2021 -- S 0484

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LC002105

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2021

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A N   A C T

RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE -- PERINATAL DOULA

SERVICES

     Introduced By: Senators Quezada, Cano, Mack, DiPalma, Felag, Lombardo, Calkin,
Acosta, Lawson, and Valverde

     Date Introduced: March 04, 2021

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. Findings.

     (1) In the United States, maternal mortality rates are among the highest in the developed

world and increased by twenty six and six tenths percent (26.6%) between 2000 and 2014.

     (2) Of the four million (4,000,000) American women who give birth each year, about seven

hundred (700) suffer fatal complications during pregnancy, while giving birth, or during the

postpartum period, and an additional fifty thousand (50,000) are severely injured.

     (3) It is estimated that half of the maternal mortalities in the United States could be

prevented and half of the maternal injuries in the United States could be reduced or eliminated with

better care.

     (4) In Rhode Island, the maternal mortality rate for the five (5) years 2013-2017 was eleven

and two tenths (11.2) per one hundred thousand (100,000) live births. During this five (5) year

period, there were six (6) cases of maternal deaths.

     (5) The severe maternal morbidity rate in RI for 2016 is two hundred nine (209) per ten

thousand (10,000) delivery hospitalizations.

     (6) In Rhode Island, there is also a large disparity for severe maternal morbidity among

non-Hispanic Black women three hundred out of ten thousand (306/10,000) compared to non-

Hispanic White women one hundred seventy nine and four tenths out of ten thousand

(179.4/10,000).

     (7) Data from the centers for disease control and prevention show that nationally, black

women are three (3) to four (4) times more likely to die from pregnancy-related causes than white

women. There are forty (40) deaths per one hundred thousand (100,000) live births for black

women, compared to twelve and four tenths (12.4) deaths per one hundred thousand (100,0000 live

births for white women and seventeen and eight tenths (17.8) deaths per one hundred thousand

(100,000) live births for women of other races.

     (8) Black women’s risk of maternal mortality has remained higher than white women’s

risk for the past six (6) decades.

     (9) Black women in the United States suffer from life-threatening pregnancy complications

twice as often as their white counterparts.

     (10) High rates of maternal mortality among black women span income and education

levels, as well as socioeconomic status; moreover, risk factors such as a lack of access to prenatal

care and physical health conditions do not fully explain the racial disparity in maternal mortality.

     (11) A growing body of evidence indicates that stress from racism and racial discrimination

results in conditions -- including hypertension and pre-eclampsia -- that contribute to poor maternal

health outcomes among black women.

     (12) Pervasive racial bias against black women and unequal treatment of black women

exist in the health care system, often resulting in inadequate treatment for pain and dismissal of

cultural norms with respect to health. A 2016 study by University of Virginia researchers found

that white medical students and residents often believed biological myths about racial differences

in patients, including that black patients have less-sensitive nerve endings and thicker skin than

their white counterparts. Providers, however, are not consistently required to undergo implicit bias,

cultural competency, or empathy training.

     (13) Currently, Oregon and Minnesota are two (2) states that permit Medicaid coverage for

doula services and New York City has launched a pilot program. Studies in Oregon, Minnesota,

and Wisconsin have shown that using a doula can save money.

     (14) Currently in the US, one in three (3) births is a C-section. They cost about fifty percent

(50%) more than conventional births. Using a doula reduces the chances of the need for a C-section

by twenty-five percent (25%).

     (15) According to the manuscript entitled "modeling the cost effectiveness of doula care

associated with reductions in preterm birth and cesarean delivery", in Minnesota, women who

received doula support had lower preterm and cesarean birth rates than Medicaid beneficiaries

regionally (4.7% vs. 6.3%, and 20.4% vs. 34.2%). Data show women with doula care had twenty-

two percent (22%) lower odds of preterm birth. Cost-effectiveness analyses indicate potential

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savings associated with doula support reimbursed at an average of nine hundred eighty six dollars

($986) (ranging from nine hundred twenty-nine dollars ($929) to one thousand forty-seven dollars

($1,047) across states).

     (16) To require Medicaid and private insurance coverage for continuous, one-to-one,

emotional and physical support services to pregnant persons by a trained, culturally competent,

registered perinatal doula.

     (17) Findings of a 2017 Cochrane, systematic review of twenty-six (26) trials involving

fifteen thousand eight hundred fifty-eight (15,858) women revealed that continuous support during

labor may improve outcomes for women and infants, including increased spontaneous vaginal

birth, shorter duration of labor, a decrease in cesarean birth, and decreases in instrumental vaginal

birth, use of any analgesia, use of regional analgesia, low five (5) minute Apgar score and negative

feelings about childbirth experiences. The study found no evidence of harms of continuous labor

support.

