BADT, Certification, and Medicaid: Answering Your FAQs with Sabia Wade

1. Can you share what trends you’re seeing with becoming a Medicaid-approved doula?

First, I'm seeing people want to become a doula, right? Because they see Medicaid as a benefit–something that can create some level of sustainability with another income pathway. And I think that's a good benefit, especially for community-based doulas who were doing this work, mostly for free or at lower cost, because they’re adding in this Medicaid process to get paid for their labor.

Second, I’m seeing that doulas who are becoming Medicaid-approved are realizing how difficult the bureaucracy, paperwork, and process of getting insurance is.

And so people are like, oh, there are way more steps than I anticipated, along with the additional administrative work, like having to learn billing and coding, or paperwork that people are not used to at this level. So I think some people are moving into Medicaid being like, really excited. And then the bureaucracy sometimes dampens the experience, unless they have support from an organization or other doula that they're working with.

The third trend I'm seeing with community-based doulas working in nonprofits is that funders are reducing their support.

Before, you'd be able to get a grant for, say, $50,000, directly for doula work. But when Medicaid came along, funders pulled back money because they thought, “Well, Medicaid takes care of this. I don't have to pay for this.” But I am starting to see a reversal, which I think is a good thing–a trend of funders saying, “Oh, I see you need more support with operating funds to help keep your team moving again.” Nonprofits are also creating grants and pathways for private doulas to have some income to help them build the support they need while moving through the Medicaid process.

2. What changes has BADT made for its Full Spectrum Doula certification process in response to these trends?

To facilitate folks becoming a certified doula to get Medicaid approval, we’ve made some changes in the past year or so to make that process smoother.

Every state that is actively participating in a Medicaid doula program has their own qualifications for becoming an approved provider. Some states have very specific criteria, so BADT sends our curriculum, application, and other details to get approved. Some states have more flexible criteria, like having at least eight hours of this, or four hours of that.

So we've had to make changes, one of them being that most of the states across the board want you to have three births to become a Medicaid-approved doula.

Prior to these Medicaid shifts, we left the practical requirement of our full spectrum doula program open to abortion support, postpartum support, or 1-3 births to qualify for certification. Now we have changed it to three births across the board so it's understandable and everyone has met the requirements for their state after completing our program.

We also added an open-note test at the end, since that is another common Medicaid requirement. But here, the test can be done over again, so it's accessible. If you need support, we encourage you to let us know what that support is–our goal is to reduce barriers for certification. We also recommend becoming familiar with Medicaid requirements in your state.

3. If people need to recertify with us, what do they need to do? How much does it cost?

Some states require that their doulas renew their certification, usually every three years. So we’ve integrated that into our system.

All that is required to re-certify is proof of attendance of one class (professional development, inside or outside BADT) during those three years.

That renewal is free, regardless of what cohort you’re in.

We offer free quarterly events that count towards that requirement, too.

We’re ensuring that we're not adding a bunch of additional fees that we have not had before. We're aiming to stick to our foundational values, while also staying in alignment with Medicaid enough for our doulas to feel like they can utilize our program, be in community, and meet the shifting requirements being put out.

4. What happens if a doula gets Medicaid-approved in one state and then moves to another state?

Currently, each state has their own differences, and you have to be certified by each in order to be approved with them. So if you are working in, let's say, California, and you get approved there as a Medicaid doula, when you move to Nevada, you’ll have to complete their process.

Unfortunately, we've yet for states or countries to have a universal pathway. We would love that.

But for now, if you’re certified in one state, as soon as you know you're moving to another state, just start the process, because the timeline can be a few weeks to a few months depending. If you can get ahead of it, get ahead of it.

5. Can I get certified in a state I don’t live in?

You often can, but the best practice is to always look up that specific state's requirements and see if they have a residential requirement. I haven't seen a residential requirement in the states that I'm aware of.

6. Can I still take BADT classes if BADT isn’t a Medicaid-approved training provider in my state?

The short answer: yes! 

The long answer: if you are in a state that works with Medicaid doulas, but BADT is not listed, always contact us first to see if we're in process or have updates because we're working on those applications all the time.

There are also some states who just are not utilizing Medicaid at all. If that's the case, or if Medicaid approval isn’t something you're aiming for, then of course come to BADT.

Even if you are aiming for Medicaid approval, and you want to come to us at a different time to get more inclusive training or join our community, then come join us!

