14132.24.
(a) The Legislature hereby finds and declares all of the following:(1) Racism and racial basis in health care contribute to the national maternal mortality and morbidity crisis, in particular for pregnant and postpartum people who are Black and Native American or indigenous.
(2) Pregnant and postpartum people who are Black are three to four times more likely than pregnant and postpartum people who are non-Hispanic White to die during pregnancy or shortly after birth. Babies of people who are Black are two and one-half times more likely to be born prematurely or to die within the first year of life than the babies of people who are non-Hispanic White. Notably, the racial disparities in maternal mortality rates exist across all levels of income, age,
and education.
(3) Doulas can reduce the impacts of racism and racial bias in health care on pregnant people of color by providing individually tailored, culturally appropriate, and client-centered care and advocacy. Doulas are not medical providers and do not provide medical care. Doulas provide pregnant and postpartum people with social and emotional support, individualized and culturally specific education, and strategies to reduce stress and other barriers to healthy pregnancies.
(4) Pregnant and postpartum people receiving doula care have been found to have improved health outcomes for themselves and their infants, including higher breast-feeding initiation rates, fewer low birth weight babies, and lower rates of cesarean births.
(5) The benefits of doula care can also have a financial impact in helping families avoid the cost associated with low birth weight babies, cesarean births, and other pregnancy-related
complications.
(6) While doula care would be a natural fit for underserved populations, including people of color, immigrants, and low-income communities, they often cannot afford to pay out-of-pocket for doula care. In California, doula care can cost anywhere from several hundred dollars to upwards of $2,000. Private insurance rarely covers doula care.
(7) Doulas place a high priority on their autonomy, their role as advocates for their clients, and their ability to tailor their work and practice to their unique client populations. Therefore, doulas, as a community, have not sought broader professionalization through formal licensure. Doulas are trained to abide by the relevant regulations and protocols in whatever setting in which they provide support. The Legislature honors and supports the autonomy of doulas, and seeks to be as inclusive as possible of the wide variety of birth support work that exists, including community-based, traditional, and
indigenous birth support work. Consequently, the Legislature seeks to identify and mobilize an educated and prepared doula workforce to serve the Medi-Cal population by supporting the ongoing practices of doulas working with communities experiencing the highest burden of birth disparities, but without the barriers to entry that licensure would entail.
(8) A Medi-Cal pilot program on doula care shall be designed to support doulas who are already part of, or who are entering, the workforce specifically to serve the Medi-Cal population. Thus, in order for the pilot program to succeed, for both the doulas and the Medi-Cal beneficiaries that they serve, the program must provide adequate and sustainable compensation for the doulas.
(9) This pilot program acknowledges that in order to have a truly sustainable, equitable, and inclusive program for doula care as a Medi-Cal benefit, practicing doulas and community-based doula groups must be leaders and partners
in this work. To the extent possible, practicing doulas and community-based doula groups shall be involved in the design, development, and implementation of the pilot program.
(b) The following definitions apply for purposes of this section:
(1) “Community-based doula group” means a group or collective of doulas working together that prioritizes doula access for underserved populations. The doula care that is provided by community-based doula groups often goes beyond basic prenatal and postpartum care, to encompass a broader and more holistic vision of support for the pregnant person and their family or supporting loved ones. Many community-based doula groups draw their membership directly from the communities that they serve. This often allows community-based doula groups to offer culturally congruent care, and not simply culturally appropriate care.
(2) “Core competencies” means the foundational and essential knowledge, skills, and abilities required for doulas serving Medi-Cal beneficiaries.
(3) “Department” means the State Department of Health Care Services.
(4) “Doula” means a birth worker who provides health education, advocacy, and physical, emotional, and nonmedical support for pregnant and postpartum persons before, during, and after childbirth, otherwise known as the perinatal period. A doula provides support during miscarriage, stillbirth, and abortion.
(5) “Full-spectrum doula care” means prenatal and postpartum doula care, continuous presence during labor and delivery, and doula support during miscarriage, stillbirth, and abortion.
(6) “Perinatal period” means the period including pregnancy, labor, delivery, and the postpartum period.
(7) “Postpartum” means the one-year period following the end of a pregnancy.
(c) (1) Commencing July 1, 2021, the department shall establish a full-spectrum doula care pilot program to operate for three years, and concluding July 1, 2024, for all pregnant and postpartum Medi-Cal beneficiaries residing in the following 14 counties that are communities that experience the highest burden of birth disparities in the state: the Counties of Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, Santa Clara, and Solano.
(2) Any Medi-Cal beneficiary who is
pregnant as of July 1, 2021, and residing in a pilot program county shall be entitled to full-spectrum doula care. For a pregnancy that is carried to term, a pregnant person shall be eligible for at least four prenatal appointments, continuous support during labor and delivery, and at least eight postpartum appointments.
(3) Doula care shall be available to any Medi-Cal beneficiary without prior authorization or cost-sharing.
(4) (A) The department shall develop multiple payment and billing options for doula care. The department shall ensure all of the following:
(i) Any doula and community-based doula group participating in the pilot program shall be guaranteed payment within 30 days of submitting a claim for reimbursement.
(ii) An individual doula shall be able to obtain a National Provider Identifier number and be directly reimbursed by the department.
(iii) A community-based doula group shall be able to obtain reimbursement for any doula working as part of their group. If a community-based doula group employs doulas on a salaried basis, the department shall determine appropriate reimbursement rates based on the salaries provided and not on a per-client or per-service basis.
