State of the States (November 2024): Efforts to Expand Access to Doula Care in Medicaid and Private Insurance
by Amy Chen
Doulas are birth support workers who provide social, emotional, and physical support for pregnant, postpartum, or post-pregnancy clients.
Research demonstrates that doula support leads to improved health outcomes for maternal and infant health.
In particular, doulas – especially doulas trained from an anti-racist, inclusive context like BADT – can help reduce the impacts of racism and racial bias in health care for pregnant people of color by providing individually tailored, culturally appropriate, and client-centered care and advocacy.
It is for these reasons that in recent years, a growing number of states have sought to include coverage of doula services for Medicaid enrollees as well as those with private insurance.
The National Health Law Program and BADT approach the expansion of access to doula care for Medicaid enrollees, from the perspective of needing to do right not just by the Medicaid enrollees receiving the benefit, but also by the doulas providing care. We are invested in creating equitable, sustainable, and inclusive programs for Medicaid coverage for doula care to benefit pregnant people as well as birth workers.
Medicaid Coverage of Doula Care
As 2024 draws to a close, a slim majority of states – 27 total plus Washington DC – have either already implemented or are in the process of implementing Medicaid coverage for doula care. These are the states labeled in green and yellow, respectively, in the map below.
A total of 18 states and Washington DC have implemented Medicaid coverage for doula care. In chronological order, they are:
Oregon passed legislation in 2011 requiring the Oregon Health Authority to begin exploring doula benefits. The state began Medicaid coverage for doula care in 2014. The state has increased its reimbursement rate twice, from $75 to $350 in 2017, and then from $350 to $1500 in 2022. Oregon is notable for having doula hubs that have formed across the state to assist doulas with many of the administratively burdensome tasks that it entails to be a Medicaid provider, such as billing and contracting.
Minnesota passed legislation to add doula care as a covered Medicaid benefit in 2013, and the doula Medicaid benefit formally began in 2014. The original reimbursement rate was $411, which in 2019 was increased to $770, and in January 2024 was increased to $2000. Also in January 2024, Minnesota issued a statewide standing recommendation for doula services (such standing recommendations obviate the need for Medicaid enrollees to obtain an individual recommendation from their physician or other licensed Medicaid provider). In May 2024, the allowed number of visits was increased from six prenatal and postpartum visits to 18 prenatal and postpartum visits, which in turn increased the reimbursement rate to up to $3200. Minnesota and California now have the highest reimbursement rates in the country.
Florida began covering doula care for Medicaid enrollees in 2019, after doula services were included as an optional expanded benefit in Medicaid managed care. This means only Medicaid managed care enrollees in the state have access to doulas (87% of Florida’s Medicaid enrollees are in managed care).
New Jersey’s State Plan Amendment to add doula services in its Medicaid program was approved in February 2021 with a retroactive start date of January 1, 2021 for the doula Medicaid benefit. New Jersey’s reimbursement structure provides a higher rate for doulas when they work with patients who are age 19 or younger. Doulas also receive a $100 incentive payment when their clients attend a postpartum follow-up visit. In 2022, the doula Medicaid reimbursement rate was increased to $1065.
Virginia’s doula Medicaid benefit began on April 1, 2022, following approval of their State Plan Amendment. Virginia’s Medicaid reimbursement rate for doula care is $959.
Nevada bill AB 256 became law in June 2021, which required Medicaid coverage for doula care. The State Plan Amendment was approved in July 2022 with a retroactive start date of April 1, 2022. In June 2023, AB 283 was signed into law to increase the state’s Medicaid reimbursement rate. The State Plan Amendment to increase the reimbursement rate was approved in April 2024, raising the reimbursement rate from $450 to $1500 in urban counties and $1650 in rural counties.
Maryland initially began Medicaid coverage for doula care in February 2022 with funding authorization for four years, but legislation signed into law later that year made coverage permanent. The State Plan Amendment was approved in June 2022. The reimbursement rate is up to $930.
Rhode Island is the only state thus far to have implemented a requirement for doula care in both Medicaid and private insurance, which they did following passage of H5929A in July 2021. The State Plan Amendment was approved in May 2022 and the benefit went into effect on July 1, 2022. The doula Medicaid reimbursement rate is $1500.
