​Doula Services Frequently Asked Questions​​

​Doula Providers - Hospitals​

The Department of Health Care Services (DHCS) covers doula services in both managed care and fee-for-service delivery systems for pregnant and postpartum individuals. Services include nonmedical support for prenatal and postpartum visits, and during labor and delivery, miscarriage, and abortion. ​​

1. ​​​​​D​o patients in hospitals have a right to a visitor of their choosing, and are there any exceptions? (Added September 6, 2024)​​

• Yes. Under applicable state and federal guidance, a patient has the right to receive the visitors for whom they designate. For more information on federal requirements, please see question #4 below.
• However, a hospital may need to establish any clinically necessary or reasonable restrictions or limitations on such rights. For example:
• The hospital does not allow any visitors at all, although this is not a standard practice and only permitted in limited circumstances.
• The hospital reasonably determines, based on a case-by-case assessment, that the presence of a particular visitor would endanger the health and/or safety of a patient, staff member or other visitor or would significantly disrupt the operations of the facility. Some examples here might include if the visitor is ill or sick (e.g., infection control), the visitor is/would significantly disrupt the operations of the hospital (e.g., small operating rooms), or the patient indicates they do not want the visitor present.
• The hospital visitation policies may differ by type of unit, for example, separate policies for intensive care units or for newborn nurseries.​​​

2. ​​​​​​​​​​​​​​​​What constitutes “patient visitation" under federal Centers for Medicare and Medicaid Services (CMS) regulations for hospitals? (Added September 6, 2024)​​​​

• Patients have the right to receive the visitors for whom the patient designates.  These visitors can include, but are not limited to, a spouse or a domestic partner (including a same-sex spouse or domestic partner), another family member, or a friend.  Additional examples may include a member of the clergy, chaplain, minister, or faith leader.  Facilities subject to the CMS patient visitation regulations must ensure their policies do not discriminate on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. The patient also has the right to withdraw or deny consent to any such visitors at any time.  These rights are protected under CMS regulations at Title 42 Code of Federal Regulations (CFR) Section 482.13(h), which are addressed in more detail in question #4 below.
• Federal and state law allows hospitals to restrict visitation for various reasons. Examples of permission restrictions and/or reasons are found in the CMS Hospital Interpretive Guidelines [Tags A-0215 to A-0217], and CMS Critical Access Hospital Interpretive Guidelines [Tags C-0154 to C-0158].
  

3. ​Why are doulas considered “visitors" at hospitals when they are providing a service to patients involving nonmedical support for prenatal and postpartum visits, and during labor and delivery, miscarriage, and abortion? (Added September 6, 2024)​​

• DHCS understands and acknowledges that there is sensitivity around doulas being considered a “visitor," particularly when a doula accompanies a birthing individual into the hospital. That said, under applicable state and federal guidance there are a finite number of categories that must be addressed under hospital policies and procedures (P&Ps) and the “visitor" category is the closest category. To this end, DHCS and hospital partners are only using this term in the narrow context to describe the category within written hospital P&Ps that doulas can reference to better understand individual hospital practices. 
  

4. Do hospitals have to have written P&Ps that include information regarding patient visitation rights, including for support persons? (Added September 6, 2024)​​

• Yes. Under applicable state and federal requirements, all hospitals must have written P&Ps regarding patient visitation rights. Some hospitals may specifically reference “doulas" while others may refer to a “support person" generally. The P&Ps must address inpatient and outpatient settings and include any clinically necessary or reasonable restrictions on visitation and the reasons for those restrictions. Additionally, all hospitals must inform patients in writing of their right to have visitors of their choosing.
• These requirements are outlined in Title 42 CFR Section 482.13(h), which includes hospitals that receive federal Medicaid dollars, as follows:
  
  “(h) A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. A hospital must meet the following requirements:
  
  (1) Inform each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights under this section.
  
  (2) Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.
  
  (3) Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.
  

​(4) Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences."

5. Given that patients have visitation rights to individuals of their choosing, can a hospital prevent Medi-Cal members from having access to their doulas in the hospital? (Added September 6, 2024)​​

• No. If the patient designates their doula as their support person, then a hospital generally must allow a doula to accompany Medi-Cal members into the hospital, including triage and assessment, labor and delivery, and post-delivery/recovery, if the hospital's written P&Ps allows a support person (visitor, doula, etc.) to accompany birthing individuals. The P&Ps must address inpatient and outpatient settings and include any clinically necessary, reasonable restrictions on visitation rights and the reasons for those restrictions. If there is a specific hospital that is denying Medi-Cal members access to their doulas, please refer to question #6 below for instructions about reporting that information to DHCS.
• However, as noted in #1 above, a doula's access or any visitor's access may be limited or restricted as described in the hospitals P&Ps, which can include case-by-case assessments by the hospital of factors including, but not limited to, being ill, exhibiting disruptive or threatening behavior, declining to comply with reasonable instructions regarding important health or safety rules, or interfering with the medical care of the birthing individual or another patient(s).
  

​​6. What can be done if a doula experiences difficulty with, or is denied access to, providing support to their client/patient? (Added September 6, 2024)​​​