The California Department of Health Care Services (DHCS) has released its comprehensive report from the Doula Implementation Workgroup, outlining critical recommendations to address ongoing challenges and improve the Medi-Cal doula benefit. This report represents months of collaborative work between 29 stakeholder representatives, including nine doulas, health care providers, community advocates, health plan representatives, and county officials.

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Background: How We Got Here

The Doula Implementation Workgroup was established in compliance with the Welfare and Institution Code to monitor and improve the implementation of California's groundbreaking Medi-Cal doula benefit. The group met regularly from March 2023 through May 2025, with support from the California Health Care Foundation and RACE For Equity serving as meeting facilitators.

The workgroup's formation came after significant advocacy from the doula community and recognition that while California had successfully created a doula benefit, implementation challenges were creating barriers for both doulas and the Medi-Cal members they serve.

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The Current State of Challenges

Despite the historic achievement of establishing Medi-Cal doula coverage, significant implementation issues have emerged that threaten the program's success. In February 2025, a coalition of doulas, advocates, and community organizations sent an urgent letter to DHCS highlighting four critical concerns:

1. Payment delays and denials - Many doulas reported they still hadn't received the 2024 targeted rate increase for services provided after January 1, 2024
2. Credentialing process difficulties - Complex and lengthy processes that discourage doula participation
3. Barriers to managed care plan contracting - Inconsistent requirements and poor communication
4. Lack of provider support - Limited technical assistance for billing and administrative processes

The coalition warned that these issues are "exacerbating distrust among the doula workforce" and threatening the viability of the entire doula benefit program.

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Key Recommendations by Organization

The workgroup developed 18 specific recommendations organized by the entity responsible for implementation. Here's what each organization is being asked to do:

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11 Recommendations for DHCS

1. Updated All-Plan Letter with Enforcement - DHCS should issue a comprehensive All-Plan Letter with clear, enforceable guidelines covering timely payments, streamlined credentialing, transparency requirements, and clear claim submission instructions. This includes addressing the ongoing issues with managed care plans failing to implement the 2024 targeted rate increase.

2. New Stakeholder Workgroup - A new two-year doula stakeholder workgroup should be formed to continue monitoring implementation, share best practices, and address ongoing concerns. The size and meeting frequency would be jointly developed by DHCS and stakeholders.

3. Policy Clarification for Pregnancy Loss - DHCS needs to clarify its policy regarding doula services after unconfirmed pregnancies that ended in miscarriage or abortion, addressing challenges doulas face when there's no documented proof of pregnancy by a licensed provider.

4. Dispute Resolution Resources - Development of a comprehensive FAQ document about dispute resolution processes and technical assistance options for doulas facing claim denials or payment issues.

5. Updated Contact Information System - Working with managed care plan associations to maintain current contact information for contracting, credentialing, reimbursement, and claim denial issues.

6. Community-Based Organization Funding - Distributing funding to managed care plans for redistribution to community-based organizations and independent doula providers through ramp-up funding, similar to the CalAIM Enhanced Care Management Incentive Payment Program.

7. Public KPI Dashboard - Creating a public dashboard showing key performance indicators including the number of doulas contracted with each plan, member utilization data disaggregated by demographics, and implementation success metrics.

8. Standing Order for Additional Visits - Issuing a standing order to pre-authorize additional postpartum visits, allowing Medi-Cal members to determine for themselves whether they want continued care for the first year after pregnancy.

9. Member Awareness Campaign - Creating a comprehensive campaign to increase Medi-Cal member awareness of the doula benefit.

10. Streamlined Operations - Working with managed care plans to identify commonalities that could streamline credentialing and billing processes while respecting the diverse needs of different plan communities.

11. CalAIM Integration - Exploring the possibility of adding doulas as providers of Enhanced Care Management and Community Support services under CalAIM for members with complex needs.

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2 Recommendations for Hospitals

1. Admission Policies Reform - Hospitals should create admission policies that treat doulas as part of the care team rather than visitors, ensuring access to all necessary areas including labor and delivery, triage, operating rooms, and postpartum units. This builds on the March 2025 All Facilities Letter issued by the California Department of Public Health.

2. Best Practices Sharing - Hospitals should adopt and share successful integration practices, such as hosting meet-and-greets between doulas and staff, offering hospital tours, creating direct communication lines, and partnering with community organizations to develop access policies.

