2019 -- H 5609

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LC001841

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2019

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A N   A C T

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

SERVICES

     

     Introduced By: Representatives Ranglin-Vassell, Kislak, Lyle, Williams, and
Blazejewski

     Date Introduced: February 27, 2019

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

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     SECTION 1. Findings.

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

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

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

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

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

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

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

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with better care.

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

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

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

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

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thousand (10,000) delivery hospitalizations.

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

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

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

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(179.4/10,000).

 

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

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

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

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

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(100,0000 live births for White women and seventeen and eight tenths (17.8) deaths per one

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

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

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risk for the past six (6) decades.

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

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complications twice as often as their white counterparts.

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

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

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

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

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discrimination results in conditions -- including hypertension and pre-eclampsia -- that contribute

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to poor maternal health outcomes among black women.

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

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

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

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

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

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

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bias, cultural competency, or empathy training.

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

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

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

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

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

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C-section by twenty-five percent (25%).

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

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

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

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

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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

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

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($1,047) across states).

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

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

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registered perinatal doula.

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

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

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

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

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

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

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continuous labor support.

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

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

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cesarean birth.

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     SECTION 2. Title 40 of the General Laws entitled "HUMAN SERVICES" is hereby

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amended by adding thereto the following chapter:

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CHAPTER 8.16

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RHODE ISLAND DOULA REIMBURSEMENT ACT

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     40-8.16-1. Short title.

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

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Act."

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     40-8.16-2. Definitions.

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     As used in this chapter:

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     (1) “Accountable care” means an accountable care entity that helps coordinate the

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medical care provided to Medicaid-eligible patients.

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

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provided during this period are rendered to the pregnant individual.

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

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

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

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     (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.

 

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

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

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     (6) “Department” means the Rhode Island department of health.

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     (7) “Doula” or “perinatal doula” means a trained professional providing continuous

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

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intrapartum, and up to the first six (6) weeks of the postpartum period. Doulas also provide

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

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professionals in multiple disciplines.

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     (8) “Doula certification organization” means an entity, nationally or internationally,

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recognized by the department for training and certifying perinatal doulas whose educational

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

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certification organizations shall include, but not be limited to, the International Childbirth

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Education Association (ICEA), the Doulas of North America (DONA), ToLabor, Birthworks, the

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Childbirth and Postpartum Professional Association (CAPPA), Childbirth International, the

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International Center for Traditional Childbearing, and Commonsense Childbirth, Inc.

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     (9) “Doula services” means services provided by a certified doula as enumerated in § 40-

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8.16-4.

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

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for separately.

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

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

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

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

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

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professional who specializes in the clinical management of breastfeeding.

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

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Services at this period are rendered to the pregnant individual.

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

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additional services through contracted arrangements between state Medicaid agencies and

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managed care organizations (MCOs) that accept a set per member per month (capitation)

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payment for these services.

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     (15) “Postpartum” means the period following childbirth or the end of pregnancy.

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     (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

 

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

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covered person.

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     (17) "Registry" means a list of doulas, maintained by the department, which satisfies the

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qualifications for registration set forth by the department.

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     (18) “State medical assistance program” means a federal financial aid of medical

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expenses of needy persons.

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     40-8.16-3. Coverage of doula services.

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

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bearing individuals through private insurance and Medicaid.

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

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seeking reimbursement has completed the following:

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

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

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provider enrollment forms;

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

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dated letter from a doula certification organization verifying that the doula has attended and

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

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certification organization’s letterhead and signed by an authorized representative;

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

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

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competency requirements outlined below:

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     (i) At least twenty-four (24) contact hours of education that includes any combination of

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childbirth education, birth doula training, antepartum doula training, and postpartum doula

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training;

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

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counselor or IBCLC;

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     (iii) Attendance at a minimum of one childbirth class;

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     (iv) Attendance at a minimum of two (2) births;

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     (v) Completion of cultural competency training;

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     (vi) Completion of HIPAA / client confidentiality training;

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

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     (viii) Completion of SafeServ certification for meal preparation.

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

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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.

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

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

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     40-8.16-4. Scope of practice.

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

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

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

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services, referrals, and advocacy;

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

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their client;

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     (3) Supporting the pregnancy, labor, and birth by providing emotional and physical

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support with traditional comfort measures and educational materials, as well as assistance during

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the transition to parenthood in the initial postpartum period through home visits;

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     (4) Empowering pregnant people and new mothers and people with evidenced-based

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information to choose best practices for birth, breastfeeding, and infant care;

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     (5) Providing support to the laboring client until the birth of the baby;

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

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the doula scope of practice;

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     (7) Working as a member of the client’s multidisciplinary team; and

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

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recovery from childbirth, and other issues related to the postpartum period.

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

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

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     (a) The department shall promulgate rules and regulations that establish a statewide

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registry for doulas and specify the qualifications necessary for doula registration.

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     (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;

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     (2) Not be listed on the department’s provider exclusion list;

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

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     (4) Be required to provide two (2) positive client references of quality job performance;

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

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and

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

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

 

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working through, with or under them.

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     40-8.16-6. Payment for doula services.

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     (a) Medical assistance coverage for doula services:

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

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40-8.16-5; and

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

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

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year postpartum, shall not exceed one thousand five hundred dollars ($1,500), and shall be

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

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

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

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time, such as documentation or paperwork.

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

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

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

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

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department. No insurer or hospital or medical service corporation may require supervision,

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

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when those requirements are also applicable to other categories of health care providers. No

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insurer or hospital or medical service corporation or patient may be required to pay for duplicate

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services actually rendered by both a perinatal doula and any other health care provider. Direct

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payment for perinatal doulas shall be contingent upon services rendered in accordance with rules

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and regulations promulgated by the department.

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     SECTION 3. This act shall take effect on July 1, 2020.

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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

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

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     This act would take effect on July 1, 2020.

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