RE: Doula Services IMPACTED PLANS: Medicaid, HIV SNP, HARP and EP
TO: MetroPlusHealth Doula and OB/GYN Providers
RE: Doula Services
IMPACTED PLANS: Medicaid, HIV SNP, HARP and EP
Dear MetroPlusHealth Provider,
Effective April 1, 2025, MetroPlusHealth will cover doula services during pregnancy and up to 12 months after the end of pregnancy, regardless of how the pregnancy ends.
Provider Requirements
Doula services may be provided through a Medicaid-enrolled individual provider, a
doula-only group or a multi-professional group.
Individual Doula Providers:
- Do not require supervision.
- Must enroll as a Medicaid provider.
- The enrolled doula is the billing provider.
Doula Group:
- The Medicaid-enrolled doula-only group or multi-professional group may serve as the billing provider when the doula providing the services is enrolled in Medicaid and affiliated with that group.
Service Locations
Doula services may be provided in a Hospital, Clinic or Community and Home Settings.
Eligibility
If your patient is pregnant or has been pregnant within the last 12 months, she is eligible for doula services. Patients are eligible for these services for each pregnancy.
Services Not Eligible for Medicaid Reimbursement
The following services are NOT eligible for Medicaid reimbursement under the doula services benefit:
- Medical and healthcare-related services including case management, that require a license.
- Services outside the level of training and certification the doula has attained.
- Services that duplicate another covered Medicaid service or that are otherwise billed.
- Advocacy for issues not directly related to the Medicaid member’s health or social care needs.
- Services that do not include direct engagement with the Medicaid member.
- Group doula services or group classes.
- Childcare.
- Shopping.
- Placenta encapsulation.
- Vaginal steams.
- Still and video photography
- Birthing ceremonies.
Informing a Medicaid Member about Medicaid Services from Non-Doula Providers
If a Medicaid member requests one of the services listed below that is not a covered doula service, the doula should educate the Medicaid member that they are eligible for coverage of these services, if medically necessary and provided by a qualified Medicaid provider. These services may include, but are not limited to:
- Behavioral health services.
- Clinical case management or care coordination.
- Family planning and reproductive health services.
- Smoking cessation agents.
- Vision care and eyeglasses.
- Medicine and supplies.
- Durable medical equipment such as a breast/chest pump.
- Health care services related to pregnancy, childbirth and postpartum.
- Lactation counseling and group lactation patient education.
- Medical Nutrition Therapy services.
- Transportation to and from health appointments
- Emergency ambulance transportation.
Members should visit https://metroplus.org/members/ or call member services at 1.800.303.9626 to find out more or to get help with accessing these benefits.
If our Medicaid member has not received services prior to April 1, 2025, doula services will be reimbursed by MetroPlusHealth (MPH) only if:
- The doula is enrolled in the Medicaid fee-for-service program and contracted with the MPH Plan.
- Doula service providers who submit claims may use a HCFA 1500 to bill for these services.
Billing Criteria & Limitations
Perinatal Visits
- Up to (8) eight perinatal visits per pregnancy.
- Perinatal visits can occur in-person or via telehealth.
- Continuous support while in labor and during childbirth.
- Eligibility services restart if a member becomes pregnant within 12 months following a prior pregnancy.
- Any unused doula services from previous pregnancies will not carry over
Labor and Delivery Encounter
- One Labor & Delivery encounter per pregnancy is reimbursable.
- A licensed perinatal services provider must be in attendance for the doula to be reimbursed.
- Labor and delivery doula services must be provided to the member in-person except in extenuating circumstances, such as illness, emergency, or unexpected labor and birth, in which case the current telehealth policy will apply.
| HCPCS Code | Diagnosis Code | Code Description | Service Description | Per Pregnancy Allowance |
|---|---|---|---|---|
| T1032 | Z32.2 (Prenatal/pregnancy) or Z32.3 (postpartum) | “Services provided by a doula birth worker” | Perinatal Service: Prenatal or postpartum doula support (minimum of 30 minutes) | Up to and including 8 times |
| T1033 | Z32.2 | “Services provided by a doula birth worker, per diem” | Labor and Delivery: In-person doula support during labor and birth( no time minimum, must be present for the birth) | Up to and including 1 time |
Not Billable: Language Interpretation Billing Guidelines
- The doula cannot bill for interpretation services provided by her/himself.
- The service must be provided by a qualified/certified independent third-party vendor (e.g., telephonic interpretation service) to members limited English proficiency and communication services for people who are deaf and hard of hearing.
- The certified billing provider will bill using the following CPT code:
| HCPCS Procedure Code | Billable Units |
|---|---|
| T1013 | One Unit: Includes a minimum of eight up to 22 minutes of medical language interpreter services. interpreter services. |
| Two Units: Includes 23 or more minutes of medical language interpreter services. |
Please refer to the link below for the NYS Medicaid Doula Services Provider Manual:
https://www.emedny.org/ProviderManuals/Doula/PDFS/Doula_Policy_Guidelines.pdf
For additional information, please visit Provider Enrollment – Doula and Doula Policy Guidelines.
If you have any questions regarding this memo, please contact MetroPlusHealth at
ProviderRelationsOps@metroplus.org.
Thank you.
MetroPlusHealth