Washington DC initially created a pilot for Medicaid coverage for doula care in January 2021, which was made into permanent Medicaid coverage for doulas in the DC 2022 Budget Support Act of 2021. The State Plan Amendment was approved in September 2022 and the Department of Health Care Finance began enrolling and reimbursing doulas in October 2022. The doula Medicaid reimbursement rate is up to $1950.71.
Michigan in 2020 introduced legislation for Medicaid coverage for doula care, SB 965. The bill did not pass, but it did launch discussions within the Department of Health and Human Services on including doula services as a Medicaid benefit. In June 2022, the State Plan Amendment was approved and the doula Medicaid benefit began on January 1, 2023. The same day the benefit began, the state’s Chief Medical Executive issued a standing recommendation for doula services, making it the first state to do so. In October 2024, the state increased doula reimbursement rates to $1500 for labor support and $100 each for a total of 12 prenatal and postpartum appointments, for a new total reimbursement rate of $2700.
California’s doula Medicaid benefit began on January 1, 2023. In November 2023, California issued a statewide standing recommendation for doula services. In December 2023, CMS approved a State Plan Amendment increasing California’s doula Medicaid reimbursement rates to up to $3100 for vaginal births and $3200 for cesarean births, making it one of the highest reimbursement rates in the country.
Oklahoma’s Health Care Authority began internal discussions on including doula services in SoonerCare in 2021. In 2023, the Health Care Authority requested funding in the state budget to cover doula services. The State Plan Amendment was approved in June 2023 with an effective start date of July 1, 2023. The reimbursement rate is up to $1044.
Massachusetts’s doula Medicaid benefit began on December 8, 2023. On the same date, the state also issued a standing recommendation for doula services. Doula Medicaid services in Massachusetts are provided as a “wrap service,” meaning MassHealth pays for all covered doula services, even for Medicaid enrollees enrolled in Medicaid managed care. The doula Medicaid reimbursement rate is up to $1700.
New York began its doula Medicaid benefit on March 1, 2024, following approval of their State Plan Amendment. Prior to that date, the state had a number of doula pilots, including a statewide pilot that began in 2018 and a New York City pilot that began in March 2022. The doula benefit will be “carved out” of the Medicaid managed care benefit package for the first year, until March 31, 2025. In April 2024, the enacted state budget included $250,000 to establish a grant program to help recruit, train, support, and mentor community-based doulas in the state. In June 2024, the state issued a statewide standing order for doula services. The reimbursement rate in New York is up to $1500 in New York City and up to $1350 in the rest of the state.
Kansas doulas formed the Kansas Doula Alliance in November 2023, following publication of a white paper outlining implementation recommendations for Medicaid reimbursement of doula services in the state. The State Plan Amendment was approved in June 2024 and the benefit began on July 1, 2024. Reimbursement is up to $1295.
Colorado included doula care in the state budget in April 2023 and in May 2023 signed SB23-288, which required the state to begin a stakeholder process for Medicaid coverage for doula care. The State Plan Amendment was approved in August 2024 with a retroactive start date of July 1, 2024. The reimbursement rate is $1500. The state budget allocated $150,000 for the implementation stakeholder process; $30,000 for outreach to Medicaid enrollees about the benefit, and $1.1 million to create a doula hub to help support doulas and Medicaid enrollees.
Arizona signed into law SB 1181 in April 2021, to create a voluntary state certification for doulas. The state’s voluntary licensing program for doulas rolled out in August 2023. In September 2024, Arizona’s State Plan Amendment was approved by CMS, with an effective start date of October 1, 2024. Doula services are covered at the rate of $16.28 per 15 min for prenatal and postpartum visits, with each visit being a maximum of two hours, and a flat rate of $781.32 for presence at labor and delivery. Interestingly, since Arizona has no minimum or maximum number of prenatal or postpartum services, there is also no maximum possible reimbursement rate. The total reimbursement rate that doulas receive will depend on how many prenatal and postpartum visits the doula and client decide are appropriate, and the length of each visit.
