BIRTH DOULA SERVICES

WAC 182-533-0610 through 182-533-0680 establish the medicaid agency's provider and documentation requirements and coverage and payment rules for birth doula services when provided to eligible apple health clients. Birth doula services improve and promote healthy pregnancy, birth, postpartum, and infant outcomes. A birth doula delivers services to eligible pregnant and post-pregnant people, their infants, and their families.

The following definitions and those found in chapter 182-500 WAC apply to birth doula services.

"Agency" - See WAC 182-500-0010.

"Birth doula" - A nonmedical support person certified under chapter 246-835 WAC and trained to provide physical, emotional, and informational support to birthing persons, their infants, and their families.

"Birth doula services" - Preventive services, as defined by 42 C.F.R. 440.130(c), provided by a birth doula to pregnant and post-pregnant people, their infants, and their families. Services include advocating for and supporting the birthing person and their family to self-advocate by helping them to know their rights and make informed decisions.

"Care coordination" - Collaboration and communication between the client's birth doula provider and other medical or health and social services providers, including Indian health care providers, or both, to partner with and address the individual client's and family's needs.

"Culturally congruent care" - See WAC 246-835-010.

"Department of health (DOH)" - The state agency that works with others to protect and improve the health of all people in Washington state and which certifies the birth doula profession under chapter 246-835 WAC.

"Health care record" - See WAC 182-502-0020 for health care record requirements.

"In person" - The client and the provider are face-to-face in the same location.

"Lived experience" - Having first-hand knowledge and insight gained from navigating challenges similar to those faced by the people in the community. This can include shared experiences like cultural backgrounds, socioeconomic status, health conditions, or barriers accessing the health and social service systems.

"Medicaid agency" - See WAC 182-500-0070.

"Postpartum period" - The period lasting until the end of the 12th month after the pregnancy ends.

"Washington apple health" - See WAC 182-500-0120.

To receive birth doula services, a client must:

(1) Be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060; and

(2) Be within one of the following eligibility periods:

(a) During pregnancy;

(b) Birth, inclusive of any end of pregnancy outcome; or

(c) The postpartum period as defined in WAC 182-533-0620.

To be eligible to provide birth doula services to Washington apple health clients, a birth doula must:

(1) Be 18 years of age or older;

(2) Be a resident of the state of Washington or a bordering city as specified in WAC 182-501-0175;

(3) Possess current certification as a birth doula with the Washington state department of health under chapter 246-835 WAC;

(4) Be enrolled as an eligible birth doula provider with the medicaid agency (see WAC 182-502-0010);

(5) Meet the requirements in this chapter, chapter 182-502 WAC, and the billing and documentation requirements found in the agency's current birth doula services billing guide;

(6) Meet the standards required by state and federal laws governing the privacy and security of personally identifying information;

(7) Participate in care coordination activities throughout pregnancy and the postpartum period with the client's prenatal clinical care provider and, if applicable, their maternity support services (MSS) provider (see WAC 182-533-0310 through 182-533-0345);

(8) Provide culturally congruent care to the client and client's family; and

(9) Have lived experience that aligns with and provides a connection between the birth doula and the community being served.

(1) Providers must fulfill the documentation requirements found in WAC 182-502-0020 and the medicaid agency's current birth doula services billing guide.

(2) Each provider must maintain a client health care record for each client that states the services provided and justifies how those services support provider reimbursement.

(3) The following must be documented in the client's health record:

(a) Consent to services to be signed at the initiation of care;

(b) The date and time/duration of services and information substantiating the time/duration of services;

(c) The nature of the care and service(s) provided;

(d) Any coordination with medical or other care providers;

(e) Any referrals and coordination efforts with community resources or community supports;

(f) If screening is provided using a validated screening tool, the name of the tool, the score, and any communication following a positive screening including referrals to community resources, coordination with clinical team, etc.; and

(g) The following required components of the prenatal intake visit:

(i) The date and time/duration of services, minimum two-hour visit;

(ii) A completed and signed consent for services form;

(iii) Provide an overview of the apple health birth doula benefit;

