ModifiedIndependent HealthPolicy N/A

Addendum to the 2025 Essential Plan Member Contract

Contract addendum applicable to all tiers of the Essential Plan describing updates to outpatient/professional maternity and newborn services effective 4/1/2025, including coverage for breastfeeding support and doula services and related provider qualifications and limits.

Policy Summary

PayerIndependent Health

PolicyAddendum to the 2025 Essential Plan Member Contract

Policy CodePolicy N/A

Change TypeCoverage additions for breastfeeding supplies and doula services

Effective DateApr 1, 2025

Next Review Date

Key ActionEnsure doulas are registered in the NY State Community Doula directory and that midwives meet licensing and facility affiliation requirements before billing.

SourceLink

POLICY UPDATE CHANGES

Effective 4/1/2025, coverage added for breastfeeding support, counseling and supplies including one (1) breast pump per pregnancy from a participating provider or designated vendor.

Coverage added for doula services with limits: eight (8) prenatal or postpartum visits and one (1) in-person labor/birth support visit per pregnancy, conditional on doula registration and a clinician recommendation or state law.

1Breast pump per pregnancy

8Covered prenatal/postpartum doula visits

1In-person doula labor/birth visit

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Summary of Addendum

This addendum to the 2025 Essential Plan Member Contract is applicable to all tiers of the Essential Plan and updates Section IX Outpatient and Professional Services specific to maternity and newborn care. All other sections remain in effect.

Effective 2025-04-01, the addendum adds coverage for breastfeeding support, counseling and supplies including one (1) breast pump per pregnancy (rental or purchase) for the duration of breastfeeding when obtained from a Participating Provider or designated vendor. It also adds coverage for doula services with specified provider registration and visit limits.

The addendum clarifies provider qualifications for midwives and defines doula coverage and registration requirements and limits; it is an addendum applicable to all Essential Plan tiers effective 4/1/2025.

Key Metadata

PolicyAddendum to the 2025 Essential Plan Member Contract

PayerIndependent Health

Effective Date2025-04-01

StatusMODIFIED

ScopeContract addendum applicable to all tiers of the Essential Plan describing updates to outpatient/professional maternity and newborn services effective 4/1/2025, including coverage for breastfeeding support and doula services and related provider qualifications and limits.

Material changesCoverage added for breastfeeding support and one (1) breast pump per pregnancy; coverage added for doula services with visit limits and registration requirement.

Covered Services and Criteria

Covered Maternity and Newborn Services

Covered when ALL of the following are met:

ALL of the following

Services provided by a Physician, midwife, nurse practitioner, Hospital or birthing center are covered for prenatal care (including one (1) visit for genetic testing), postnatal care, delivery, and complications of pregnancy.
Services of a midwife are covered only if the midwife is licensed pursuant to Article 140 of the New York Education Law, practicing consistent with Section 6951 of the New York Education Law and affiliated or practicing in conjunction with a Facility licensed pursuant to Article 28 of the New York Public Health Law.
Duplicate routine services provided by both a midwife and a Physician will not be paid.

Breastfeeding support, counseling and supplies (Effective 2025-04-01)

Covered when ALL of the following are met:

Billing, Documentation & Provider Requirements

Documentation Required

Midwife licensing and facility affiliation documentation

To bill for midwife services, ensure the midwife is licensed pursuant to Article 140 of the New York Education Law, practices consistent with Section 6951 of the New York Education Law, and is affiliated with or practicing in conjunction with a Facility licensed pursuant to Article 28 of the New York Public Health Law. Note that duplicate routine services provided by both a midwife and a physician will not be paid.

Prior Authorization

Doula coverage requires recommendation or state law provision

Doula services are covered only when recommended by the member's physician, midwife, physician assistant, or nurse practitioner, or as otherwise provided under state law. For services of a Doula to be covered, the Doula must be registered in the New York State Community Doula directory in accordance with Title VI-a of Article 25 of the New York Public Health Law.

Definitions

Doula: A non-clinical support person whose services are covered when registered in the New York State Community Doula directory per Title VI-a of Article 25 of the New York Public Health Law and recommended by an authorized clinician or as provided by state law.

What Changed

2025-04-01addedLatest

Effective 4/1/2025, breastfeeding support, counseling and supplies added: coverage includes the cost of renting or purchase of one (1) breast pump per pregnancy for the duration of breastfeeding when obtained from a Participating Provider or designated vendor.

2025-04-01addedLatest

Doula services added: coverage when recommended by a physician, midwife, physician assistant or nurse practitioner or as provided under state law; doula must be registered in the New York State Community Doula directory per Title VI-a of Article 25 of the NY Public Health Law; limits of eight (8) prenatal or postpartum visits per pregnancy and one (1) in-person labor/birth support visit per pregnancy.

Document effective date: 2025-04-01. This is an addendum applicable to all tiers of the Essential Plan describing updates to outpatient/professional maternity and newborn services, including coverage for breastfeeding support and doula services and related provider qualifications and limits.