(B) (i) Payment for doulas shall include prenatal care, care during labor and delivery, postpartum care, and additional services that encompass a broader and more holistic vision of support for the pregnant person and their family or supporting loved ones.
(ii) In setting reimbursement rates for doula care, the department and
Medi-Cal managed care health plans shall take into consideration all of the following:
(I) The current rate for any existing, paid, community-based doula pilot programs that are already serving the Medi-Cal population.
(II) The cost of living in the pilot program counties.
(III) The sustainable living wage, as calculated in the pilot program counties.
(C) Presence at a stillbirth shall be reimbursed at the same rate as presence at a labor and delivery resulting in a live birth. Postpartum services shall also be covered for a stillbirth.
(D) There shall be a separate reimbursement for presence during miscarriage or abortion.
(E) The department and Medi-Cal managed care health plans shall separately reimburse for each prenatal and postpartum appointment. There shall also be separate reimbursement for administrative costs, including travel costs.
(F) If the pilot program continues beyond the first three years, the department shall make efforts to revisit the reimbursement rate as necessary to account for inflation, cost of living adjustments, and other factors.
(G) Pursuant to paragraph (4) of subdivision (d), a doula shall provide documentation that they have met the core competencies specified by the board, as described in paragraphs (1) and (2), inclusive, of subdivision (d), to be authorized by the department to be reimbursed under the Medi-Cal program.
(5) The department shall establish a centralized registry listing any
doula who is available to take on new clients in each of the 14 counties participating in the pilot program.
(A) The registry shall align with existing Medi-Cal provider directory requirements.
(B) The registry shall be searchable by Medi-Cal managed care health plan, geographical area, race and ethnicity of the doula, languages spoken by the doula, and any relevant specializations, including adolescents, homeless, substance use disorder, or refugee or immigrant populations.
(C) The information included on the registry shall be accessible by internet website, an application on a smartphone, paper, and telephone.
(6) Each Medi-Cal managed care health plan in each county participating in the pilot program shall provide information about the availability
of doula care in their materials and notices on reproductive and sexual health, family planning, pregnancy, and prenatal care. A Medi-Cal managed care health plan shall inform all pregnant and postpartum enrollees at each prenatal and postpartum appointment about the availability of doula care, the benefits of doula care, that doula care is available in addition to other prenatal and postpartum care, and how to obtain a doula.
(d) (1) The department shall convene a doula advisory board that shall decide on a list of core competencies required for doulas who are authorized by the department to be reimbursed under the Medi-Cal program. This board shall reconvene, as deemed necessary by the department, throughout the duration of the pilot program.
(2) Core competencies shall include, at a minimum, a demonstration of competency, through training or attestation of
equivalency or lived experience, in all of the following areas:
(A) Understanding of basic anatomy and physiology as related to pregnancy, the childbearing process, the postpartum period, breast milk feeding, and breast-feeding or chest-feeding.
(B) Capacity to employ different strategies for providing emotional support, education, and resources during the perinatal period.
(C) Knowledge of and ability to assist families with utilizing a wide variety of nonclinical labor coping strategies.
(D) Strategies to foster effective communication between clients, their families, support services, and health care providers.
(E) Awareness of integrative health care systems and various specialties of
care that a doula can provide information for in order to address client needs beyond the scope of the doula.
(F) Knowledge of community-based, state-funded and federally funded, and clinical resources available to the client for any need outside the doula’s scope of practice.
(G) Knowledge of strategies for supporting breast-feeding or chest-feeding, breast milk feeding, and lactation.
(3) At least two-thirds of the membership of the board shall be composed of practicing doulas who are providing doula care to Medi-Cal beneficiaries. At least two-thirds of the practicing doulas on the board shall be from communities experiencing the highest burden of birth disparities in the state, including doulas who are low income, doulas of color, doulas from and working in rural communities, and doulas who speak a language
other than English.
(4) In order to be authorized by the department to be reimbursed under the Medi-Cal program, a doula shall provide documentation that they have met the core competencies specified by the board. The board may also create alternative ways to meet the core competencies, such as by providing documentation of certification through another doula certification program that meets the required core competencies.
(5) The department shall seek to work with outside entities, such as foundations or nonprofits, to make trainings available at no cost that meet the core competencies to people who wish to become doulas who are from communities experiencing the highest burden of birth disparities in the state, including people who are low income, people of color, people from and working in rural communities, and people who speak a language other than English, who wish to become
doulas. These trainings shall be available in a manner that makes them accessible to these populations.
(e) The department shall allocate funding and resources for data collection, reporting, and analysis for purposes of conducting an evaluation of the pilot program.
(1) The department shall ensure that an evaluation of the pilot program begins no later than July 1, 2023, and that it be completed by January 1, 2024. The department shall submit a report to the appropriate policy and fiscal committees of the Legislature.
(2) The department shall include the board and relevant stakeholders, including practicing doulas, community-based doula groups, and consumer advocates, in the department’s evaluation design.
(3) The evaluation shall examine the impact of
the pilot program on a range of outcomes, including those focused on client and client family experience, prenatal and postpartum care engagement, doula workforce retention, cost savings, and clinical outcomes.
(f) If, after the first three years of the pilot program, the pilot program is achieving improved birth outcomes for persons using doulas and their babies, the department shall consider the feasibility of a statewide doula benefit for Medi-Cal beneficiaries during the perinatal period. If the pilot program is not achieving improved birth outcomes for persons using doulas and their babies during that period, the department may terminate the pilot program.
(g) This section shall remain in effect only until January 1, 2026, and as of that date is repealed.