New York State Doula Pilot Program

Medicaid Coverage of Doula Services:
Final Pilot Design

  • Document is also available in Portable Document Format (PDF)
November 2018

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).
  • New York State will launch the Medicaid Doula Pilot on March 1st, and Medicaid will begin accept applications on December 1st.

Overview of Pilot


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 six zip codes already funded through NYCDOHMH´s By My Side program (11207, 11208, 11212, 11216, 11221 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.

Scope of Services

  • What services will be covered by the pilot?
    • Up to and including 3 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 in–person 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

Kings County Erie County
  • Affinity Health Plan
  • Empire BlueCross BlueShield Health Plus
  • Fidelis Care New York, Inc.
  • HIP (Emblem Health)
  • Healthfirst PHSP, Inc.
  • MetroPlus
  • United Healthcare Community Plan
  • WellCare of New York
  • Fidelis Care New York, Inc
  • HealthNow New York, Inc.
  • Independent Health´s MediSource
  • United Healthcare Community Plan
  • Wellcare of New York
  • YourCare Health Plan

Doula Fee Schedule (Fee–for–Service)

Service Payment
Prenatal Care Visit $30
Labor and Delivery $300
Postpartum Visit $30
  • The total for 7 visits plus labor and delivery is $510
  • Rationale:
    • The established fee schedule is aligned with the Medicaid fee schedule for professional fees (physicians, NPs, and midwives).
    • Fees are approximately 43% of NY OB/GYN professional fees and 50% of midwife fees.

Billing Guidance (Fee–for–Service)

Visit Type Procedure Code Max Number of
Billable Visits
Prenatal Care Visit 99600 3
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 at www.health.ny.gov/DoulaPilot.
Date Topic Goal
November 29, 2018 "How to Enroll in Medicaid" Medicaid's Provider Enrollment team will conduct a webinar to assist doulas with the enrollment process
Late–November thru January "How to Bill Medicaid" Medicaid's billing vendor will conduct online and in–person trainings to educate doulas on billing policies and procedures as needed
November Outreach DOH will distribute pamphlets to stakeholders to share with eligible Medicaid members on the doula pilot
January Outreach A Medicaid Update will be released to all providers notifying them of the doula pilot services
Ongoing Outreach DOH will utilize NYS State of Health Marketplace social media channels as well as the Department's to provide general information on the doula pilot

Collaboration with Managed Care Organizations

  • The Medicaid program will be reaching out to each of the Plans that will be participating in the pilot areas to discuss the program design and discuss any particular questions or concerns the Plan may have.
  • The Medicaid program will also be scheduling monthly calls with all the of the Plans to share additional updates and next steps on the Medicaid doula pilot.
  • The Medicaid program will provide 60–day notification to the Plans on November 19th.
    • The Plans will also receive additional policy documents and FAQs on the doula pilot.

Resources

  • Additional information on the Medicaid doula pilot can be found here.
  • If you have additional questions or comments, please send them to doulapilot@health.ny.gov