     (18) An update last year by Cochrane, found that pregnant women who received the

continuous support that doulas provide were thirty-nine percent (39%) less likely to have cesarean

birth.

     SECTION 2. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance

Policies" is hereby amended by adding thereto the following section:

     27-18-85. Perinatal doulas.

     (a) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state on or after July 1, 2022, shall provide coverage for the services of perinatal

doulas if the services are within the perinatal doulas' area of professional competence as defined by

regulations promulgated by the doula certification organization. No insurer or hospital or medical

service corporation may require supervision, signature, or referral by any other health care provider

as a condition of reimbursement, except when those requirements are also applicable to other

categories of health care providers. No insurer or hospital or medical service corporation or patient

may be required to pay for duplicate services actually rendered by both a perinatal doula and any

other health care provider. Direct payment for perinatal doulas shall be contingent upon services

rendered in accordance with rules and regulations promulgated by the doula certification

organization.

     (b) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state that is required to cover perinatal doula services as defined in subsection

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(a) of this section, shall report utilization and cost information related to perinatal doula services to

the office of the health insurance commissioner on or before July 1, 2023 and each July 1 thereafter.

The office of the health insurance commissioner shall define the utilization and cost information

required to be reported.

     (c) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare

supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily

injury or death by accident or both; and (9) Other limited benefit policies.

     SECTION 3. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

Corporations" is hereby amended by adding thereto the following section:

     27-19-77. Perinatal doulas.

     (a) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state on or after July 1, 2022, shall provide coverage for the services of perinatal

doulas if the services are within the perinatal doulas' area of professional competence as defined by

regulations promulgated by the doula certification organization. No insurer or hospital or medical

service corporation may require supervision, signature, or referral by any other health care provider

as a condition of reimbursement, except when those requirements are also applicable to other

categories of health care providers. No insurer or hospital or medical service corporation or patient

may be required to pay for duplicate services actually rendered by both a perinatal doula and any

other health care provider. Direct payment for perinatal doulas shall be contingent upon services

rendered in accordance with rules and regulations promulgated by the doula certification

organization.

     (b) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state that is required to cover perinatal doula services as defined in subsection

(a) of this section, shall report utilization and cost information related to perinatal doula services to

the office of the health insurance commissioner on or before July 1, 2023 and each July 1 thereafter.

The office of the health insurance commissioner shall define the utilization and cost information

required to be reported.

     (c) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare

supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily

injury or death by accident or both; and (9) Other limited benefit policies.

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     SECTION 4. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service

Corporations" is hereby amended by adding thereto the following section:

     27-20-73. Perinatal doulas.

     (a) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state on or after July 1, 2022, shall provide coverage for the services of perinatal

doulas if the services are within the perinatal doulas' area of professional competence as defined by

regulations promulgated by the doula certification organization. No insurer or hospital or medical

service corporation may require supervision, signature, or referral by any other health care provider

as a condition of reimbursement, except when those requirements are also applicable to other

categories of health care providers. No insurer or hospital or medical service corporation or patient

may be required to pay for duplicate services actually rendered by both a perinatal doula and any

other health care provider. Direct payment for perinatal doulas shall be contingent upon services

rendered in accordance with rules and regulations promulgated by the doula certification

organization.

     (b) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state that is required to cover perinatal doula services as defined in subsection

(a) of this section, shall report utilization and cost information related to perinatal doula services to

the office of the health insurance commissioner on or before July 1, 2023 and each July 1 thereafter.

The office of the health insurance commissioner shall define the utilization and cost information

required to be reported.

     (c) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare

supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily

injury or death by accident or both; and (9) Other limited benefit policies.

     SECTION 5. Chapter 27-41 of the General Laws entitled "Health Maintenance

Organizations" is hereby amended by adding thereto the following section:

     27-41-90. Perinatal doulas.

     (a) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state on or after July 1, 2022, shall provide coverage for the services of perinatal

doulas if the services are within the perinatal doulas' area of professional competence as defined by

regulations promulgated by the doula certification organization. No insurer or hospital or medical

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service corporation may require supervision, signature, or referral by any other health care provider

as a condition of reimbursement, except when those requirements are also applicable to other

categories of health care providers. No insurer or hospital or medical service corporation or patient

may be required to pay for duplicate services actually rendered by both a perinatal doula and any

other health care provider. Direct payment for perinatal doulas shall be contingent upon services

rendered in accordance with rules and regulations promulgated by the doula certification

organization.

     (b) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state that is required to cover perinatal doula services as defined in subsection

(a) of this section, shall report utilization and cost information related to perinatal doula services to

the office of the health insurance commissioner on or before July 1, 2023 and each July 1 thereafter.

The office of the health insurance commissioner shall define the utilization and cost information

required to be reported.

     (c) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare

supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily

injury or death by accident or both; and (9) Other limited benefit policies.

