130 CMR 463.00 — Doula Services

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 463.000) Page iv Doula Services Manual Transmittal Letter DS-2 Date 11/08/24

4. Program Regulations:

130 CMR 463.000: Doula Services

130 CMR 463.00 Doula Services

463.401 Introduction .................................................................................................... 4-1

463.401: Introduction .................................................................................................... 4-1

463.402 Definitions ....................................................................................................... 4-1

463.402: Definitions ....................................................................................................... 4-1

463.403 Eligible Members ............................................................................................. 4-1

463.403: Eligible Members ............................................................................................. 4-1

463.404 Provider Eligibility ........................................................................................... 4-2

463.404: Provider Eligibility ........................................................................................... 4-2

463.405 Maximum Allowable Fees ............................................................................... 4-3

463.405: Maximum Allowable Fees ............................................................................... 4-3

463.406 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services .......... 4-3

463.406: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services .......... 4-3

463.407 Covered Services ............................................................................................ 4-3

463.407: Covered Services ............................................................................................ 4-3

463.408 Noncovered Services ...................................................................................... 4-4

463.408: Noncovered Services ...................................................................................... 4-4

463.409 Service Limitations ......................................................................................... 4-4

463.409: Service Limitations ......................................................................................... 4-4

463.410 Prior Authorization

463.410: Prior Authorization .......................................................................................... 4-4

463.411 Recordkeeping Requirements ........................................................................... 4-5

463.411: Recordkeeping Requirements ........................................................................... 4-5

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 463.000) Page 4-1 Doula Services Manual Transmittal Letter DS-2 Date 11/08/24

463.401 Introduction

463.401: Introduction

130 CMR 463.000 establishes the requirements for the provision and payment of doula services under MassHealth. All doulas participating in MassHealth must comply with MassHealth regulations including, but not limited to, 130 CMR 463.000 and 130 CMR 450.000: Administrative and Billing Regulations.

463.402 Definitions

463.402: Definitions

The following terms used in 130 CMR 463.000 have the meanings given in 130 CMR 463.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 463.000 is not determined by these definitions, but by application of 130 CMR 463.000 and 130 CMR 450.000: Administrative and Billing Regulations.

Doula. A qualified professional who provides non-medical emotional, informational, and physical support to individuals and families during pregnancy, delivery, and the post-pregnancy period.

Group Doula Visit. A perinatal visit, or visit for labor and delivery support, in which a doula supports more than one member who is in their perinatal period.

Labor and Delivery. Childbirth or delivery of a fetus following pregnancy, inclusive of all pregnancy outcomes.

Perinatal. The period encompassing pregnancy and labor and delivery, through 12 months following delivery, inclusive of all pregnancy outcomes. For adoptive parents of infants, the period in which the adopted infant is younger than one year of age.

463.403 Eligible Members

463.403: Eligible Members

(A) (1) MassHealth Members. The MassHealth agency pays for doula services only when provided to eligible MassHealth members during the perinatal period, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105: Coverage Types specifically states, for each coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106: Emergency Aid to the Elderly, Disabled and Children Program.

(B) For information on verifying member eligibility and coverage types, see 130 CMR 450.107: Eligible Members and the MassHealth Card.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 463.000) Page 4-2 Doula Services Manual Transmittal Letter DS-2 Date 11/08/24

463.404 Provider Eligibility

463.404: Provider Eligibility

Payment for services described in 130 CMR 463.000 will only be made to doulas or group practices who are participating in MassHealth on the date of service. Doulas must meet the following eligibility requirements.

(A) In-state Providers. To be eligible to participate in MassHealth, an in-state doula must meet the following qualifications: (1) be at least 18 years old; (2) complete trainings provided by the Executive Office of Health and Human Services (EOHHS) on topics including, but not limited to: (a) overview of the MassHealth Doula Services Program, including best practices for meeting the needs of diverse MassHealth members and their families; (b) federal and state laws and regulations established for the protection of the privacy and security of the member information doulas create, use, collect, store, and/or transmit; (c) navigating MassHealth-covered services and community resources for MassHealth members; and (3) demonstrate competency in the following areas, either through the Formal Training Pathway or Experience Pathway as defined in 130 CMR 463.404, subject to EOHHS review and approval: (a) basic understanding of the following topics at a minimum, as those topics relate to the ability to provide emotional, informational, and physical support to individuals and families during the perinatal period, regardless of the outcome of the pregnancy:

1. maternal anatomy and physiology during the perinatal period, including basic fetal growth and development in each trimester of pregnancy;
2. common medical interventions during pregnancy, childbirth, and the postpartum period;
3. common potential complications associated with pregnancy, childbirth, and the postpartum period, including but not limited to
   1. pregnancy and infant loss;
   2. mental health conditions including Perinatal Mood and Anxiety Disorders
   (PMADs); c. substance use disorder (SUD); and d. high blood pressure;
4. labor and delivery comfort measures;
5. best practices for supporting members in advocating for their needs and making informed decisions using a trauma-informed approach; and
6. basic newborn care, including the fundamentals of breastfeeding/chestfeeding. (b) Formal Training Pathway. Provide a certificate of completion or other proof of doula training(s) attended, and/or proof of doula certification by a doula-certifying organization and a completed attestation form, using the template provided by EOHHS, stating that the completed formal training(s) covered the required competencies listed above.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 463.000) Page 4-3 Doula Services Manual Transmittal Letter DS-2 Date 11/08/24

(c) Experience Pathway. Provide the following recommendations using templates provided by EOHHS:

1. recommendations from at least three different former clients for whom the prospective MassHealth doula provided doula services (either paid or volunteer) within the last five years; and
2. recommendations from at least two different licensed health care providers such as physicians, midwives, social workers, or nurses who observed the applicant providing doula services within the last five years.