Missouri’s Department of Social Services Medicaid Agency in September 2024 issued an emergency rule calling for doula services to be reimbursed through Missouri HealthNet, the state's Medicaid program, for six months starting on October 1, 2024. This was followed shortly after by approval of a State Plan Amendment formally adding doula services to the state’s Medicaid program as of the same date, October 1, 2024. The Missouri Community Doula Council is handling enrollment of doulas as Missouri Healthnet providers. Reimbursement is up to $1600.
Ohio implemented Medicaid coverage for doula care as part of a broader statewide Maternal and Infant Support Program aimed at improving infant and maternal outcomes, with a focus on reducing racial disparities. The doula Medicaid benefit began on October 3, 2024. Reimbursement is up to $1200.
Nine states are currently in the process of implementing Medicaid coverage for doula care. Many of these states will roll out coverage in early 2025. In alphabetical order, they are:
Connecticut has signed into law multiple pieces of legislation over the years on its path to implementation of Medicaid coverage for doula care. In 2021, part of Public Act No. 21-35 required the Commissioner of Public Health to conduct a scope of practice review on establishing a state certification process for doulas. Also in 2022, HB 5500 was signed into law, creating a Doula Advisory Committee to develop recommendations for training and continuing education requirements required for doula certification. In June 2023, HB 986 was signed into law, which laid out specific requirements for doula certification. Parallel to these efforts, the Department of Social Services is incorporating doula care as part of its planned HUSKY Maternity Bundle Payment Program, which will shift maternity care payment from fee-for-service to a bundled payment. The state’s doula Medicaid benefit is expected to roll out in late 2024.
Delaware’s Division of Medicaid and Medical Assistance has been holding regular meetings with a Doula Ad Hoc Committee on implementation of the doula Medicaid benefit since 2023. The Delaware Certification Board is currently accepting applications for doulas to become Certified Doulas for Medicaid Reimbursement. The State Plan Amendment was approved in June 2024 with an effective date of 1/1/2024. However, implementation is still ongoing.
Illinois signed into law HB 158 in April 2021, which included coverage of perinatal doula services alongside coverage of home visiting services (typically provided by a trained nurse or social worker). The Southern Illinois University School of Medicine has been contracted to administer the Illinois Medicaid-Certified Doula Program. In June 2024, CMS approved Illinois’ State Plan Amendment with a retroactive start date of February 1, 2024. Coverage is expected to roll out on January 1, 2025.
New Hampshire included Medicaid coverage for doula care in its 2023 state budget. In July 2024, SB 337 was signed into law, which creates a voluntary doula certification process. Implementation of doula Medicaid coverage is still ongoing.
New Mexico’s Health Care Authority shared a proposed State Plan Amendment for public comment in June 2024. The State Plan Amendment has not yet been approved.
Pennsylvania has created a pathway for doulas to be certified by the state, and the Pennsylvania Certification Board maintains a list of approved Certified Perinatal Doulas. Some Medicaid managed care plans have already begun reimbursing for doula services, but doula coverage has not yet rolled out across the board for all Medicaid enrollees in the state.
South Dakota introduced HB 1081 in January 2024, which would have implemented Medicaid coverage for doula care. Less than two weeks later, the South Dakota Department of Social Services announced that it would be including Medicaid coverage for doula care as part of its Pregnancy Health Home effort, which aims to improve care and management of prenatal, postpartum and well-child care services for pregnant and parenting Medicaid enrollees. In July 2024, the Department announced that it plans to implement doula Medicaid coverage in late 2024.
Tennessee signed into law SB 2150 in June 2022, which required the Department of Health to collaborate with TennCare to study existing doula certification programs. In May 2023, SB 394 was signed into law, which created a doula services advisory committee to advise the Department of Health on core competencies and reimbursement rates for Medicaid coverage for doula care. Following passage of SB 394, the Department of Health set up the TN Doula Services Advisory Committee, which began meeting in Sep 2023. The Committee is tasked with producing a report for the legislature on Medicaid coverage for doula services by March 2025.
Washington signed into law HB 1881 in March 2022, which created state-certified birth doulas as a new health profession. In March 2024, Medicaid coverage for doula care was included in the state budget at a reimbursement rate of $3500 with an additional $100,000 allocation for a doula hub and referral system. The State Plan Amendment to add doula services as a benefit in Medicaid was approved in September 2024 with an effective start date of January 1, 2025. In October 2024, the Washington State Health Care Authority and Department of Health issued a joint statewide standing recommendation for doula services. When Washington rolls out doula coverage at $3500, it will be the highest reimbursement rate in the country for doula Medicaid services.
