Doula Services in California’s Medi-Cal Program See Increased Reimbursement Rates

Breanna Reeves

One year after adding doula services as a covered benefit under Medi-Cal, California’s Medicaid program, California now offers the highest doula benefit reimbursement rate in the country for doula Medicaid services.

Last January, the Department of Health Care Services (DHCS) added doula services, expanding access to essential maternal care services and set a maximum rate at which doulas would be reimbursed at $1,154 with one initial visit paid at $126.31, eight perinatal visits paid at $60.48 per visit and one labor and delivery visit paid at $544.28. 

DHCS submitted a new State Amendment Plan (SPA) to the Center for Medicaid Services (CMS) last December, requesting an increase in Medi-Cal reimbursement rates for “targeted” Medi-Cal providers which include doulas, nurse practitioners, licensed and certified nurse midwives, and other primary care providers.

The new doula reimbursement rate for the total set of prenatal and postpartum appointments, which applies to both fee-for-service and managed care programs, totals just over $3,000 for a vaginal delivery and cesarean birth.

Since the implementation of doula services as a Medi-Cal benefit, doula providers and birth advocates have worked to improve the application process, advocated for a higher reimbursement rate and developed a doula directory.

“The doula community, and advocates have been just incredible. They are so persistent, and have so much passion and really love the field,” said Alexis Robles-Fradet, a health policy analyst at the National Health Law Program (NHeLP). Robles-Fradet has worked closely with doulas and birth advocates to develop the initial SPA for doula benefit services and conduct research on other doula programs.

“It’s been inspiring. It's incredible. I don't think any of this would be happening without the doula community. I think they've been just absolutely key in making the benefit what it is, and increasing these rates so that they are the highest in the country.”

As required by Senate Bill 65, authored by Senator Nancy Skinner (D-Berkeley), DHCS convened the Doula Implementation Workgroup who make recommendations regarding the benefit and address barriers to implementation. Members of the group include stakeholders, doulas, perinatal experts and maternal health educators from across the state.

DHCS began meeting with doulas and other stakeholders in September 2021 to establish the benefit. The process of developing the benefit was not without challenges as many doulas disagreed with the initial $450 reimbursement rate proposed in Gov. Gavin Newsom’s 2021 budget and the prerequisites for Medi-Cal doula enrollment.

DHCS have implemented changes since the benefit has taken effect such as removing some barriers to the process of families requesting a doula which initially required Medi-Cal patients to have a written recommendation from a physician or “other licensed practitioner of the healing arts.” Now,  DHCS has issued a standing recommendation for doula services from the DHCS Medical Director Dr. Karen Mark “that fulfills the requirement for a recommendation for an individual who is pregnant or was pregnant within the past year.” 

There are still some kinks being worked out as doulas enroll as providers through Medi-Cal’s enrollment system, Provider Application and Validation for Enrollment (PAVE).

“It has been very challenging because when I applied to PAVE it was February or March, so the benefit had been just brand new, so not too many of us knew how to navigate it. One of the biggest things for me was trying to obtain a business license,” explained Priya Kalyan-Masih, a bilingual doula who supports birthing families in Apple Valley. 

Kalyan-Masih completed medical school in Mexico, where she found an appreciation for the role of a doula who is tasked with supporting individuals during their pregnancy and birthing journey.

Applying to become a doula within Medi-Cal involved a lot of requirements such as obtaining a fictitious business name, registering her business with the town and county, and understanding specific codes within the application system. Kalyan-Masih said her application was rejected two or three times until she had all the necessary documents.

“I cried,” Kalyan-Masih said as she recalled what it felt like to finally receive her application approval letter. “So many steps went into just getting that.”

At the end of the month, Kalyan-Masih will celebrate one year of being a doula after completing doula training with the Sankofa Birthworkers Collective of the Inland Empire and the Riverside Community Health Foundation. Since completing training, Kalyan-Masih has served 35 families across the high desert region of San Bernardino County.

With the Medi-Cal doula benefit in its second year, DHCS has enrolled 197 individual providers and 17 doula groups, but expects that the increased reimbursement rate “may encourage additional doulas to enroll in Medi-Cal and begin providing services to Medi-Cal members,” DHCS wrote via email. About 40 doulas who serve families in both San Bernardino and Riverside Counties are enrolled as providers.

As the Doula Implementation Workgroup resumes their monthly meetings to discuss the benefit and continue to improve the rollout, Robles-Fradet explained that it will be important to examine the sustainability of the doula workforce.

“I think next steps are going to be evaluating if this is a sustainable rate for high cost of living areas, as well as with other factors contributing to costs such as medical insurance,” said Robles-Fradet.

While the new reimbursement rate exceeds $3,000 (at a maximum), the pay depends on the number of births, prenatal and postpartum visits a provider attends. As doula providers vary in the services they offer, so will their pay. Robles-Fradet estimated that if a doula provides support for 12 births, including attending all visits, they would earn roughly $39,000 (gross).

According to the Bureau of Economic Analysis, who measures the cost-of-living across different cities in the U.S. and compares it to the national average cost of goods and services (100), California has the second highest cost of living in the U.S. Within the state, cities like San Francisco (117.9) have the highest cost of living, exceeding the state’s average (112.5).

“I think those are still areas that the doula workforce could use support in and that could be through organizing, which is something that we're working with doulas on and different advocates,” Robles-Fradet explained.

The services and support doulas offer is a labor of love, and while DHCS is encouraged that more doulas will enroll as providers to serve Medi-Cal beneficiaries, some doulas enjoy working outside of the system and offering services directly to communities or through private services.  

Kalyan-Masih hopes more doulas will participate in the benefit and serve Medi-Care populations, and look beyond the reimbursement number.

“I don’t want people to see the number and chase the number because it's really a work of heart and passion,” Kalyan-Masih said. “And to be able to give so much of yourself over the course of a year just for one client you have to work from your heart and not the numbers.

This article is published as part of the Commonwealth Health Equity Reporting Fellowship.