New York State Doula Pilot Program

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Medicaid Coverage of Doula Services:
Final Pilot Design

  • Document is also available in Portable Document Format (PDF)
February 2019

New York State´s Medicaid Doula Pilot

  • On April 23rd, the State announced a comprehensive initiative to target maternal mortality and reduce racial disparities in health outcomes. This initiative includes a Medicaid pilot program to cover doulas.
  • Since then, New York State (NYS) Medicaid has gathered information about coverage of doula services from:
    • Doula programs operating in New York; and
    • Other Medicaid programs that cover doula services (District of Columbia, Oregon & Minnesota).
  • The Medicaid pilot program will be implemented through a phased-in approach in order to ensure access to this new benefit. Phase 1 of the pilot launches Erie County on March 1, 2019. The Department continues to work with doulas in Kings County to enroll as Medicaid providers and Phase 2 of the pilot will launch in Kings County when provider capacity is reached.

Purpose of Today´s Discussion

Doula Pilot Areas

  • What is the setting for the doula pilot?
  • Geographic-based
    • Highest prevalence counties in New York State (Erie and Kings) based on:
      • High maternal and infant mortality rates
      • Significant # of Medicaid Births
    • Pilot will exclude the three zip codes already funded through NYCDOHMH´s By My Side program (11207, 11212, and 11233).

Maternal https://www.health.ny.gov/statistics/chac/birth/b33.htm
Infant https://www.health.ny.gov/statistics/chac/birth/b27.htm

Doula Services Eligibility

  • Who is eligible to receive doula services?
  • Medicaid eligible pregnant women in fee-for-service or Medicaid Managed Care who reside in the selected zip codes (Erie and Kings) would be eligible to receive doula services.
  • The Medicaid doula pilot will be implemented through a phased-in approach in order to ensure access to this new benefit. Phase 1 of the pilot will launch in Erie County on March 1, 2019. Phase 2 of the pilot will launch in Kings County when provider capacity is reached.

Scope of Services

  • What services will be covered by the pilot?
    • Up to and including 4 prenatal visits
    • Support during labor and delivery
    • Up to and including 4 postpartum visits

Enrollment in the Medicaid Program

  1. Apply for NPI Number
  2. Complete NYS Medicaid enrollment forms
  3. Provide an attestation of doula training and proof of doula training
  4. Contract with Medicaid Managed Care Organizations

To participate in the doula pilot program, a doula must be enrolled as a provider in the NYS Medicaid program.
To enroll, a doula must:

  1. Apply for a National Provider Identification Number (NPI#) at the National Plan and Provider Enumeration System website
  2. Complete and return all required NYS Medicaid Provider Enrollment forms:
    1. NYS Medicaid Enrollment Form (Practitioner Enrollment - form #436801)
    2. Electronic Funds Transfer (EFT) Authorization (Electronic Funds Transfer (EFT) Authorization - form #701101)
    3. Electronic Transmitter Identification Number (ETIN) Certification Statement for New Enrollment (ETIN Certification Statement for New Enrollments - form #490602)
  3. Provide a signed and dated attestation of receiving doula training in the following core competencies:
    • At least 24 contact hours of education that includes any combination of childbirth education, birth doula training, antepartum doula trainings, and postpartum doula training.
    • Attendance at a minimum of one (1) breastfeeding class.
    • Attendance at a minimum of two (2) childbirth classes.
    • Attendance at a minimum of two (2) births.
    • Submission of one (1) position paper/essay surrounding the role of doulas in the birthing process.
    • Completion of cultural competency training.
    • Completion of a doula proficiency exam.
    • Completion of HIPAA/client confidentiality training.
  4. Provide a copy of the doula training certificate - or - an original signed and dated letter from the doula training organization stating the doula has attended and completed their doula training course (this letter must be on the organization´s letterhead and signed by the organization´s authorizing representative.

The doula will be required to return the signed and dated doula training attestation form, proof of doula training, and all completed NYS Medicaid Provider Enrollment forms to:

Mailing Address

Provider Enrollment - Doula Pilot
Room A 129
431 Broadway
Albany, New York 12204

Medicaid Managed Care Provider Enrollment

  • Once a doula is enrolled as a NYS Medicaid Fee-for-Service provider, they will be eligible to enroll as a provider with each of the Managed Care Organizations (MCO) participating in the pilot (see slide 13).
  • Doulas that are interested in more information regarding the MCOs´ enrollment process for this pilot must contact the individual plans.

Reimbursement for Doulas

  • How will doula services be reimbursed?
  • Depending on the payor, there will be two different ways to bill:
    • Fee-For-Service:
      • Doulas will bill the Medicaid program directly through fee-for-service (FFS) via the eMedNY system.
  • Managed Care
    • Doulas will submit a claim to the Managed Care Plan, which will then reimburse the doula.
  • In order to follow federal Medicaid requirements applicable to covered services, doula services will be reimbursed on a FFS schedule.

Plans Participating in the Pilot

County Plan Name Contact Number
Erie County MMC Plans Fidelis Care New York, Inc. (800) 749-0820
HealthNow New York, Inc (716) 887-6900
Independent Health's MediSource (800) 736-5771
United Healthcare Community Plan (877) 842-3210
WellCare of New York (800) 288-5441
YourCare Health Plan (800) 683-3781
Kings County MMC Plans Affinity Health Plan (800) 553-8247
Empire BlueCross BlueShield Health Plus (800) 454-3730
Fidelis Care New York, Inc. (800) 749-0820
HIP (Emblem Health) (646) 447-5000
Healthfirst PHSP, Inc. (866) 463-6743
MetroPlus (800) 597-3380
United Healthcare Community Plan (877) 842-3210
WellCare of New York (800) 288-5441

*The Medicaid pilot program will be implemented through a phased-in approach in order to ensure access to this new benefit. Phase 1 of the pilot launches Erie County on March 1, 2019. The Department continues to work with doulas in Kings County to enroll as Medicaid providers and Phase 2 of the pilot will launch in Kings County when provider capacity is reached.

Doula Fee Schedule (Fee-for-Service)

Service Payment
(as of 1/1/2023)
Prenatal Care Visit $30.30
Labor and Delivery $363.60
Postpartum Visit $30.30
  • The total for 8 visits plus labor and delivery is $606.
  • Rationale:
    • The established fee schedule is aligned with the Medicaid fee schedule for professional fees (physicians, NPs, and midwives).

Billing Guidance (Fee-for-Service)

Visit Type Procedure Code Max Number of
Billable Visits
Prenatal Care Visit 99600 4
Labor and Delivery 99499 1
Postpartum Visit 99600+ UA Modifier 4
  • Category of Service: 0464 (Doula)
  • Managed care plans may have different procedure codes depending on their particular systems.

Evaluation

  • How will the Medicaid program determine the effectiveness of the pilot?
  • The New York State Department of Health will collect information from mothers on breastfeeding rates, and satisfaction and experience with the pilot via surveys.
  • The Department will also collect information on mothers´ attendance at postpartum visits via claims.
  • The Department will work with managed care plans on creating a mechanism to identify mothers that are participating in the doula pilot.
  • The Department will also be collecting provider satisfaction information on the doulas via surveys starting at 4 months from the beginning of the pilot and at the end of the pilot.
  • It is the Department´s expectation that doulas will complete the surveys to ensure the success of both the pilot and the evaluation.

Doula Outreach and Education

  • The New York State Department of Health will organize a series of webinars and in-person trainings to assist doulas as they become enrolled Medicaid providers and bill the Medicaid program for services.
  • Additional information on trainings can be found here.

Resources