2019-03-21: Introduced, referred to Senate Health and Human Services
2019-04-19: Scheduled for hearing and/or consideration (04/25/2019)
2019-04-25: Committee recommended measure be held for further study
2019-06-21: Scheduled for consideration (06/25/2019)
2019-06-25: Committee recommends passage
2019-06-25: Placed on Senate Calendar (06/27/2019)
2019-06-25: Placed on Senate Calendar (06/26/2019)
2019-06-25: Placed on Senate Calendar
2019-06-27: Senate passed as amended (floor amendment)
2019-06-28: Referred to House Finance
Changes since original draft
2019 – S 0678
S T A T E O F R H O D E I S L A N D
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2019
A N A C T
RELATING TO HUMAN SERVICES – MEDICAL ASSISTANCE–PERINATAL DOULA
Introduced By: Senators Quezada, Valverde, Murray, Euer, and Goldin
Date Introduced: March 21, 2019
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 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. Title 40 of the General Laws entitled "HUMAN SERVICES" is hereby amended by adding thereto the following chapter:
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."
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 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) "Department" means the Rhode Island department of health.
(7) "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 six (6) weeks of the postpartum period. Doulas also provide assistance by referring childbearing individuals to CBOs and certified and licensed perinatal professionals in multiple disciplines.
(8) "Doula certification organization" means an entity, nationally or internationally, recognized by the department for training and certifying perinatal doulas whose educational requirements includes the core curriculum topics described in this chapter. These doula certification 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.
(9) "Doula services" means services provided by a certified doula as enumerated in § 40- 8.16-4.
(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 the period following childbirth or the end of pregnancy.
(16) "Private insurers" means insurance schemes financed through private health 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 department, which satisfies the qualifications for registration set forth by the department.
(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 certification organization verifying that the doula has attended and completed its training or curriculum. To be considered authentic, a letter must be on the doula certification 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) At least twenty-four (24) contact hours of 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 valid certified lactation counselor or IBCLC;
(iii) Attendance at a minimum of one childbirth class;
(iv) Attendance at a minimum of two (2) births;
(v) Completion of cultural competency training;
(vi) Completion of HIPAA / client confidentiality training;
(vii) Completion of CPR certification for children and adults; and
(viii) 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 with the state medical assistance program.
(e) 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.
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 pregnancy, labor, and birth by providing emotional and physical support 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 pregnant people and new mothers and people with evidenced-based information to choose best practices for birth, breastfeeding, and infant care;
(5) Providing support to the laboring client until the birth of the baby;
(6) Referring clients to their health care provider for medical advice for care outside of the doula scope of practice;
(7) Working as a member of the client's multidisciplinary team; and
(8) Offering evidence-based information on infant feeding, emotional and physical recovery from childbirth, and other issues related to the 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 department shall promulgate rules and regulations that establish a statewide registry for doulas and specify the qualifications necessary for doula registration.
(b) Individuals seeking entry on a statewide registry of doulas shall, at a minimum:
(1) Be at least eighteen (18) years of age;
(2) Not be listed on the department's provider exclusion list;
(3) Successfully complete training in all competencies as outlined in § 40-8.16-3;
(4) Be required to provide two (2) positive client references of quality job performance;
(5) Receive and maintain certification by an approved doula certification organization; and
(6) 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 exceed one thousand five hundred dollars ($1,500), and shall be eligible towards the following activities: 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 department. 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 department.
SECTION 3. This act shall take effect on July 1, 2020.
BY THE LEGISLATIVE COUNCIL
A N A C T
RELATING TO HUMAN SERVICES – MEDICAL ASSISTANCE–PERINATAL DOULA
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, 2020. ======== LC002194 ========
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