     SECTION 6. Title 40 of the General Laws entitled "HUMAN SERVICES" is hereby

amended by adding thereto the following chapter:

CHAPTER 8.16

RHODE ISLAND DOULA REIMBURSEMENT ACT

     40-8.16-1. Short title.

     This act shall be known and may be cited as the "Rhode Island Doula Reimbursement Act."

     40-8.16-2. Definitions.

     As used in this chapter:

     (1) "Accountable care" means an accountable care entity that helps coordinate the medical

care provided to Medicaid-eligible patients.

     (2) "Antepartum" means the period of pregnancy before labor or childbirth. Services

provided during this period are rendered to the pregnant individual.

     (3) "Community-based organization (CBO)" means a public or private nonprofit

organization that is representative of a community or significant segments of a community and

engaged in meeting that community’s needs in the areas of social, human, or health services.

     (4) "Competencies" means key skills and applied knowledge necessary for doulas to be

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effective in the work field and carry out their roles.

     (5) "Contact hour" means an hour of classroom, group, or distance learning training, and

does not include homework time, preparatory reading, or practicum.

     (6) "Doula" or "perinatal doula" means a trained professional providing continuous

physical, emotional and informational support to a pregnant individual, from antepartum,

intrapartum, and up to the first twelve (12) months of the postpartum period. Doulas also provide

assistance by referring childbearing individuals to CBOs and certified and licensed perinatal

professionals in multiple disciplines.

     (7) "Doula certification organization" means the Rhode Island certification board.

     (8) "Doula services" means services provided by a certified doula as enumerated in § 40-

8.16-4.

     (9) Doula training organization" means an entity, nationally or internationally, recognized

by the doula certification organization for training perinatal doulas whose educational requirements

includes the core curriculum topics described in this chapter. These doula training organizations

shall include, but not be limited to, the International Childbirth Education Association (ICEA), the

Doulas of North America (DONA), ToLabor, Birthworks, the Childbirth and Postpartum

Professional Association (CAPPA), Childbirth International, the International Center for

Traditional Childbearing, and Commonsense Childbirth, Inc.

     (10) "Fee-for-service" means a payment model where services are unbundled and paid for

separately.

     (11) "Insurer" means every nonprofit medical service corporation, hospital service

corporation, health maintenance organization, program that provides free or low-cost health

coverage to low-income individuals, or other insurer offering and insuring health services; the term

shall in addition include any entity defined as an insurer under § 42-62-4.

     (12) "International board-certified lactation consultant" or "IBCLC" means a health care

professional who specializes in the clinical management of breastfeeding.

     (13) "Intrapartum" means the period of pregnancy during labor and delivery or childbirth.

Services at this period are rendered to the pregnant individual.

     (14) "Managed care" means providing for the delivery of Medicaid health benefits and

additional services through contracted arrangements between state Medicaid agencies and managed

care organizations (MCOs) that accept a set per member per month (capitation) payment for these

services.

     (15) "Postpartum" means one year after a pregnancy ends.

     (16) "Private insurers" means insurance schemes financed through private health

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premiums, i.e., payments that a policyholder agrees to make for coverage under a given insurance

policy, where an insurance policy generally consists of a contract that is issued by an insurer to a

covered person.

     (17) "Registry" means a list of doulas, maintained by the doula certification organization,

that satisfies the qualifications for registration set forth by the doula certification organization.

     (18) "State medical assistance program" means a federal financial aid of medical expenses

of needy persons.

     40-8.16-3. Coverage of doula services.

     (a) Doula services shall be eligible for coverage throughout Rhode Island for child-bearing

individuals through private insurance and Medicaid.

     (b) Doula services shall be covered by the state medical assistance program if the doula

seeking reimbursement has completed the following:

     (1) Applied for and being given a National Provider Identification Number (NPI#);

     (2) Completed and received approval for all required state medical assistance program

provider enrollment forms;

     (3) Provided a copy of a doula training certificate or an authentic, original, signed and dated

letter from a doula training organization verifying that the doula has attended and completed its

training or curriculum. To be considered authentic, a letter must be on the doula training

organization’s letterhead and signed by an authorized representative;

     (4) Provided a signed and dated attestation of being trained in the following competencies

through one program or a combination of programs, the result of which is meeting all doula core

competency requirements outlined below:

     (i) An education that includes any combination of childbirth education, birth doula training,

antepartum doula training, and postpartum doula training;

     (ii) Attendance at a minimum of one breastfeeding class or holding a valid lactation

certification;

     (iii) Attendance at a minimum of one childbirth class or valid childbirth education

certification;

     (iv) Completion of cultural competency training;

     (v) Completion of HIPAA / client confidentiality training;

     (vi) Completion of CPR certification for children and adults; and

     (vii) Completion of SafeServ certification for meal preparation.

