The benefit is part of the Birth Equity Initiative, signed by Gov. JB Pritzker in July 2024. For people with private insurance plans subject to state regulation, the law requires coverage of doula services without cost-sharing, with coverage capped at $8,000. Doulas provide support during pregnancy, labor and the weeks after birth, including help with newborn care.

But the law did not establish minimum standards for how many doulas insurers must include in their networks or how accessible those providers must be. Families who cannot find an in-network doula may face large upfront bills and a complicated reimbursement process. The state estimates that only about 30% of Illinois residents with private insurance are covered by plans it can regulate; other plans are not required by the state to provide the benefit.

Grano, who has a history of postpartum depression and was experiencing a high-risk pregnancy, said she contacted Blue Cross before she was pregnant to confirm coverage. After initially being told the benefit was unavailable, she learned it would begin when her plan renewed in July. The insurer later told her it had only five in-network doulas in the Chicago area, according to messages she shared with reporters.

When those providers did not work out, Grano was told she could hire an out-of-network doula and submit a claim. The estimated cost of a month of overnight care was about $10,000. Grano and her husband, E.J. Fagan, worried they could not risk paying that amount without knowing whether they would be repaid.

After questions were sent to Blue Cross, the company expedited Grano’s case and added her doula to its network. The couple no longer faces the same upfront bill, but the insurer approved 16 visits, half the number Grano had initially been told she could receive. Blue Cross spokesperson Tricia Ament said the company was adding in-network doulas but did not say how many.

Other families have encountered reimbursement problems. Katie Lombardi and Louis Massard, a Chicago couple whose daughter was born in May, said they paid about $4,500 for overnight doula care. Blue Cross reimbursed some claims but not others, and the couple said the insurer still owed them about $1,800 while seeking to recover a similar amount it had already paid.

The obstacles are discouraging families who need support, said Anna Rodney, owner of Chicago Family Doulas, an organization working with more than 500 doulas. Some families stop trying to use insurance because the process is too difficult, she said. Rodney also said joining insurer networks can be burdensome for doulas, many of whom work as independent contractors and need timely payment.

The benefit was intended to address serious gaps in maternal health. In Illinois, Black women are three times as likely as white women to die from pregnancy-related medical conditions, according to state data. Research has linked doula support with improved outcomes for mothers and babies, including fewer premature births and lower cesarean-section rates.

State insurance officials say they can investigate complaints and audit insurers, but they do not require companies to report how many doulas are in their networks or how much they pay for doula claims. Because the benefit is new, violations may not appear in state reviews until 2027 or 2028, a department spokesperson said. Families and providers are encouraged to file complaints.

State Rep. Robyn Gabel, a Democrat and lead sponsor of the law, said she plans to introduce legislation in January to require insurers to maintain adequate doula networks. “If a family is interested in having a doula, they should be able to have one,” she said.

For Grano, getting coverage required months of calls and messages while preparing for another cesarean section. She said she worries that families without the time or resources to keep pressing insurers will be unable to use a benefit meant to make care more accessible.