisory Committee in Maryland was formed in 2015 after legislation passed authorizing the state’s Board of Nursing to license direct-entry midwives to perform midwifery outside a hospital setting, primarily in homes. The committee is comprised of seven members appointed by the Board of Nursing, including three licensed direct-entry midwives, a licensed certified nurse-midwife, a representative of the Maryland Hospital Association, and a consumer member who may not be or ever have been a licensed midwife or health care practitioner who is directly involved with pregnancy and labor.
To learn more about Medicaid financing and licensure of midwifery, visit our resource.

Determine structure of Medicaid benefit

States have several options when incorporating doula and midwifery services in their Medicaid programs.

Identify Medicaid authority needed for benefit

Medicaid is a state-federal program in which the federal government sets broad requirements and states can make decisions regarding eligibility, populations served, services, and payment strategies through the Medicaid State Plan. To adjust their state plan, states can submit amendments for approval to CMS. CMS has 90 days to make a decision once a state plan is submitted. States can test innovative care models with section 1115 demonstration waivers.

CMS outlines adding doula services in a 2021 state health official letter. The letter states doula services can be covered under Medicaid as a preventive service, service of licensed practitioner, clinic service, and freestanding birth center service.

State legislatures can introduce and pass bills directing Medicaid agencies to offer new services, often leading to the submission of a state plan amendment.

  • Minnesota: In 2013, Minnesota enacted legislation (SF 699) that directed the Medicaid program to cover doula services. A state plan amendment (SPA) was approved in 2014.
  • New Mexico: New Mexico submitted a SPA in 2006 to launch the Birthing Options Program. The program was created with the midwifery community and allows pregnant members enrolled in Medicaid an out-of-hospital birthing option.

Define scope of the Medicaid benefit

Medicaid programs are not required to cover doula or midwifery services by midwives without a nursing degree; therefore, states have flexibility in determining services covered and length of benefit. States generally mirror the scope of practice of APRNs for CNMs.

  • New Jersey: Doula services are generally provided during the prenatal, birth, and postpartum period. New Jersey covers eight prenatal and postpartum visits in addition to birth attendance and 12 visits for members 18 years or younger. In Minnesota and Rhode Island, additional visits can be covered with prior authorization.
  • Maryland: In addition to general maternity care services, CNMs in Maryland are permitted to provide abortion services as per the Abortion Access Care Act, which went into effect on July 1, 2022. CNMs can also receive Medicaid reimbursement for substance use disorder (SUD) screening and treatment, mental health screening and treatment, and care coordination as part of enriched maternity services.
  • Florida: Licensed midwives in Florida, credentialed as certified professional midwives (CPMs), are reimbursed for Medicaid-covered services appropriate to the care of low-risk pregnant people, including antepartum, delivery, and the postpartum period. Licensed midwives are also reimbursed for Healthy Start prenatal risk screening (i.e., SUD and mental health screening).

Outline reimbursement structure

Medicaid services are reimbursed through a fee-for-service, managed care system, or combination. With fee-for-service, states pay providers for the service they provide. States that operate under a managed care environment contract with an MCO and pay each MCO a per-member per-month fee. As of 2020, over 80 percent of Medicaid members were enrolled in managed care. Currently, most states that reimburse for doulas statewide do so through a fee-for-service model. All states reimburse for services provided by certified nurse-midwives. As of April 2022, 18 states reimburse both certified nurse-midwives and midwives without a nursing degree.

  • Florida: In Florida, doula services are available through the state’s contracted MCOs as an optional expanded benefit. Licensed midwives in Florida are reimbursed at 80 percent of the physician rate and have a specific fee schedule.
  • Washington: In Washington, both licensed midwives, which are midwives who do not have a nursing degree, and certified nurse-midwives are reimbursed for services. Licensed midwives can bill Medicaid for SUD screening and mental health screening under the global obstetrical care bundled payment. Licensed midwives are also reimbursed in the Bree Collaborative maternity bundle.

Create the Medicaid billing structure

States have broad authority in establishing billing structures for perinatal health providers under Medicaid. Providers must have an NPI to be reimbursed for services. The following options are available:

  • Billing as an individual provider. Doulas and midwives can bill as an individual provider by obtaining their own NPI and enrolling as a Medicaid provider.
    • Maryland: In Maryland, doulas can bill independently. Individual doulas must apply for an NPI from the National Plan & Provider Enumeration System website as a type 1 provider. Doula organizations and groups can enroll as a type 2 provider. Doulas must also enroll in Maryland Medicaid’s electronic portal ePREP. Doulas approved as Medicaid providers can contract with MCOs and bill for services using a CMS 1500 form.
  • Billing as a group.
    • Maryland, Nevada, and Rhode Island: Maryland, Nevada, and Rhode Island allow doulas to practice and bill as a collective group. In Maryland, doula groups must obtain a Type 2 NPI. Doulas in Nevada can also link to provider agencies (e.g., obstetricians, physicians, midwifery practices, independent providers) with the option to bill independently if desired.
  • Billing under other licensed providers. In some states, midwifery and doula services are billed for by other licensed providers (e.g., physicians, nurse practitioners, or certified nurse-midwives for doula services). Under this arrangement, midwives and doulas are not required to obtain an NPI.
    • Minnesota: In Minnesota, doulas provide services and bill under the supervision of a Medicaid-enrolled provider (physicians, nurse practitioners, or certified nurse-midwives) and their NPI. All non-labor and non-delivery sessions are billed with the CPT code S9445, and the labor and delivery session is billed with CPT code 99199. The U4 modifier is used for both codes.