Private Insurance Coverage for Doulas
There has also been a dramatic increase in interest in expanding access to doula care in the private insurance context in recent years. Eight states – four in 2024 alone – have signed into law legislation requiring doula care coverage by private health plans.
These are the states labeled in green, purple, and red in the map below. Most of these states either have also implemented Medicaid coverage for doula care, or are currently in the process of doing so.
The states that have or will be expanding access to doula care in private insurance are, in chronological order of legislative passage:
Rhode Island signed into law H5929A in July 2021, which required doula coverage in both Medicaid as well as private insurance. Coverage rolled out in both Medicaid and private insurance on July 1, 2022.
Louisiana signed into law HB 272 in June 2023, which requires private health plans in the state that cover maternity services to include coverage for doula care. Louisiana was the second state to pass legislation requiring coverage of doula care by private insurance. The state does not cover doulas in the Medicaid context.
Utah signed into law HB 415 in March 2023, which requires coverage of doula services in Utah's Public Employees' Benefit and Insurance Program. Utah does not cover doulas in the Medicaid context.
California’s Public Employees’ Retirement System (CalPERS) will be including doula care as a benefit for their members starting on January 1, 2025. On the same date, some private health plans in the state will also be expanding access to doula care as part of implementation of AB 904, which was signed into law in October 2023. California’s doula Medicaid benefit began on January 1, 2023.
Colorado signed into law SB24-175 in March 2024. The bill will require private health plans in the state to cover doula services in the same scope as they do in the Medicaid context. Colorado’s doula Medicaid benefit began on July 1, 2024.
Virginia signed into law SB 11 in April 2024, which will require the state to cover doula care in private insurance. Virginia’s doula Medicaid benefit began on April 1, 2022.
Illinois signed into law HB 5142 in July 2024, which will require all private health plans to cover doula care, as well as midwifery care and home births. Doula coverage is expected to roll out on January 1, 2025 for Medicaid as well as private insurance coverage.
Delaware signed into law HB 362 in September 2024, which will require private insurers to cover doula services. Delaware’s State Plan Amendment to include doula services in Medicaid was approved in June 2024 with an effective date of January 1, 2024. However, implementation still appears to be ongoing.
Doula Call to Action: Stay Engaged
This blog post has focused specifically on states that have implemented or will implement Medicaid coverage for doula care, as well as those states that have or will implement private coverage of doula care. However, a number of states have also taken adjacent or related actions, such as state-funded doula pilot programs or the creation of state doula advisory boards. Many of these actions are intended to be a stepping stone along the path to expansion of doula care in Medicaid and/or private insurance. Meanwhile, ongoing action to expand access to doula care will certainly continue on both the Medicaid and private insurance fronts as we head into 2025.
Doulas, state advocates, and other stakeholders are encouraged to follow what is happening in their state on the National Health Law Program’s Doula Medicaid Project State Tracker and to get involved in their local communities. Additional resources, including our Doula Medicaid Resource Library and information and sign-up for our listservs, are also available on our main Doula Medicaid Project site.
Finally, BADT is currently listed as a Medicaid-approved training in a handful of states, and is actively working on approval in several other states. Check out the details here!
Bio: Amy Chen is a Senior Attorney in the National Health Law Program’s California office, where she works on sexual and reproductive health law and policy. Her California work includes improving access to pregnancy coverage and services, and supporting implementation of California’s doula Medi-Cal benefit. Her national work includes leading NHeLP’s efforts to reduce maternal health disparities and address systemic barriers to comprehensive pregnancy care. She also leads NHeLP’s Doula Medicaid Project, which works to expand access to full spectrum doula care for all pregnant, postpartum, and post-pregnancy people.
Before joining NHeLP, Amy worked at Bay Area Legal Aid in Oakland, California for eight years, where she provided direct legal services to individuals and families across the San Francisco Bay Area, and advocated on a wide range of issues including health care reform, Medi-Cal, Covered California, and private health insurance.
Amy has three children and had a doula for all three of her births.