A doula is a trained, non-medical professional who offers continuous emotional, physical, and informational support before, during, and after childbirth. These services aim to improve outcomes for both mother and baby by providing personalized care throughout the perinatal period. Determining coverage in California requires examining the state’s public programs and the policies of private carriers.
California’s Mandate for Medi-Cal Coverage
California significantly expanded access to doula care by adding the service as a covered benefit under Medi-Cal, the state’s Medicaid program, beginning January 1, 2023. This change resulted from legislative efforts to address maternal health disparities and improve birth outcomes. Coverage is mandatory for all Medi-Cal recipients, regardless of whether they are enrolled in a fee-for-service plan or a Managed Care Plan.
The comprehensive benefit covers support services throughout pregnancy and up to one year postpartum. Services include an extended initial visit, typically lasting up to 90 minutes, and a total of eight subsequent visits for prenatal or postpartum support. The program also covers continuous support during labor and delivery, including for vaginal births and cesarean sections, and support for pregnancies that end in miscarriage or abortion. For complex recovery needs, the plan allows for two extended postpartum visits, each lasting up to three hours.
Coverage Status for Private Insurance Plans
Currently, there is no statewide mandate compelling all private health insurance companies in California to cover doula services. Coverage remains inconsistent, often depending on the specific type of plan an individual holds, particularly for state-regulated plans.
A state law signed in late 2023 requires many state-regulated public and private health plans to implement a health equity plan by January 1, 2025. This plan must address racial disparities in maternal and infant outcomes and encourages the use of doula care. Although this measure does not create a universal coverage mandate, it has prompted major carriers to establish or expand their doula benefit programs.
Many large private insurers, including Kaiser Permanente, Health Net, and Anthem Blue Cross, have begun offering coverage or pilot programs. Individuals with private insurance must contact their insurer directly to verify specific coverage, including limits on visits or reimbursement amounts, as plan benefits vary widely. Coverage may also be available through plans for public employees, such as those offered by the California Public Employees’ Retirement System (CalPERS).
Navigating the Reimbursement Process
For doula services to be reimbursed through Medi-Cal, the doula must be officially enrolled as a Medi-Cal provider with the Department of Health Care Services (DHCS). Enrollment requires doulas to meet specific qualifications, including being at least 18 years old and possessing current adult and infant CPR certification. They must also attest to completing basic training on HIPAA.
To initiate coverage, a recommendation for doula services from a licensed practitioner, such as a physician or nurse midwife, is required. This requirement is often satisfied by a statewide standing order that applies automatically to all eligible Medi-Cal members.
For the doula to be paid, they must utilize specific procedure codes (CPT or HCPCS codes) when submitting a claim to the state or the managed care plan. These codes categorize the service provided, such as an extended initial visit or labor support.
All claims must be submitted with a specific modifier, such as ‘XP,’ which signals that the doula is a separate practitioner from the medical provider. This modifier ensures the doula’s non-medical services are distinct from the physician’s bill. If a member requires more than the standard number of postpartum visits, a second, individualized recommendation from a licensed provider is required to authorize up to nine additional visits.
Non-Insurance Payment Alternatives
For individuals whose insurance plans do not cover doula support, several financial options can make the services more accessible. Doula services are considered a qualified medical expense under Internal Revenue Service guidelines. This designation allows individuals to pay for the service using pre-tax funds from a Flexible Spending Account (FSA) or a Health Savings Account (HSA).
Using FSA or HSA funds typically requires obtaining a Letter of Medical Necessity (LMN) from a healthcare provider, specifying that the doula support is medically relevant to the health of the mother or child. The doula must provide a detailed invoice, often called a superbill, which the client submits to their FSA/HSA administrator for reimbursement.
Some doulas offer payment plans or reduced rates through a sliding scale based on a client’s income. Families can also look for community-based organizations or grant programs that offer financial assistance for doula services.
When insurance coverage is denied, paying out-of-pocket is an option. The doula’s superbill can still be submitted to the insurance company to see if any portion of the expense can be applied toward an out-of-network deductible. This requires proactively discussing billing and payment expectations with the doula before services begin.