WA doulas now eligible for highest Medicaid reimbursement in U.S.

Some doula services are now covered for Washington residents on Apple Health, a significant change in the way the state pays for pregnancy and labor care for almost half its annual births.

As of Jan. 1, birth doulas are eligible for a $3,500 payment per delivery, the highest Medicaid reimbursement for doulas in the country, according to advocates of the change. The new benefit took years of work and reflects a step toward addressing birth inequities – especially among Black and Indigenous communities, who face higher risk of negative birth outcomes – said Senait Brown, policy director of Doulas For All, which is composed mainly of doulas and childbirth educators of color who led the push for legislative change.

State lawmakers approved the reimbursement during the 2024 session, building on legislation passed two years prior that created a credentialing process for doulas interested in pursuing state certification.

“Moving forward, doulas can practice without having that burden of worry or fear they won’t be covered,” said Tiara Calahan, a holistic birth doula from Skyway who’s part of Doulas For All, which is housed within Seattle-based organization Surge Reproductive Justice. “We can take adequate maternity leave, take time off, hire backup doulas – things like that. Now the work is more equitable and sustainable for us.”

Doulas in the U.S., which along with midwives have roots within Black and Indigenous communities, primarily serve as patient advocates, Calahan said. They offer physical, emotional and educational support to pregnant people and their families before, during and after birth. Some offer full-spectrum services, while others focus specifically on pregnancy, birth or postpartum care.

They differ from midwives, who also center holistic birth practices but are clinically trained. Doula work can include guiding pregnant people through breathing techniques, navigating different labor positions and performing a range of spiritual and cultural rituals.

Doulas are trained professionally or through ancestral practices, and do not provide medical or clinical care. They also do not need to be licensed to provide services in Washington.

“Doulas are certainly not a silver bullet,” said Elizabeth Tinker, clinical nurse consultant at the state Health Care Authority, which regulates Apple Health. “They’re not expected to solve all of the problems that exist, but they are an evidence-based intervention that has been demonstrated to improve outcomes for all people.”

No other state ‘quite exactly like Washington’

Past research has reported the presence of doulas can reduce the risk of premature labor and unnecessary interventions, like cesarean sections, as well as improve the overall birthing experience and mental health of the birthing parent after delivery. The American College of Obstetricians and Gynecologists also points to evidence of shortened labor and decreased need for pain medication.

Yet, because doula care is not generally covered by insurance, services are often unaffordable. Apple Health covers about 45% of annual births in Washington, including care during and after pregnancy, Tinker said.

“We’re not just trying to make money and make this a viable economic career. We’re also trying to end these health disparities in our communities,” said Tabitha Milian, a Seattle-area childbirth educator, community lactation specialist and postpartum doula.

In the past several years, more states have experimented with Medicaid reimbursement benefits for doulas as research has grown, including Oregon, California, Rhode Island and Colorado, said Brown, with Doulas For All.

As of this year, about 21 other states are actively reimbursing for doula services through Medicaid, according to National Health Law Program, which tracks similar efforts across the country. At least six others are in the process of implementing benefits.

The reimbursement maximums differ depending on the state, generally ranging from about $960 in Virginia to about $3,200 in Minnesota and for cesarean births in California, according to the organization.

Developing legislation in Washington was grueling and time-consuming. But with input from hundreds of doulas, community advocates and lawmakers, the state landed at a benefit several doulas said they were very excited about.

“No one is quite exactly like Washington,” Brown said. “We’re pretty proud of what we’ve been able to do.”

How to get reimbursed, involved

Now, doulas who want to get reimbursed for their services through Apple Health can take steps to become eligible, including completing a birth doula certification with the Department of Health; obtaining a National Provider Identifier number (a unique identification number for providers who accept insurance); and enrolling with ProviderOne, the state’s system for submitting Apple Health claims.

The benefit covers one prenatal intake visit, continuous labor and delivery support and 20 hours for additional prenatal and postpartum visits, according to the Health Care Authority. More information about what is and isn’t covered is available in the HCA’s doula services billing guide.

Apple Health members interested in doula services can look through the state’s online Find-A-Provider search tool, but the website isn’t the most user-friendly, said Michelle Madrigal, HCA’s doula services program manager. She encouraged people to reach out to their primary or pregnancy care providers first.

Families can also start by connecting with Doulas For All, which is building out a statewide referral system and a “doula hub,” or an online portal that provides resources, education and peer support for patients and doulas-in-training, Brown said.

“When it comes to (Doulas For All), despite the fact that we’re a queer, BIPOC-centering group, everyone is welcome,” said Sage Kissiah-Grove, a full-spectrum doula who works with the group. “Our biggest goal is making sure we’re decolonizing and promoting accessibility. And as long as you’re interested in doing work to make sure everyone has access to these services, we want you here.”

The group hopes to get a version of the directory running by this summer but will continue its work throughout the year – and in the future – to expand this reimbursement model, Brown said. She and others want to one day coordinate with commercial payers and managed care organizations on a similar reimbursement model, as well as work with hospitals to move away from “exploitative” contracts that push to increasingly regulate the doula profession and undercut work to improve accessibility, Brown said.

“We want to be proactive about how doulas will be integrated into hospital settings, where they have historically not been welcomed,” Brown said during a Thursday news conference.

As of this week, more than 260 doulas are state-certified or are pending enrollment and are on their way to unlocking Apple Health reimbursement, Brown said. Yet the work is not done.

She and other Doulas For All members detailed Thursday what they plan to advocate for during this year’s legislative session, which began this week. In addition to continued fee waivers from the state Department of Health, which eliminates the fee required to become state-certified, the group is also planning to ask for placeholder language in the budget for the doula hub and referral system.

“It took a lot of work and organizing and strategy to get this across the finish line,” Calahan said in an interview. “A government agency didn’t come and save us. Our community gathered and saved ourselves.”