7. Can people who trained with another organization use that training to get certified with us? Why or why not?

At BADT, we honor other organizations, how they train, and what they train on.

However, we have built a training that is not just about the training; it's also about how we help you integrate the content.

So we're learning, you know, obviously how babies get here, but we're also learning about inclusion, different “-isms,” trauma-informed care, and how we actually have conversations amongst each other in a space of people who are so different, right?

In that way, we're also building community.

We're building a collective experience.

We can't sign off on a certification from another organization or transfer a certification to our organization without that experience.

So we do not apply other trainings to our certifications or transfer certifications, both out of respect for the organization and for the people who went through our training.

BADT is not just a space you come to and earn a certificate. (Some of our students don't ever want a certificate.) It's about the community you gain and the relationships you build in the process. And that can't be duplicated or signed off on.

8. What does Medicaid reimbursement look like in practice?

In practice, once approved as a Medicaid doula, you'll work with clients within whatever frame Medicaid in your state gives you.

For example, in California, you may have eight one-hour-long in-person or virtual appointments per client. Those appointments can also skew mostly prenatal or postpartum, depending on your client’s needs. Once you complete a visit, you will then input whatever the managed care system requires for payment information. Each managed care system, meaning each insurance provider, will have a different process for billing and coding. Say a prenatal appointment code is 141.1; you’ll put that in for payment. Some managed care systems have technology online where you put in your invoice, but for others, you may still have to actually write it down and fax it over.

I think the biggest admin that is added to this process is not only learning about and doing the coding, but also knowing that every managed care system you work with will have a different process.

For example, if you're working with Kaiser, their process and technology will be different from Blue Cross Blue Shield. There is no universal system. You can put visits in per interaction, or you may combine visits and put them in once a month all at one time. Then, you're going to wait–it could be a couple of weeks, depending on what state you're in, the managed care system, or other factors.

You’ll then learn if the claim has been approved or declined. If approved, then great! You will see your money hopefully in the next 2-6 weeks, depending. If declined, you may have to make a phone call and ask why. It may be because the code is incorrect, or it may be because, unfortunately, sometimes AI is working with the claims. So it may actually be declined for incorrect reasons until it reaches a human. Whatever the reason is, hopefully when you go to get it re-approved, it goes smoothly. If it doesn't, you may have to go through another process.

Another thing that's really difficult is, when working with clients, you want to be able to keep moving forward, right? You want to be able to do as many prenatal visits and births as you can, but it gets really difficult. Doulas have to make a big choice when, for example, the managed care system is inefficient or holding a payment for weeks at a time. So now you're working with this 36-week-pregnant client, you've already done four prenatals, and they've been approved, but you haven't seen payment for them. Or they've been declined, but no one can give you a reason why. It starts to be like, well, can I attend this person's birth? Am I ever going to get paid for any of it?

The other thing to be mindful of is claims do expire.

Say you have a managed care plan that says after six months from the date of the prenatal visit or event, if the claim has not been completed, then it's expired. That's also the difficulty–doulas want to be present for their clients, but what do they do if they’re not getting paid for weeks and sometimes months?

9. Any final words of wisdom for folks navigating this process for the first time?

My words of wisdom would be to diversify your income within your doula practice.

If you're going to work with Medicaid clients, I think that's great. And, if you can still get clients with private pay or health insurance with a flexible spending account, sometimes you can get your funds back more quickly.

If possible, start off with 20% to 30% of your client load with Medicaid clients, so you can figure out the process of the systems you're working with and how slow or fast they move when processing claims (i.e., of 8 clients, 2 to 3 would be Medicaid, and the other 5 would be private pay). This way, you ensure you actually get paid for your work and figure out how much admin work you can realistically manage. Because starting off with Medicaid and learning these processes at the same time can be a lot, so I want to validate that.

So just aim to find balance and give yourself time to learn these administrative processes.

I know as doulas we aim to serve, and that's what we do.

A lot of us, we're just bleeding hearts, right? But having that awareness will help you to still be able to serve in the ways you want without depleting yourself.

In essence, Medicaid is a great strategy for being able to work with the community, with doulas, especially those who are already doing this work–especially marginalized doulas who are already doing this work. It is a beautiful concept and idea.

And, I want people to have a realistic view of Medicaid and what it takes to make it work in a way that is balanced and healthy, not only for the client, but for the doula. So that's my advice.