Breanna Reeves
Before the Medi-Cal Doula Services Benefit went into effect in January 2023, the Department of Health Care Services (DHCS) held monthly doula stakeholder workgroup meetings to discuss and debate the doula benefit and requirements outlined in the plan.
Jessica Miller began attending the meetings last September to better understand what the program requirements would be. After months of deliberation, the workgroup outlined the requirements for doulas and doula groups, but according to Jessica, there was a lack of step-by-step guidance.
DHCS defines doulas as birth workers who provide health education, advocacy and physical, emotional and nonmedical support for birthing people before, during and after childbirth. This includes support during miscarriage, stillbirth and abortion. Doulas are not licensed or clinical providers and do not perform medical procedures nor do they require supervision.
Doula – a word that can be understood in both languages
After years working as a licensed vocational nurse and completing several training programs, Jessica put all her knowledge together and formally launched Jurupa Valley Doulas in 2022 alongside her mom, Trina Blackwell, and her husband, Daniel Miller. They provide services to the communities of Corona, Norco, downtown Riverside and Jurupa Valley.
Named after the city they live in, the trio used the word doula in the name because they felt it was easier for both Spanish speakers and English speakers to seek them out.
“It’s a word that they can say in both languages,” Jessica explained.
Her calling to offer doula services to the community was inherited from several generations of community birth workers.
While the services delivered by doulas have been systemized by the healthcare system in what many believe to be beneficial to communities of color, others question if the cultural practice of supporting birthing families will further be obstructed by mountains of paperwork, additional requirements assigned to doulas and overall gaps in implementation.
A family of birth workers across generations
As a fourth generation birth worker, Jessica continues the work that her great grandmother carried out as a traditional midwife in Michoacán, Mexico.
Jessica’s great grandmother spent most of her life as the town’s midwife who provided services to the community in exchange for other services, as was the custom in the community. As her great grandmother got older, the town eventually took care of her after years of her servicing the community. Jessica’s great grandmother lived to be nearly 104 years old and passed her skills onto her daughter, Mercedes. Mercedes supported birthing families before her untimely death at the age of 39 from ovarian cancer.
Growing up, Jessica noticed that people in the community relied on her aunt and mother to support birthing families. Her mother, Trina, gave birth alone, when she was just a teenager. It wasn’t until she was older did Jessica realize that a lot of the additional support her mother gave to her family and community members who only spoke Spanish, was considered doula work.
“I didn’t realize that I had been around doulas my whole life, essentially,” Jessica said.
Trina is a certified pregnancy loss doula and certified nurse who has spent the last 16 years working at the Community Care & Rehabilitation Center in Riverside. Like her mom, Jessica joined the medical field as a licensed vocational nurse in 2005.
Jessica spent years acquiring different skills and learning as much as she could. She enrolled in a nine-month lactation consultant program called Grow Our Own and enrolled in a medical case management program at the University of California at Riverside.
In 2022, Jessica and her mother participated in Riverside Community Health Foundation’s free Spanish Doula Training. Jessica is a bilingual full-spectrum doula, clinical lactation specialist and medical case management professional.
“I’ve been following my daughter. Wherever she decides to go, I’ll go. Wherever she takes me, I know it’s the right way. So, instead of me doing it for her, she does it for me. I am very blessed to have her,” Trina shared.
Doula provider approval process is burdensome
Jurupa Valley Doulas started the process of enrolling to become a provider under Medi-Cal last December. They were intentional about starting the process early because they believed their information was already on file somewhere, as they were assured during a Doula Medi-Cal Provider Transition Training session.
The training, hosted in December by the Riverside Community Health Foundation, welcomed attendees to boast the benefits of enrolling and discussed how to enroll as a doula provider with stakeholders from DHCS, Inland Empire Health Plan (IEHP), Molina Health and Health Net. During the training, insurance companies told doulas they would begin the process of submitting their information and certifications so that everything would already be on file, and once approved, the process would run smoother.
That hasn’t been true for Jurupa Valley Doulas. In the six months since Jurupa Valley Doulas was approved on Jan. 4, Jessica has gone down a rabbit hole, trying to navigate the local, state and insurance requirements to deliver services as a doula group.
“She had to find the answers that other companies were either unwilling to provide or didn’t have the answers themselves [for] a brand new program,” Daniel added. According to the Millers, some insurance companies are only recently figuring out a way to inform their employees that they now cover doula services.
Among the list of 25 Doula Services Benefit Managed Care Plan Contacts listed by DHCS, two operate in Riverside and San Bernardino Counties: IEHP and Molina Healthcare. Across the entire listed points of contact for each managed care plan, IEHP is the only plan that does not have a specific point of contact name listed.
Jessica explained that when she initially signed up to be a provider under the Medi-Cal Doula Benefit, she was unprepared for the onslaught of extra steps that were needed outside of the state’s requirements. In addition to completing the electronic Medi-Cal Provider Application for Validation and Enrollment (PAVE) — only offered in English — Jessica has faced unexpected requirements for different insurance providers, county and state license requirements and additional training programs. The costs of these different requirements began to add up.
