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Doula Services Benefit Design and Reimbursement Methodology

The Doula Services State Plan amendment (SPA) (DC-22-0006) was submitted to the Centers for Medicare and Medicaid (CMS) on Friday, July 22, 2022, with a proposed effective date of October 1, 2022. The submitted SPA has an estimated total fiscal impact of $826,551 in fiscal year (FY) 2023 and $784,169 in FY 2024.

Based on comments received during the public comment period, the District made three (3) changes to the draft SPA previously posted on Monday, June 27, 2022 and found at the bottom of this webpage.

Changes included in the submitted SPA are:

  1. Defining the perinatal period, which is the time before, during, and up to six (6) weeks after delivery.
  2. Removing the word childbirth throughout the SPA pages, since perinatal is inclusive of childbirth, it was already stated in the SPA that the twelve (12) visits include attendance at delivery.
  3. Moving the “up to six (6) weeks after delivery” language into the definition of perinatal to prevent any misunderstanding that all doula services end at six (6) weeks.

We received additional comments on the maximum allowable hours per postpartum visit, the timeframe for and amount of reimbursement, and doula qualifications. Respectively, no changes were made to the SPA based on these comments for the reasons below:

  1. The maximum allowable hours per postpartum visit contained in the published SPA are consistent with the standard of practice described by doulas and other providers in the Maternal Health Advisory Group.
  2. The amount of reimbursement was based on a thorough multifactor financial analysis that considers all the expenses associated with the delivery of doula care. While one commenter expressed concern that the amount of reimbursement was high and may lead to doula providers to equate their work with the work of scientifically trained professionals, such a concern has no impact on the multifactor financial analysis performed by the District.
  3. Doula qualifications are under development by DC Health and are not appropriate for inclusion in the SPA submission.


The Department of Health Care Finance (DHCF) is looking for stakeholders to review and comment on a draft Doula Services State Plan Amendment (SPA) and related billing documents by Friday, July 1, 2022. There will be additional opportunities to provide comments during the doula services rulemaking process.

The SPA will authorize Medicaid coverage for doula services and the billing document lays out how those services will be billed. DHCF is interested in stakeholder input on the scope of the doula benefit. This summary below is intended to provide background on the SPA and related billing documents and provide instructions on how to provide written comments to DHCF.


The Fiscal Year 2022 Budget Support Act of 2021 (BSA) requires DHCF to cover doula services in Medicaid, the D.C. HealthCare Alliance Program (Alliance), and Immigrant Children’s Program (ICP) effective October 1, 2022. Accordingly, DHCF established a Maternal Health Advisory group, comprised of doulas, health care providers, health care insurers, community members, and stakeholders from D.C. Health. The group convened eight (8) times over the past six (6) months to discuss services to be included in the benefit, the reimbursement mechanism, and rates for the services. DHCF has also met with smaller stakeholder groups to discuss specific topics such as reimbursement and shared questions on topics such as what is covered. DHCF’s final proposal was discussed with the Maternal Health Stakeholder group on Monday, June 13, 2022.

Documents on Doula Services: The first (1st) two (2) components, Sections 3.1A and 3.1B of the State Plan, describe the extent to which services are provided, including what services are covered and whether there are any limitations on the amount of services available or prior authorization requirements.

While Sections 3.1A and 3.1B of the State Plan are generally identical under the District’s State Plan, each section describes coverage for different categories of families and children, aged, blind, or disabled individuals, and pregnant women, who are eligible for Medicaid. Section 3.1A generally covers eligibility groups either receiving or deemed to be receiving cash assistance. Under Section 3.1B, states have the option to cover groups, referred to as medically needy groups, that are not captured in Section 3.1A. To ensure all Medicaid beneficiaries have access to the service, it must be specified in both sections.


Under the proposed doula services, all pregnant individuals covered under the State Plan would have access to a total of 12 doula visits across the prenatal, childbirth, and postpartum periods.

Services covered during the perinatal and birthing period include:

  • Perinatal counseling and education, including infant care, to prevent adverse outcomes.

  • Labor support, including the development of a birth plan.
  • Coordination with community-based services, to improve beneficiary outcomes.
  • Other nonclinical activities to support the beneficiary, consistent with District Law.

Postpartum doula services include:

  • Visits to provide basic infant care,
  • Accompanying the beneficiary to a clinician visit,
  • Lactation support,
  • Emotional and physical support,
  • Selfcare, and
  • Other nonclinical activities to support the beneficiary, consistent with District Law.

Document on Doula Reimbursement: The third (3rd) component of the proposed amendment is Attachment 4.19-B which describes the reimbursement methods for the doula services.

The amendment proposes to reimburse prenatal doula visits on a per visit basis and provide a flat rate for labor and delivery. The amendment also proposes to reimburse postpartum doula services on a per unit basis in fifteen (15) minute units not to exceed twenty-four (24) units or six (6) hours per postpartum doula visit.

As a reminder, the proposed language is subject to change pending DHCFs review of written comments received and further internal discussions prior to the Medicaid State Plan submission to CMS on or before July 15, 2022. Consistent with the BSA requirement, the proposed effective date for the SPA is October 1, 2022.


This notice informs all interested parties of DHCF’s posting of the proposed amendment to the State Plan, with an opportunity for interested parties to provide written comments by July 1, 2022, to [email protected] If you have any questions, please contact Chanelle Parkar, Policy Analyst, at [email protected].