(iv) Co-design a plan of care across antepartum, delivery, and postpartum periods, as appropriate;

(v) Initiate discussion and implementation of birth plan or client/family preferences for care;

(vi) Support the client in establishing care as needed, including clinical pregnancy care, behavioral health services, dental services, etc. Coordinate with the managed care organization if needed to assist the client in accessing desired services, timely appointments, or any other care coordination or case management need;

(vii) Review the client's health history including any previous pregnancies, births, and loss of life;

(viii) Coordinate with medical providers regarding mental and emotional health screenings, and if appropriate, support symptom reduction through care navigation or peer support;

(ix) Review social determinants of health (SDOH) and other social-related health needs. Provide resources and support guided by client or family priorities; and

(x) Assess family and other relational support networks.

(1) To be covered, birth doula services must:

(a) Be preventive in nature according to 42 C.F.R. 440.130(c); and

(b) Provide physical, emotional, and informational support to pregnant, birthing, and postpartum people.

(2) The medicaid agency covers the following birth doula services:

(a) One prenatal intake visit billed only once per client, per pregnancy. The visit must take place in person. Required components of the prenatal visit are listed in WAC 182-533-0650;

(b) Continuous labor and delivery support billed only once per client, per pregnancy. This must take place in person and be provided to one client at a time;

(c) One comprehensive postpartum visit per pregnancy; and

(d) Additional prenatal and postpartum visits per client, per pregnancy across the prenatal and postpartum periods.

(3) The agency determines the maximum number of units of services allowed per client when directed by the legislature to achieve targeted expenditure levels for payment of birth doula services for any specific biennium. The maximum number of units allowed per client is published in the agency's current birth doula services billing guide.

(4) The agency evaluates requests for authorization of covered services that exceed limitations on a case-by-case basis in accordance with WAC 182-501-0169.

(5) For birth doula services not allowed via telemedicine, see WAC 182-533-0680.

Under this chapter, the medicaid agency does not cover the following services when provided by birth doulas:

(1) Childcare;

(2) Chore services including, but not limited to, shopping and cooking;

(3) Group services;

(4) Phone calls, text messages, and emails;

(5) Documentation time; and

(6) Travel time and mileage.

(1) The medicaid agency pays for the birth doula services described in WAC 182-533-0660 when they are:

(a) Provided to a client who meets the eligibility requirements in WAC 182-533-0630;

(b) Provided to a client during a face-to-face encounter, including audio-visual telemedicine (see WAC 182-533-0680);

(c) Provided and billed according to the agency's current birth doula services billing guide; and

(d) Documented in the client's health care record or chart per WAC 182-533-0650.

(2) The agency pays for:

(a) The prenatal intake visit at a flat rate with a minimum of two hours of one-to-one service delivered face-to-face;

(b) Labor and delivery support at a flat rate with one-to-one service delivered face-to-face; and

(c) Additional prenatal and postpartum visits per unit of time with one unit being equal to 15 minutes. Providers must bill for the direct service delivery at the minimum time equivalent.

(3) For clients enrolled in managed care or fee-for-service (FFS) who are eligible for birth doula services, the agency pays for covered birth doula services through FFS using the agency's published fee schedule.

(4) The agency uses the appropriate payment methodology found in WAC 182-531-1850 for birth doula services.

The medicaid agency pays for birth doula services provided via telemedicine according to WAC 182-501-0300 and the limitations in this section.

(1) The agency pays for birth doula services provided via telemedicine only when:

(a) The prenatal intake has been provided in person;

(b) The first visit with a new birth doula has been provided in person if the client changes their birth doula; and

(c) The servicing provider for the telemedicine service uses the same billing provider's national provider identifier (NPI) used to bill for the in-person prenatal intake visit.

(2) If the client changes their birth doula, the first visit with the new birth doula must be performed in person. The agency will not pay for the first visit via telemedicine. The change of birth doula must be documented in the birth doula's client health care record.

(3) The agency does not pay for the following birth doula services provided via telemedicine:

(a) The prenatal intake visit;

(b) The first visit with a new birth doula if the client changes their birth doula; and

(c) Labor and delivery support.