Challenges and Strategies in Expanding Non-Traditional Pregnancy-Related Services: Findings from a Survey of State Medicaid Programs

Maternal and infant mortality rates in the U.S. are far higher than those in similarly large and wealthy countries, with people of color at increased risk for poor maternal and infant health outcomes compared to their White peers. As a result, policy makers at both the federal and state levels are increasingly focusing on improving maternal and infant health outcomes and reducing disparities. At the federal level, the Consolidated Appropriations Act made permanent the option for states to extend Medicaid postpartum coverage to 12 months. As of April 2024, 46 states have implemented the 12-month extension. In addition, the Biden administration has identified maternal health as a priority, and their recent budget proposal includes enhanced efforts to improve maternal care. The nation’s governors, acting through the National Governors Association, have recognized the urgent need for action releasing the Tackling the Maternal and Infant Health Crisis: A Governor’s Playbook in July 2023. Also, in the 2023 Medicaid budget survey, conducted by KFF and Health Management Associates (HMA), nearly a third of all responding states mentioned initiatives to improve maternal and child health as a top priority for the year ahead.

The Medicaid program has potential to influence maternal and infant health outcomes as it finances about 4 in 10 U.S. births. While Medicaid’s coverage of maternity care has traditionally focused on prenatal and postpartum physician visits and labor and delivery care, a growing number of states have added new pregnancy or postpartum benefits in recent years, such as doula services, lactation services, and home visiting programs, to promote better maternal and infant health outcomes and reduce racial/ethnic health disparities.

To better understand state initiatives to expand Medicaid coverage of these less commonly covered pregnancy-related services, the 23^rd annual Medicaid budget survey, conducted by KFF and HMA asked states about strategies and challenges in promoting access to “non-traditional pregnancy-related care and services” and included childbirth education classes, doula services, home births, and home visits by lactation consultants as examples. The budget survey question was limited to services that were separately reimbursed as of July 1, 2023, outside of a hospital bundled payment and not as a component of an office or clinic visit. Maternity care is often reimbursed as a bundled payment that covers all professional services provided during the perinatal period, including prenatal care, labor and delivery, and postpartum care. These bundled payments do not typically cover non-traditional services. A previous KFF survey collected additional detail on pregnancy-related services included in bundled rates as of July 2021 and also identified specific pregnancy-related services provided by each state – detail that was not collected by the 2023 budget survey.

Forty-eight states (including DC) responded to the survey, although response rates for specific questions varied. The full report highlights state action to expand pregnancy and postpartum benefits including doula services, lactation supports, and home visiting programs.

What types of non-traditional (less commonly covered) pregnancy-related services are states separately reimbursing for?

As of July 1, 2023, more than two-thirds of responding states (32 of 47) reported coverage of at least one separately reimbursed, non-traditional pregnancy-related service. The following list describes services mentioned in state responses. A broader group of states may provide these services (like doula services) through a bundled payment.

• Doula services. Doula services were the most frequently mentioned non-traditional service. Doulas are professionals who support pregnant and postpartum people by providing a variety of services throughout the pregnancy and postpartum period, including visits during the prenatal period, labor coaching and support at the time of delivery, and postpartum care and assistance. Doula services are linked to more positive delivery outcomes, including reductions in C-sections, premature deliveries, and length of labor.
• Childbirth and/or parenting classes. There are a variety of education-related support services that can aid pregnant and postpartum individuals with pregnancy, delivery, and childrearing. These include childbirth education classes, infant and parenting education classes, and group prenatal care (e.g., Centering Pregnancy group prenatal care). While some states cover these services through their Medicaid programs, some states offer these services through other public health programs.
• Outpatient lactation supports. Lactation support can be provided in multiple settings in the postpartum period, including in the hospital before discharge, at outpatient visits, or at home. Many Medicaid enrollees are also eligible for WIC, which provides lactation support.
• Lay or “direct entry” midwife services as a non-traditional covered service. Midwives use a holistic, person-centered care model that has been linked to better maternal and infant outcomes. Most states only include certified nurse-midwives (CNMs) in their provider networks, as required by federal law, but recent state action has extended Medicaid coverage to other midwife providers, including midwives who may be credentialed to provide childbirth support and services despite not having a formal nursing education. States use various terms to refer to midwives without a nursing degree, including licensed midwife, direct entry midwives, licensed lay midwife, certified midwives, certified professional midwives, traditional midwife, and verifiable midwife.
• Home births. International studies suggest that home births may be as safe as hospital births for low-risk pregnant individuals and infants when they are part of an integrated and regulated system. Nevertheless, home births account for a small share of births in the U.S., although there has been growing interest since the start of the COVID-19 pandemic. Doulas, midwives, or physicians may be in attendance for home births.
• Other services. Other covered pregnancy-related services mentioned by at least one state as “non-traditional” include specialized care management or care coordination programs, home visiting programs, and pregnancy care via telehealth.

In addition to state efforts, there are federal efforts to expand access to non-traditional pregnancy-related services. In June 2022, the White House identified workforce expansion and diversification as one of its five goals for addressing the nation’s maternal health crisis. This goal includes, in part, promotion of doulas, midwives, and community health workers. Subsequently, CMS announced the Transforming Maternal Health (TMaH) Model in December 2023. The new model aims to improve maternal and infant health outcomes and reduce disparities by providing technical assistance and grant funding to up to 15 state Medicaid agencies. TMaH will help participating states improve access to care, including care from doulas and perinatal community health workers. The Biden Administration’s recently proposed budget also directs more than $300 million to improving maternal health, including an additional $5 million to grow and diversify the doula workforce. The proposed budget also includes an optional Medicaid maternal health support benefit aiming to address equity issues in maternal health outcomes. The benefit would include coverage of doulas, community health workers, and peer support workers. However, with a divided Congress, those budget proposals are not likely to be passed this year.

