Rule 5160-8-43 | Doula Services.
(A) Definitions applicable to this rule.
(1) "Doula" is an individual listed in the registry specified in section 4723.89 of the Revised Code.
(2) "Doula service" is any of the support activities specified in section 4723.89 of the Revised Code.
(3) "Independent" and "non-independent," with respect to a doula, have the same meanings as in rule 5160-4-02 of the Administrative Code.
(B) Providers.
(1) Independent doulas may receive medicaid payment for submitting a professional claim for covered services they provide.
(2) The following eligible providers may receive medicaid payment for submitting a professional claim on behalf of a doula, either independent or non-independent, for covered services provided by the doula:
(a) An ambulatory health care clinic;
(b) A federally qualified health center (FQHC);
(c) A freestanding birth center;
(d) A hospital;
(e) A professional medical group; or
(f) A rural health clinic (RHC).
(C) Coverage.
(1) A coverage period is defined by the following beginning and ending dates:
(a) The date of conception, if known, or the date of the first antepartum visit; and
(b) The earlier of the following dates:
(i) Three hundred sixty-five days after delivery; or
(ii) Discontinuation of the individual's medicaid eligibility.
(2) During a coverage period, payment may be made for the following doula services:
(a) One comprehensive support service, regardless of duration, provided during labor and delivery; and
(b) Antepartum and postpartum support services, including consultation and telehealth visits, provided in fifteen-minute units up to a maximum of forty-eight units.
(3) Payment for doula services in excess of these limits may be made through the prior authorization (PA) process described in rule 5160-1-31 of the Administrative Code.
(D) Allowances and constraints.
(1) Separate payment may be made for both an evaluation and management service and a doula service rendered by different providers to the same individual on the same date of service.
(2) There are no place-of-service restrictions for doula services.
(E) Claim payment.
(1) For a covered doula service rendered at an FQHC or RHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.
(2) For any other covered doula service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.
Last updated October 3, 2024 at 8:49 AM
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