(B) Out-of-state Providers. To participate in MassHealth, an out-of-state doula must obtain a MassHealth provider number and meet the following criteria: (1) be legally authorized to perform the services of a doula in their own state; (2) participate in their state’s Medicaid program (or the equivalent); and (3) meet the conditions set forth in 130 CMR 450.109: Out-of-state Services.

463.405 Maximum Allowable Fees

463.405: Maximum Allowable Fees

EOHHS determines the payment rate for doula services in accordance with 101 CMR 319.00: Rates for Doula Services. Payment is subject to the conditions, exclusions, and limitations set forth in 130 CMR 463.000 and 130 CMR 450.000: Administrative and Billing Regulations.

463.406 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

463.406: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

The MassHealth agency pays for all medically necessary doula services for EPSDT-eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services: Introduction, without regard to service limitations described in 130 CMR 463.000, and with prior authorization.

463.407 Covered Services

463.407: Covered Services

(A) The MassHealth agency pays for medically necessary doula services including perinatal visits and labor and delivery support provided in-person or via telehealth.

(B) Doula services must be recommended by a physician or other licensed practitioner of the healing arts acting within the scope of their practice under state law. Such licensed practitioners include the following: (1) certified nurse practitioners, certified nurse midwives, certified registered nurse anesthetists, clinical nurse specialists, psychiatric clinical nurse specialists, physician assistants, clinical social workers, psychologists; and (2) other licensed practitioners as indicated in written guidance from the MassHealth agency.

(C) Doula Claims Submissions. Providers eligible to render doula services in accordance with 130 CMR 463.404 may submit claims for doula services when they provide those services directly to MassHealth members. See Subchapter 6 of the Doula Manual for service code descriptions and billing requirements.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 463.000) Page 4-4 Doula Services Manual Transmittal Letter DS-2 Date 11/08/24

463.408 Noncovered Services

463.408: Noncovered Services

The MassHealth agency does not pay for the following:

(A) Doula services for purposes other than those identified in 130 CMR 463.407;

(B) Otherwise payable service codes when those codes are used to bill for circumstances that are not payable under 130 CMR 463.409;

(C) Travel time and mileage; or

(D) Group doula visits.

463.409 Service Limitations

463.409: Service Limitations (A) The MassHealth agency pays for up to eight hours of perinatal visits per perinatal period per member without prior authorization. Visits above these limits require prior authorization in accordance with 130 CMR 463.410. (B) The MassHealth agency pays for labor and delivery support, one per perinatal period.

463.410 Prior Authorization

463.410: Prior Authorization

(A) Services that Require Prior Authorization. The MassHealth agency requires that doulas obtain prior authorization as a prerequisite to payment for more than eight hours of perinatal visits per member per perinatal period.

(B) Submission Requirement. The doula must submit all prior authorization requests in accordance with the billing instructions in Subchapter 5 of the Doula Manual. Prior authorization determines only the medical necessity of the authorized service, and does not establish or waive any other prerequisites for payment, such as member eligibility, or resort to health insurance payment. See 130 CMR 450.303: Prior Authorization for additional information about prior authorization.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 463.000) Page 4-5 Doula Services Manual Transmittal Letter DS-2 Date 11/08/24

(C) Notice of Approval or Denial of Prior Authorization. (1) Notice of Approval. For all approved prior authorization requests for doula services, the MassHealth agency sends written notice to the member and the doula about the frequency, duration, and intensity of care authorized, and the effective date of authorization. (2) Notice of Denial or Modification and Right of Appeal. (a) For all denied or modified prior authorization requests, the MassHealth agency notifies both the member and the doula of the denial or modification and the reason. In addition, the member will receive information about the member’s right to appeal and the appeal procedure. (b) A member may request a fair hearing from the MassHealth agency if it denies or modifies a prior authorization request. The member must request a fair hearing in writing within 30 days after the date of receipt of the notice of denial or modification. The MassHealth Board of Hearings will conduct the hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules.

463.411 Recordkeeping Requirements

463.411: Recordkeeping Requirements

(A) Providers of any service covered under 130 CMR 463.000 must maintain complete records of all services rendered for each MassHealth member. All records must be kept for a minimum of six years after the date of service. Payment for maintaining the member’s record is included in the fee for doula services. Each record must contain sufficient information to document fully the nature, extent, quality, and necessity of the care furnished to the member for each date of service claimed for payment. If the documentation is not sufficient to justify the service for which payment is claimed by the provider, the MassHealth agency will not pay for the service or, if payment has been made, may consider such payment to be an overpayment subject to recovery in accordance with 130 CMR 450.000: Administrative and Billing Regulations.

(B) The doula provider records must contain, at a minimum, the following: (1) MassHealth member identification, including name, date of birth, and the MassHealth member’s identification number; (2) the date, location, duration, and purpose of each perinatal visit, including a summary of doula services provided, signed by the doula; (3) the date, location, duration, and summary of doula services provided for labor and delivery support, signed by the doula; (4) upon completion of services, a summary of the services provided to the member, including any referrals made, signed by the doula; and (5) if the record or any component included therein is released for use by another party, the record must also contain a release form signed by the member. Release of the record to MassHealth for authorized use does not require the member's consent.

(C) Doula providers are responsible for ensuring the privacy and security of all member information in their possession. Each doula provider must establish reasonable safeguards designed to protect the privacy and security of all member information in their possession, including doula provider records.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 463.000) Page 4-6 Doula Services Manual Transmittal Letter DS-2 Date 11/08/24

REGULATORY AUTHORITY

130 CMR 463.000: M.G.L. c. 118E, §§ 7 and 12.