Implement Medicaid Benefit

Implement quality and performance initiatives

State Medicaid programs can implement initiatives such as value-based payments and performance improvement projects to incentivize perinatal health services and positive birth outcomes. Value-based payment models aim to financially reward providers for achieving quality goals and/or cost savings. The Medicaid and CHIP Maternity Core Set also allow states to measure progress to improving perinatal health outcomes.

  • Virginia: Virginia provides a $50 value-based incentive payment if a doula performs at least one postpartum visit and the client is seen by an obstetric clinician for one postpartum visit after a labor and delivery claim. An additional $50 value-based incentive payment is made if in addition to the postpartum doula visit, the newborn is seen by a pediatric clinician after a labor and delivery claim.
  • New Jersey: New Jersey makes an $100 value-based incentive payment to a doula if the doula provides at least one postpartum service visit and the member is seen by an obstetric clinician for one postpartum visit after a labor and delivery claim.

Build and sustain a diverse workforce

As of 2019, the majority (85.52 percent) of certified nurse-midwives and certified midwives identified as White. Research shows that greater racial diversity in the health care workforce improves access to care and quality of care for people of color and can help reduce racial disparities in health outcomes. Midwives of color are uniquely positioned to provide high quality care to communities of color because of their shared lived experiences and backgrounds.

New Jersey: New Jersey contracted with HealthConnect One to establish a Doula Learning Collaborative. As of July 2021, there were 79 doulas trained and certified through the New Jersey Department of Health. The goal of the learning collaborative is to increase the number of community-trained doulas, engage with health systems, and support Medicaid reimbursement.

Monitor and Evaluate Quality Improvement and Outcomes and Address Barriers to Care

Engaging in process and outcome evaluations can determine the benefit’s impact and lead to amending the benefit structure as needed. Additionally, addressing barriers raised by providers can ensure access to services for Medicaid members.

Increase reimbursement rates

Oregon was the first state to offer a statewide Medicaid benefit for doula services in 2012 with a reimbursement rate of $350 per pregnancy. In 2022 the Oregon Health Authority (OHA) amended the Medicaid State Plan to increase the fee-for-service reimbursement to $1,500 per pregnancy, citing a recognition for the importance of birth doulas as traditional health workers that can lead to improved maternal health outcomes. OHA also states, “This rate increase helps advance OHA’s goal to eliminate health inequities by 2030.” The fee covers two prenatal care visits, care during delivery, and two required postpartum home visits at a minimum.

Evaluate pilot programs

As of June 2022, New York state’s doula pilot program has served 787 people through six MCOs. The pilot covers up to four prenatal visits, support during labor and delivery, and up to four postpartum visits. As a part of the pilot, the state designed an evaluation to collect information on breastfeeding rates, member satisfaction with pilot, attendance at postpartum visits, and provider satisfaction.

An evaluation of claims to date shows that 82 percent of claims are for prenatal visits, 6 percent are for labor and delivery support, and 12 percent are for postpartum visits. A survey sent to pilot participants found 97 percent of respondents said having a doula improved or somewhat improved their childbirth experience.

Assess malpractice insurance barriers

The cost of malpractice insurance can be a barrier for birthing centers and midwives who assist with home births. Midwives without coverage or those with liability concerns are less likely to provide obstetric services. In September 2022, New Hampshire authorized the use of $252,000 of American Rescue Plan State Fiscal Recovery Funds to create a stabilization fund to support birthing centers and home birth midwives.

Convene provider workgroup

Maryland’s Midwives Workgroup was formed in 2012 by the Department of Health and Mental Hygiene to submit a legislative report that provides options of action to:

  • Analyze the shortage of CNMs, including barriers in training CNMs and barriers in nurse-midwifery practice in hospitals and non-hospital settings.
  • Conduct a review of current legislation and regulations in other states concerning the licensing, educational requirements, and scope of practice of CPMs.
  • Review available evidence regarding the safety and outcome of births attended by CPMs, CNMs, and obstetricians, as well as the safety of home births and birth center births compared to hospital births, and more.

Determine network adequacy

As states recruit, train, and certify more doulas and midwives, it is vital to ensure there is equitable access to services across the state both geographically and through managed care contracting.

Additional Resources

Improving Maternal Health Access, Coverage, and Outcomes in Medicaid. Institute for Medicaid Innovation, 2020. www.medicaidinnovation.org/_images/content/2020-IMI-Improving_Maternal_Health_Access_Coverage_and_Outcomes-Report.pdf

Improving Our Maternity Care Now Through Doula Support. HealthConnect One, National Health Law Program, National Partnership for Women and Families, and Tewa Women United, 2022. www.nationalpartnership.org/our-work/health/maternity/doula-support.html

Midwife Medicaid Reimbursement Policies by State. National Academy for State Health Policy, 2022. www.nashp.org/midwife-medicaid-reimbursement-policies-by-state

Routes to Success for Medicaid Coverage of Doula Care. National Health Law Program, 2018. https://healthlaw.org/resource/routes-to-success-for-medicaid-coverage-of-doula-care

State Medicaid Approaches to Doula Service Benefits. National Academy for State Health Policy, 2022. www.nashp.org/state-medicaid-approaches-to-doula-service-benefits

Acknowledgements

This toolkit was written by Allie Atkeson and Anoosha Hasan. The authors would like to thank Carrie Hanlon, Karen VanLandeghem, and Hemi Tewarson for their review and feedback. This toolkit was made possible by the Pritzker Children’s Initiative.

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