Updates to a Defense Health Agency demonstration project should allow more TRICARE beneficiaries to access labor and delivery care while increasing payments to providers of that care.

Services provided by doulas – trained professionals who provide physical and emotional support during labor, delivery, and the early postpartum time – are not typically covered by commercial health plans. But recognizing the unique conditions of military life, Congress authorized the Childbirth and Breastfeeding Support Demonstration in the FY 2021 National Defense Authorization Act (NDAA) to evaluate the impact of certified labor doulas within the TRICARE population.

Servicemembers and spouses may benefit from additional maternity care resources since they often deliver without the support of their spouse, family, and friends due to geographic separation.

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The demonstration began Jan. 1, 2022; nearly 700 beneficiaries participated through April 2023, with a total of 2,300 antepartum or postpartum doula visits. Nearly 500 beneficiaries had continuous labor support from a doula as part of the demonstration. Overseas expansion is planned for 2025.

What’s New

In the second phase of the five-year demonstration, beneficiaries will have more flexibility with antepartum and postpartum doula visits thanks to changes in how these visits are billed and paid.

Current rules allow for six untimed visits. Under rules outlined in an April 11 Federal Register notice, visits will be billed in 15-minute increments, with each beneficiary eligible for up to 24 such increments. This will allow the beneficiary and their doula to select the most appropriate use of their visit allowance – some visits might be a quick 15-minute check-in, while others are lengthier to allow for more support when it is most needed.

The new phase also will include higher reimbursements for some doulas. Using an updated reimbursement methodology, the national rate for all covered doula services will be about $550 more per TRICARE beneficiary than under the current rates. National rates will be adjusted using the Medicare Geographic Adjustment Factor, so reimbursements will vary by locality.

The changes will be fully implemented by Jan. 1, 2025, with a transition period from June 10 of this year until that date.

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Certification Concerns

Phase 2 also adds a requirement that all certified labor doulas under the demonstration must be a participating provider under TRICARE. This means they will be required to file claims and accept the TRICARE reimbursement rate as payment in full.

Non-participating providerswill be ineligible for reimbursement of services rendered on or after Jan. 1, 2025. For example, if a non-participating provider renders antepartum visits in late December, those may be reimbursed; however, if the beneficiary goes into labor on Jan. 2, 2025, charges for labor support will be denied unless the doula has become a participating provider.

Because most commercial health plans don’t consider doula services a covered benefit, TRICARE has faced numerous challenges in implementing the demonstration. Doulas are not licensed in any state, and there are more than 150 training and certification organizations with no consensus on requirements for education, experience, or scope of practice.

This creates challenges in determining appropriate provider authorization criteria. Most doulas operate self-pay practices and are unfamiliar with working with insurers, resulting in a steep learning curve. MOAA appreciates the efforts to evolve policy as the demonstration progresses.

When the five-year demonstration concludes, an independent evaluation will assess the impact of childbirth support services on the TRICARE program and beneficiaries.