The state of Connecticut (CT) Department of Social Services Medicaid program (known as HUSKY Health) plans to incorporate access to doula services as a core feature of the upcoming HUSKY Maternity Bundle program anticipated to launch in September 2024.

The goal for the additional high-value services is to bridge the equity gaps in maternity care for historically marginalized birthing people, including those with substance use disorders, and help to achieve the aims of the Maternity Bundle, which include reducing maternal mortality, improving maternal health outcomes and member experiences, and improving health equity for birthing people in CT.

Under the new program, medical practices will receive additional funds from HUSKY Health to add doulas to their care team and to strengthen lactation support. Doula services will be rendered and reimbursed under the medical provider through the bundle. 

PMC developed this integration toolkit to support models in which doulas work within a medical practice, in particular in Connecticut, where the approach to Medicaid doula coverage expansion is unique and temporarily requires that the payment for doula services flow through providers as part of a bundle payment. Legislation was recently passed that creates state certification for doulas, allowing doulas to directly bill the Medicaid program, HUSKY Health. Once direct payment is in place in 2024, the two payment pathways (direct payment and payment through providers) will co-exist in Connecticut.

Although doulas do not provide medical advice or make decisions on behalf of patients, they play an important role in supporting birthing people’s bodily autonomy and ability to exercise informed choice, including making choices that are not aligned with medical recommendations. For this reason, it is important for doulas to be able to provide patient-centered support and education that is not unduly influenced by medical providers’ preferences or oversight. A financial relationship between the provider or facility and doula complicates this independence.

However, there are also benefits to the more integrated approach. Doulas who work within a medical practice can participate in interdisciplinary team-based care to best support their patient, and reduce their administrative burden of Medicaid enrollment and billing through the provider’s assistance. Conversely, doulas who choose to remain separate from healthcare providers are able to practice independently, but must commit to completing the administrative, billing, and revenue cycle management tasks that come along with the ability to bill Medicaid and other payors for services. They may also miss out on opportunities to enhance care through stronger alignment with the patient’s care team.

There are also ways to mitigate the influence of the financial relationship on doula independence in models where the payment passes through providers. This includes having clear policies about roles, responsibilities, and scope of practice, educating providers and all stakeholders on the doula role, and forming doula collectives or co-ops that increase doula negotiating power and can help coordinate back-end services such as data collection.

PMC’s role in the doula integration was to design processes and tools that would facilitate doula and provider relationships, easing the initial burden of doula and provider collaboration. The toolkit documents were developed with collaboration in mind and are most relevant for those choosing to establish a doula program as part of a healthcare facility or medical practice. However, some tools may be adapted for referral arrangements where doulas remain independent.

PMC strongly believes that all pregnant and birthing people deserve access to doula services as a covered benefit. Our payment systems should offer flexibility and allow for doula services to be rendered from both independent doulas and those embedded within medical establishments.