What are challenges and strategies to expand access to non-traditional pregnancy-related services?

While non-traditional pregnancy-related services have the potential to improve maternal health outcomes and reduce disparities, access-related challenges may limit utilization, despite state efforts to establish coverage and encourage take-up. Documented access-related barriers include workforce shortages, restrictive provider training/licensure requirements, low reimbursement rates, billing complexities, and quantity limitations. The 2023 Medicaid budget survey asked states about these challenges and initiatives to address them. The survey divided these challenges into six categories: 1) workforce shortages, 2) provider enrollment//training/certification/licensing needs, 3) low reimbursement rates, 4) billing challenges, 5) quantity limitations on hours/visits allowed, and 6) “other.”

Twenty-five states reported a challenge in at least one specified category. The following section describes the challenges most frequently mentioned by states and the approaches cited for addressing those challenges, if any. In some cases, initiatives to respond to challenges involve collaborative efforts between Medicaid agencies and managed care organizations (MCOs), state-level provider licensing boards, and/or private licensing entities.

The most frequently cited challenges related to provider enrollment, training, certification, or licensing. Eighteen states reported challenges in this category. States have varying approaches and standards for certifying or licensing non-traditional providers. For example, doulas have not historically received state medical board licenses, though many do receive certifications from private entities (which may involve significant training and cost). However, to receive Medicaid reimbursement, doulas must enroll as Medicaid providers and meet the state Medicaid department’s relevant qualification standards. Some doulas find this process to be challenging as it can involve costly and administratively burdensome training standards. Also, midwives can have varying levels of education and training (as described above) which could impact their ability to meet Medicaid enrollment requirements or limit the settings for which they can receive Medicaid reimbursement, particularly those who have not received nursing degrees.

Only a few states mentioned initiatives to address these challenges: Michigan has developed provider support materials, trainings, and toolkit information; Montana reported developing an outreach and education plan; New Jersey Medicaid staff are working with MCOs and the New Jersey Department of Health-funded Doula Learning Collaborative to provide technical assistance; in Virginia the Department of Health and the Virginia Certification Board are working to increase the number of doula training entities; and Wisconsin reported that it planned to update the state’s administrative code to allow additional non-traditional providers to become certified.

Seventeen states reported workforce shortage challenges. Several states reported that broader health care workforce shortages were also affecting the non-traditional pregnancy-related services workforce. States specifically mentioned shortages of doulas, lactation consultants, and providers of childbirth classes. In addition to widespread shortages brought on by the COVID-19 pandemic, states cited training requirements (discussed above) as a barrier to growing the non-traditional workforce. A few states noted specific initiatives to address workforce shortages in rural areas. For example, Kansas allows access to lactation consultants via telehealth to help improve access in rural areas, and New Mexico uses midwife services to improve access to care in rural areas with existing physician/OBGYN shortages.

At least four states described efforts to increase their doula workforce: New Jersey is working with non-profits, MCOs, and their sister agencies to increase access to accepted doula trainings; Virginia is recruiting more doulas to create an adequately sized doula workforce for their expected number of pregnant enrollees; Michigan is financing doula training courses, and Maryland is collaborating with their state’s Maternal and Child Health Bureau to recruit more doulas.

Fifteen states cite billing challenges for non-traditional pregnancy-related service providers. Several states noted that these providers are not familiar with Medicaid and MCO billing processes, which may be complex and time-consuming resulting in delays in payments as well as frustrations working with Medicaid agencies and MCOs. For example, Michigan reported that providers don’t always have the technology needed for Medicaid billing and New Jersey reported that doulas are not accustomed to the amount of paperwork for Medicaid billing. Some states are providing technical assistance, resources, and training to help providers navigate billing. For example, New Mexico reported exploring ways to streamline the billing process and Virginia is working with MCOs to provide support to doulas in Medicaid and MCO billing.

Eleven states reported low reimbursement rates for non-traditional providers as a challenge. Low reimbursement rates can disincentivize providers from enrolling in Medicaid, limiting access for Medicaid enrollees. This has been a barrier for perinatal professionals for many years. For example, in California implementation of Medicaid coverage for doula services was delayed due to disputes between the state and doula organizations over reimbursement rates. Non-traditional providers emphasize patient education and support, which means that they often spend extensive time with patients, and many have reported that Medicaid rates are not sufficient for covering their costs. Some states reported actions to address low reimbursement rates. Iowa and Indiana are evaluating their current reimbursement rates; Ohio is matching reimbursement rates to other programs, like the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program; Kansas has plans to increase reimbursement rates for lactation services, and Wisconsin recently increased rates for prenatal care coordination services.

Five states reported challenges related to quantity limitations on hours or visits for doula services, childbirth education classes, and/or lactation supports. For example, while Virginia Medicaid currently reimburses doula services for up to eight prenatal/postpartum visits (90 minutes for the initial prenatal visit and one hour for other visits), the state reported that doulas have expressed the desire to have more allowed visits – e.g., a total of 12-16 visits, 6-8 prenatal and 6-8 postpartum visits — and longer visits. Also, Indiana reported that efforts were underway to develop doula-specific service limitations as the Community Health Worker benefit currently used to reimburse doula services was subject to visit limits that were “not conducive to doula activities.”

Four states commented on “other” challenges: California commented on working with hospitals to allow doulas access during birth; Georgia cited access to services in rural areas as a challenge; Missouri noted as a challenge the need to disenroll members from MCOs for a home birth to be covered through fee-for-service reimbursement payment; and Oklahoma commented on the challenge of structuring the doula services benefit in a way that allows doulas and patients to be matched on the basis of race, ethnicity, and language.