ModifiedSharp-Health-PlanPolicy N/A

Provider Alert - Doula Services

Notifies providers that, effective Jan 1, 2025, Sharp Health Plan will cover contracted doula services for eligible commercial members (excluding Medicare Advantage). Defines eligibility groups, covered service components, visit limits, and a list of non-covered services.

Policy Summary

PayerSharp-Health-Plan

PolicyProvider Alert - Doula Services

Policy CodePolicy N/A

Change TypeAdded coverage for contracted doula services

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionConfirm the member is a commercial member (not Medicare Advantage) and meets one of the enrollment criteria (CalPERS, FEHB, or MMHCMP) and is pregnant or was pregnant in the last 12 months before scheduling or billing doula services.

SourceLink

POLICY UPDATE CHANGES

Effective Jan. 1, 2025, coverage for contracted doula services will be available for eligible commercial members.

Defines eligible enrollment groups: CalPERS, FEHB, or enrollment in MMHCMP.

Lists specific non-covered doula services (e.g., belly binding, photography, placenta encapsulation, yoga).

11Maximum total doula visits permitted

2025-01-01Coverage effective date

0Medicare Advantage availability

Summary of changes and impact

Effective 2025-01-01, Sharp Health Plan is expanding benefits to cover contracted doula services for eligible commercial members; these services are not available to Medicare Advantage members.

Eligible members must be Commercial members who are currently pregnant or have been pregnant in the last 12 months and meet one of these enrollment criteria: CalPERS, FEHB, or enrollment in the MMHCMP program.

Covered components and visit limits include: 1 initial visit + up to 8 additional routine prenatal/postpartum visits (any combination) + up to 2 extended three-hour postpartum visits for a maximum total of 11 doula visits; coverage also includes support during labor and delivery, abortion, or miscarriage.

Explicitly non-covered services include: belly binding, birthing ceremonies, group babywearing classes, maternal or infant massage, photography, placenta encapsulation, shopping, vaginal steams, and yoga.

Key facts

Effective date2025-01-01

Maximum total visits11

Medicare Advantage availability0

Eligible enrollment groupsCalPERS / FEHB / MMHCMP

Eligibility and covered services

Member eligibility for doula services

Doula services available when ALL of the following are met:

ALL of the following

Member is a Commercial member (services are not available for Medicare Advantage members)
ONE of
- Member is enrolled in a commercial plan with Sharp Health Plan through the California Public Employees' Retirement System (CalPERS)
- Member is enrolled in a commercial plan with Sharp Health Plan through the Federal Employees Health Benefits Program (FEHB)
- Member is enrolled in the Sharp Health Plan Maternal Mental Health Case Management Program (MMHCMP)

Exclusions — non-covered doula services

Non-covered doula services

The following services are explicitly not covered:

ANY of the following

Belly binding
Birthing ceremonies
Group classes about babywearing
Massage (maternal or infant)
Photography

What providers must do

Documentation Required

Verify member eligibility

Confirm the member is a commercial member (not Medicare Advantage) and meets one of the enrollment criteria (CalPERS, FEHB, or MMHCMP) and is pregnant or was pregnant in the last 12 months before scheduling or billing doula services.

Member is a Commercial member (services are not available for Medicare Advantage members)
Member is enrolled through CalPERS, FEHB, or enrolled in MMHCMP
Member is currently pregnant or was pregnant in the last 12 months

Billing Rule

Visit limits and service reporting

Contracted doulas may provide 1 initial visit + up to 8 additional prenatal/postpartum visits in any combination, support during labor/delivery/abortion/miscarriage, and up to 2 extended three-hour postpartum visits; adhere to contracted billing practices and seek payer guidance for coding.

Definitions

Contracted doula services: Services provided by doulas who have a contract with Sharp Health Plan, including prenatal and postpartum visits, labor and delivery support, and the specified extended postpartum visits.

MMHCMP: Sharp Health Plan Maternal Mental Health Case Management Program.

Frequently asked questions

Question	Answer
Are doula services covered for Medicare Advantage members?	No. Services are not available for Medicare Advantage members.
How many doula visits are covered?	1 initial visit + up to 8 additional prenatal/postpartum visits (in any combination) + up to 2 extended three-hour postpartum visits (total up to 11).

Document changes

2024-12-17review

Policy reviewed on Dec. 17, 2024.

2025-01-01addedLatest

Effective Jan. 1, 2025, coverage for contracted doula services will be available for eligible commercial members.

2025-01-01addedLatest

Covered doula service components and limits

Covered when the member meets eligibility above:

ALL of the following

1 initial visit
Up to 8 additional visits before giving birth, during pregnancy and after giving birth, in any combination
Combined with initial visit yields up to 9 routine visits; separate extended postpartum visits allowed (each extended postpartum visit is three hours; up to two visits allowed)
Support during labor and delivery, abortion or miscarriage, including labor and delivery resulting in stillbirth
Up to 2 extended three-hour postpartum visits after the end of a pregnancy
Each extended postpartum visit is three hours; up to two visits allowed

ref": "b1_1

title": "Covered doula service components and limits

ref_extra_cleanup":