“My mom is still having to work. Then, on the side, she’s taking on some clients on her days off. Daniel is still working full time. Then on the side, he sometimes helps, but I’m the one that’s handling Jurupa Valley Doulas on a full-time basis,” Jessica explained.
Doulas who are still waiting to be approved as providers for specific insurance plans have been instructed to use specific clearing houses or billing processes. While doulas wait to be added to provider networks, they are still supporting families and are expected to absorb the costs of fees that come from the process of joining provider networks.
Difficulties with billing create more obstacles
One larger insurance company, who Jessica declined to name, that has given the “most grief” over contracting and supplying information emailed the group with a billing update. The email acknowledged that the contract implementation process is taking longer than expected, but gave doulas options on how to bill claims until they are added to the company’s provider portal. Doulas were given the option to submit paper claims using a CMS 1500 form or to use clearing houses listed in the email.
“You can use any of the following clearing houses to submit electronically. These clearinghouse services will be free to you once you are added to our provider network, but prior to that there will be a fee. Each clearinghouse has their own enrollment process and price structure which you can reach out to them directly for…,” the email read.
Jessica said other doulas reached out to her after receiving the email, asking her if she knew how to fill out the CMS 1500 form and if she could show them because they have been unable to submit any billing claims. Jessica shared the resource of the Small Billing Providers Unit (SPBU) which supports and trains providers with billing DHCS for fee-for-service.
As a bilingual doula who works in a community with doulas who solely speak Spanish, Jessica has addressed the fact that many of these supportive services are only offered in English. While on the phone with a billing representative, Jessica asked, “What are you guys going to do when you start getting doulas that only speak Spanish reaching out to you [and] wanting you to teach them how to do the billing?”
The representative said it is something they would have to figure out.
According to DHCS, SPBU provides billing assistance and training for providers who submit up to100 claims per month to DHCS and do not use a billing service or agency. If a doula does not qualify for services by the SPBU, they can contact the Medi-Call Telephone Service Center to request a provider field representative who can answer enrollment or billing questions.
Doulas who service clients under managed care plans have roughly 90 days to submit their billing claims, depending on the insurance company. For fee-for-service recipients, doulas have up to six months to submit their billing claims. After six months, claims are reimbursed at a reduced rate.
Juggling the different billing requirements outlined by different managed care plans and Medi-Cal fee-for-service “may leave a lot of doulas without pay by the time that billing is figured out,” Jessica commented.
Though the challenges of approval are great, the needs of the community are greater
DHCS recognized that common challenges with implementing new benefits are related to navigating the enrollment process, billing inquiries, questions related to contracting with managed care plans and city and county licensing and liability questions.
DHCS believes with the development of a new doula stakeholder workgroup, birth workers will have an opportunity to ask questions and gain additional clarity. The stakeholder group will meet periodically throughout the year to review the department’s implementation of the doula benefit.
“I think because it’s so new [and] my wife is one of the few that is pushing so hard to get it done, that they have asked her questions — not to quiz her, but to get the answers so that they can continue,” Daniel explained.
“The insurance company, one in particular, was not informed what a doula was and that they now offered that as part of a service. They were not informed. Jurupa Valley Doulas continuously had their application lost and denied for the fact that they were ill-informed on their own services.”
Daniel is a certified nurse assistant, certified doula and childbirth educator who saw the opportunity to be proactive when his wife decided to create Jurupa Valley Doulas. Born to a teenage sex worker, Daniel hopes that as a doula and educator he can deliver passionate care to those, like his young mother, who need it.
While working at a five-star Rehabilitation Center, he felt uneasy about how staff treated patients — “it made me feel kind of dirty,” he recalled. That feeling propelled him to become involved in birth work.
“I saw my opportunity to actually do something productive and become a doula and learn. I can then teach my clients how to advocate for themselves and avoid becoming a statistic, or try to lower the chances of a bad birth story,” Daniel said.
Together Daniel, Trina and Jessica are navigating the Medi-Cal benefit and the process of working with insurance companies for managed care plans, but it’s not easy. Jurupa Valley Doulas was recently contracted and on-boarded by a medical insurance company whose individual application requires they register with a credentialing website and complete a two-hour class on Culturally and Linguistically Appropriate Services (CLAS) in Maternal Health Care. Both are only available in English.
Jessica said the requirements imposed on doulas by the insurance companies may discourage doulas from enrolling and becoming community doulas, resulting in some doulas providing private services.
“We’re not complaining. We’re just simply stating that it’s not been an easy road to get here. To get here has basically been on breadcrumbs and tiny little snippets of clues,” Daniel said.
As of June 5, 2023, DHCS has approved 117 doula applications, including eight doula groups. The goal of the benefit is to make access to doula services easier for underserved communities, who are most at risk for receiving inadequate care, developing fatal symptoms and dying from pregnancy-related causes. Jessica is one of many doulas who enrolled to make an impact in the community, not just to get paid, but it has been a struggle to do either with the additional requirements and fees imposed by insurance companies.
This article is published as part of the Commonwealth Health Equity Reporting Fellowship.