Now Reimbursed by Medicaid, Doulas Adjust to a More Complicated Future

New York State’s Medicaid program is expanding to include coverage for doulas — the workers who assist mothers before, during and after childbirth. That should open up access, particularly for low-income mothers.

And while many doulas welcome the opportunity to be reimbursed by Medicaid, some are concerned about the downsides, such as the loads of paperwork and heightened oversight.

“There’s a very big fear of doula work becoming very regulated and very under the shadows of all these people and policies,” said Vickiana Peña, 35, a doula based in the Bushwick neighborhood of Brooklyn.

Doulas are trained to support mothers in a variety of ways: They provide emotional support, connect mothers with community resources and educate parents about newborn care. During labor, they advocate for the mother’s medical preferences and facilitate techniques to ease delivery.

That is especially important for mothers in New York, where pregnancy carries significant risk. The state has the 23rd highest maternal mortality rate in the nation. Black mothers in New York are particularly vulnerable, with a death rate five times higher than white mothers, according to the latest data available, from 2018 to 2020. And studies show that doula care can help mothers experience healthier births.

Following a successful pilot program, the state opened up coverage for doula services last March. Medicaid can now reimburse doulas up to $1,350 upstate and $1,500 in New York City.

The number of doulas signed up as Medicaid providers has almost tripled since coverage was expanded in March, stated Danielle De Souza, a state health department spokesperson. Currently, there are more than 120 doulas enrolled statewide, according to an online directory. (New York is joining 29 other states and Washington, D.C. that are affiliating doulas with Medicaid or have already done so).

But some doulas are concerned about how they will adjust, confronting uncertainties with billing paperwork, government policies and a lack of a central licensing.

‘The paperwork doesn’t work right’

Debi Tracy, 58, a perinatal educator at Mount Sinai South Nassau Hospital in Long Island and a practicing doula, described the burdensome paperwork associated with medical billing. She noted that doulas, unlike doctors, are often independent and lack administrative support.

“How much time and effort and strain is it going to take for them to take care of those things when they want to just be there to take care of the women, their craft?” Tracy said.

Some doulas have pointed to issues with Medicaid managed-care plans. For the time being, doulas directly bill Medicaid using fee-for-service.

But starting next year, doulas enrolled in Medicaid will be required to bill managed-care plans as well. Doulas will have to contact each managed-care organization for billing. In New York, about 77% of Medicaid recipients use a managed-care plan.

“I haven’t had a lot of luck yet getting myself connected to the managed-care organizations yet,” said Vicki Bloom, 56, a Westchester-based doula who has been practicing for almost 15 years. “The state is going to have to do a better job facilitating it, or the program is going to fall apart.”

A report on the state’s pilot program revealed how some doulas felt that submitting paperwork for managed care was too time-consuming and that many claims were flat-out rejected.

Another issue is licensing. No federal or state agency regulates doulas. Instead, they are typically certified through a specialized training program such as DONA (Doulas of North America) International.

To enroll for Medicaid reimbursement in New York, doulas need to prove that they’ve received at least 24 hours of doula training, have assisted with at least 30 births, or had 1,000 hours of doula experience over the past decade.

But the lack of standardization can create problems with managed-care plans, Bloom said. Most of these have to verify some sort of license, she said. “The paperwork doesn’t work right.”

Shelly Louis, a Brooklyn doula, said she was still trying to understand the billing process. “Medicaid is a big world, a new world,” Louis said. “I’m still trying to figure out what they cover, what they’ve done, how the system works.”

According to Department of Health spokesperson De Souza, doulas are being readied for the changes: “The Department of Health has provided extensive information to the doula provider community to prepare for this transition and will continue to support doulas in the process to the extent possible.”

‘A core piece of humanity’

Other doulas see Medicaid enrollment positively.

“So many people are able to access what was once viewed as a luxury,” said Ayanah Alexander, 26, a doula in Rochester. She had to pay for a doula out of pocket during her son’s birth three years ago. “It wasn’t cheap.”

Breonna Orum, also based in Rochester, was inspired to become a doula after the birth of her third child, when she first hired a doula of her own. Orum had to undergo an emergency C-section after doctors lost track of her daughter’s heartbeat. Her doula calmed her and walked her through the process, advocating on Orum’s behalf when she lost consciousness for an hour.

“It definitely makes a huge difference,” Orum said. “I felt like when I didn’t have a voice, I did still have a voice in the room.”

For Cristina Morales-Vega, 35, a Brooklyn-based doula, the benefits of Medicaid access will surpass any bureaucratic issue. “If you’re a doula operating with humanity first, you’re always going to work to serve that person and help them and get the care that they need — no matter what,” she said.

But Morales-Vega hasn’t yet enrolled with Medicaid. She is waiting to hear from others what it’s like.