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6 Recommendations for Managed Care Plans

1. Doula-Specific Contracts - Plans should work with doulas to create simplified, doula-specific contracts that eliminate irrelevant sections designed for licensed providers and use plain language to explain requirements.

2. Tailored Training Programs - Each plan should provide easily accessible training specifically designed for doulas on submitting clean claims, recognizing that doulas often handle their own billing unlike other provider types.

3. Designated Support Staff - Plans should assign specific staff members to assist doulas with credentialing, contracting, reimbursement, and denied claims, with clear response time expectations.

4. Eliminate Documentation Duplication - Plans should not require doulas to resubmit documentation already provided to DHCS during the enrollment process.

5. Best Practices Sharing Among Plans - Plans with high doula benefit utilization should share successful strategies with other plans for connecting members with doulas.

6. Dashboard Reporting - Plans should report specific metrics to support the DHCS dashboard, including numbers of contracted doulas, submitted claims, payments made, member requests, and service utilization.

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2 Recommendations for the State Legislature

1. Training and Capacity Building Funding - The legislature should authorize funding for pilot programs and grants to community-based organizations for training new doulas and providing technical assistance, particularly in areas with fewer doulas and populations experiencing health disparities.

2. Web-Based Doula Directory - Funding should be provided for DHCS to create a user-friendly, sortable web-based directory of doulas, obstetricians, and midwives that allows members to search by language, county, managed care plan, and specialties.

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Progress Made and Ongoing Challenges

The report acknowledges both successes and persistent challenges since the workgroup began. Positive developments include:

• The California Hospital Association delivered training on doula access requirements
• Some managed care plans have implemented doula-specific policies and designated staff
• DHCS has undertaken member outreach efforts including notices, flyers in multiple languages, and upcoming social media campaigns
• Some hospitals have created successful doula integration programs

However, significant problems remain:

• Many doulas still haven't received proper payment for 2024 rate increases
• Complex and inconsistent credentialing processes across different plans
• Limited hospital access in some facilities
• Insufficient technical support for billing and administrative processes
• Poor communication between plans and doulas

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What This Means for Doulas

These recommendations represent a roadmap for addressing the systemic issues that have made it difficult for doulas to participate in the Medi-Cal system. Key implications include:

Immediate Relief: The push for updated All-Plan Letters with enforcement mechanisms could help resolve payment delays and improve plan responsiveness.

Long-term Support: Funding for community-based organizations and ramp-up support could provide the technical assistance many doulas need to navigate the system successfully.

Improved Access: Hospital policy changes and better member outreach should increase opportunities for doulas to serve Medi-Cal families.

Transparency: The proposed dashboard will provide public accountability for how well the benefit is working and where improvements are needed.

Continued Advocacy: The new stakeholder workgroup ensures doula voices will continue to be heard as implementation evolves.

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The Path Forward

While these recommendations are not binding requirements, they represent consensus among diverse stakeholders about what needs to change. The report emphasizes that many of the recommendations focus on sharing best practices and promoting successful approaches that some organizations have already implemented.

The success of these recommendations will depend on sustained advocacy from the doula community and continued collaboration among DHCS, managed care plans, hospitals, and community organizations. The proposed new stakeholder workgroup will play a crucial role in monitoring progress and holding organizations accountable for implementing changes.

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Taking Action

Doulas can support implementation of these recommendations by:

• Staying engaged with the new stakeholder workgroup when it's established
• Documenting ongoing challenges with payment, credentialing, and access
• Working with their managed care plans to implement best practices
• Supporting community-based organizations that provide technical assistance
• Advocating for legislative funding for training and directory development

The Doula Implementation Workgroup's report represents a critical moment in the evolution of California's Medi-Cal doula benefit. While significant challenges remain, the comprehensive nature of these recommendations and the collaborative process that developed them provide a clear path toward making the benefit work better for both doulas and the families they serve.

The ultimate goal remains unchanged: ensuring that Medi-Cal members have meaningful access to doula services that can improve birth outcomes and provide crucial support during one of life's most important experiences. These recommendations, if implemented effectively, could transform the current system's problems into a model for other states considering similar programs.

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If you want additional details, check outthe full DHCS report.