2021 -- H 5929 SUBSTITUTE A

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LC002088/SUB A/5

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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: Representatives Ranglin-Vassell, Cassar, Kislak, Donovan, Diaz, Ajello,
Cortvriend, Carson, Speakman, and Knight

     Date Introduced: February 25, 2021

     Referred To: House Finance

     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

LC002088/SUB A/5 - Page 2 of 9

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) 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.

     (17) 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) As used in this section, "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 community-based organizations

and certified and licensed perinatal professionals in multiple disciplines.

     (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 on or after July 1, 2022, shall provide coverage for the services of perinatal

doulas in accordance with each health insurers' respective principles and mechanisms of

reimbursement, credentialing, and contracting, if the services are within the perinatal doulas' area

of professional competence as defined by the doula certification standard developed and maintained

by the Rhode Island certification board in collaboration with the department of health, and are

currently reimbursed when rendered by any other health care provider. 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.

LC002088/SUB A/5 - Page 3 of 9

     (c) 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 subsections

(a) and (b) 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.

     (d) 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) As used in this section, "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 community-based organizations

and certified and licensed perinatal professionals in multiple disciplines.

     (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 on or after July 1, 2022, shall provide coverage for the services of perinatal

doulas in accordance with each health insurers' respective principles and mechanisms of

reimbursement, credentialing, and contracting, if the services are within the perinatal doulas' area

of professional competence as defined by the doula certification standard developed and maintained

by the Rhode Island certification board in collaboration with the department of health, and are

currently reimbursed when rendered by any other health care provider. No insurer or hospital or

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

LC002088/SUB A/5 - Page 4 of 9

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.

     (c) 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 subsections

(a) and (b) 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.

     (d) 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 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) As used in this section, "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 community-based organizations

and certified and licensed perinatal professionals in multiple disciplines.

     (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 on or after July 1, 2022, shall provide coverage for the services of perinatal

doulas in accordance with each health insurers' respective principles and mechanisms of

reimbursement, credentialing, and contracting, if the services are within the perinatal doulas' area

LC002088/SUB A/5 - Page 5 of 9

of professional competence as defined by the doula certification standard developed and maintained

by the Rhode Island certification board in collaboration with the department of health, and are

currently reimbursed when rendered by any other health care provider. 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.

     (c) 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 subsections

(a) and (b) 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.

     (d) 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) As used in this section, "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 community-based organizations

and certified and licensed perinatal professionals in multiple disciplines.

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

LC002088/SUB A/5 - Page 6 of 9

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 in accordance with each health insurers' respective principles and mechanisms of

reimbursement, credentialing, and contracting, if the services are within the perinatal doulas' area

of professional competence as defined by the doula certification standard developed and maintained

by the Rhode Island certification board in collaboration with the department of health, and are

currently reimbursed when rendered by any other health care provider. 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.

     (c) 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 subsections

(a) and (b) 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.

     (d) 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.

LC002088/SUB A/5 - Page 7 of 9

     SECTION 6. 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

***

     This act would provide for health care coverage by health insurance companies for

perinatal doula services.

     This act would take effect on July 1, 2022.

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