KFF and the Health Management Associates (HMA) released their 23rd Annual Medicaid Budget Survey for State Fiscal Years 2023 and 2024 in collaboration with the National Association of Medicaid Directors (NAMD). This year’s survey includes findings about challenges and strategies in expanding non-traditional pregnancy-related services, such as doula care. In the U.S., Medicaid finances more than 4 in 10 births and traditionally the services that covered are prenatal visits, labor and delivery, and postpartum. Forty-six states and Washington D.C., have implemented the 12-month postpartum extension option and all but Arkansas and Wisconsin have plans to implement. In recent years, states have begun to cover “non-traditional” pregnancy supports under Medicaid, such as doula services, child birth education lactation support, and home visiting.
The budget survey question related to non-traditional pregnancy-related care and services asked about services that were separately reimbursed outside of a hospital bundled payment and not as a component of an office or clinic visit. States were also asked to indicate any challenges that they faced in promoting access to non-traditional pregnancy-related services. Forty-seven states including Washington D.C. responded to the survey. As of July 1, 2023, 32 of 47 states reported coverage of at least one non-traditional pregnancy-related service that is separately reimbursed from bundle payments. (See X below)
States named doula services as the most common non-traditional support for pregnancy. Other services included childbirth and/or parenting classes, outpatient lactation supports, lay midwifery services, home births, care coordination programs, home visiting programs, and telehealth services.
As shown below, states cited provider enrollment, training certification, or licensing as the largest access challenges. There are several layers to this challenge. Studies have shown that doulas can help to improve maternal health outcomes. Doulas often receive certifications through private organizations and states may have varying regulations on what training they require a doula to have before becoming a Medicaid provider. Some doulas have found the process of becoming Medicaid providers to be difficult due to cost and administrative burden. To combat this challenge, New Jersey Medicaid staff are working with managed care organizations and the New Jersey Department of Health to fund a Doula Learning Collaborative that will provide technical assistance.
States also named workforce shortages as a key challenge. New Mexico uses midwifery services to improve access to care in rural areas that have OB/GYN shortages. States can also recognize midwives that have the proper skills and training to help support a mother through pregnancy, labor, delivery, and postpartum care. Maryland is also working with their Maternal and Child Health Bureau to recruit more doulas. Midwives and doulas help to support more positive birth outcomes, particularly for people of color. However, both providers often face low Medicaid reimbursement rates which was a challenge reported by 11 states.
Five states reported quantity limitations as a challenge. Doulas do not traditionally bill for services by the hour, so reimbursed visits are often not enough. Virginia Medicaid reimburses doula services for up to 9 visits that is broken down into 90 minutes for the initial prenatal visit and one hour for subsequent visits. Doulas in Virginia have expressed the desire to have more allowable visits to be 12-16 visits broken down into 6-8 prenatal and postpartum visits, respectively. Other challenges mentioned by states include California working with hospitals to allow doulas to be present during births and Missouri commenting on a challenge where Medicaid enrollees have to be disenrolled from MCOs in order to have a home birth be covered by fee-for-service reimbursement.
It’s great to see more and more states implement new, non-traditional pregnancy-related services. While the challenges to make them a reality in the more clinical health system can seem daunting, with sustained commitment and leadership, states can learn and adapt to ensure the policy changes are a true reality for pregnant people and their families. At their best, these new services can reach more pregnant people in their unique and diverse communities and help to improve their overall care. Ongoing attention to implementation of these services, allowing for course corrections when needed, is critical to help move the needle on improved maternal and infant health outcomes in the United States.