     (c) Once enrolled as a state medical assistance program provider, a doula shall be eligible

to enroll as a provider with fee-for-service, managed care, and accountable care payers, affiliated

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with the state medical assistance program.

     (d) In order to follow federal Medicaid and private insurance requirements applicable to

covered services, doula services shall be reimbursed on a fee-for-service schedule.

     (e) Notwithstanding the provisions of subsection (b) of this section, a doula who can

provide alternative and sufficient documentation of training and practice as a doula for a period of

at least six (6) months prior to the passage of this chapter shall not be required to provide the

certificate or letter required by subsection (b)(3) of this section, and shall have six (6) months to

complete the training requirements of subsection (b)(4) of this section.

     40-8.16-4. Scope of practice.

     A doula may provide services to a pregnant individual such as:

     (1) Services to support pregnant mothers and people, improve birth outcomes, and support

new mothers and families with cultural specific antepartum, intrapartum, and postpartum services,

referrals, and advocacy;

     (2) Advocating for and supporting physiological birth, breastfeeding, and parenting for

their client;

     (3) Supporting the antepartum, intrapartum, and postpartum period with traditional comfort

measures and educational materials, as well as assistance during the transition to parenthood in the

initial postpartum period through home visits;

     (4) Empowering individuals and families with evidenced-based information to choose best

practices for birth, breastfeeding, and infant care;

     (5) Providing continuous support to the laboring individual until the birth of the baby at

any location of delivery;

     (6) Referring clients to their appropriate provider for medical advice for care outside of the

doula scope of practice;

     (7) Working as a member of the individual's multidisciplinary team; and

     (8) Offering evidence-based information on newborn and infant feeding, emotional and

physical recovery from childbirth, and other issues related to the antepartum, intrapartum, and

postpartum period.

     (b) A doula shall not engage in the "practice of medicine," as defined in § 5-37-1.

     40-8.16-5. Establishing a statewide registry of perinatal doulas.

     (a) The doula certification organization shall promulgate rules and regulations that

establish a statewide certification for perinatal doulas solely for the purpose of establishing the

qualifications necessary for doulas to qualify for reimbursement under this chapter.

     (b) Individuals seeking entry on a statewide registry of doulas shall, at a minimum:

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     (1) Be at least eighteen (18) years of age;

     (2) Not be listed on the doula certification organization’s provider exclusion list;

     (3) Successfully complete training in all competencies as outlined in § 40-8.16-3;

     (4) Receive and maintain certification by an approved doula certification organization; and

     (5) Maintain personal liability insurance either individually or through a collaborative,

association, or business of doulas that can prove liability insurance coverage for all doulas working

through, with or under them.

     40-8.16-6. Payment for doula services.

     (a) Medical assistance coverage for doula services:

     (1) Chapter 8 of title 40 shall include "doula services" as described in §§ 40-8.16-4 and 40-

8.16-5; and

     (2) The coverage available for doula services per pregnancy, regardless of the number of

infants involved, which shall be billed on a fee-for-service basis, shall be available through one

year postpartum, shall not be less than eight hundred fifty dollars ($850.00), and shall be eligible

towards the following activities, such as: prenatal visits, physical and emotional support during a

childbearing individual's labor and birth, telephone or virtual communications between doula and

client, time spent being on call for the birth, postpartum visits, and time spent on administrative

time, such as documentation or paperwork.

     (b) Every individual or group hospital or medical expense insurance policy or individual

or group hospital or medical services plan contract delivered, issued for delivery, or renewed in this

state shall provide coverage for the services of perinatal doulas if the services are within the

perinatal doulas' area of professional competence as defined by regulations promulgated by the

doula certification organization. No insurer or hospital or medical service corporation may require

supervision, signature, or referral by any other health care provider as a condition of

reimbursement. No insurer or hospital or medical service corporation or patient may be required to

pay for duplicate services actually rendered by both a perinatal doula and any other health care

provider. Direct payment for perinatal doulas shall be contingent upon services rendered in

accordance with rules and regulations promulgated by the doula certification organization.

     (c) The state medical assistance program, managed care organizations, and accountable

care payers that are required to cover perinatal doula services under § 40-8.16-3, shall report

utilization and cost information related to perinatal doula services to the executive office of health

and human services on or before July 1, 2023 and each July 1 thereafter. The executive office of

health and human services shall define the utilization and cost information required to be reported.

     (d) This chapter shall not apply to insurance coverage providing benefits for: (1) Hospital

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confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare

supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily

injury or death by accident or both; and (9) Other limited benefit policies.

     SECTION 7. This act shall take effect on July 1, 2022.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE -- PERINATAL DOULA

SERVICES

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     This act would provide for medical assistance health care for expectant mothers and would

establish medical assistance coverage and reimbursement rates for perinatal doula services.

     This act would take effect on July 1, 2022.

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