Open Enrollment Is When Your Clients Decide If They Can Afford You

Talk about FSA money during open enrollment, when clients pick next year's amount. An FSA pays for care on the date it happens, not the date it is paid, so this year's money covers visits already done but generally not a birth next year. Clients due next year can pay now another way and submit to next year's FSA.

Key Takeaways

• Open enrollment is when clients choose next year's FSA amount, so it is the best time for a doula to mention that doula care is an eligible expense on many plans.
• A health FSA reimburses care incurred during the plan year, and the IRS treats care as incurred on the date it is provided, not the date it is paid.
• An FSA cannot make advance reimbursements for future care, so this year's FSA generally cannot pay for a birth in the next plan year.
• A client can pay a doula now with other money and later submit the receipt to the FSA for the plan year in which the birth happened.
• HSA money does not expire, so HSA clients have no year-end deadline for doula care.

Every fall I bring up HSA and FSA money with my clients and the families I'm interviewing. Not in December, when the account is almost empty and everyone is scrambling. In October and November, when most people are sitting at their kitchen table picking next year's benefits.

That is the conversation that decides whether some families can afford you.

When should a doula talk to clients about FSA money?

Open enrollment is when your clients choose how much to set aside in a Flexible Spending Account (FSA) for next year, and sometimes which health plan to carry. If they know your fee and roughly when they will need you, they can plan for it. If they find out in March, the amount is already locked.

So I tell families plainly. Doula support is an eligible expense on many plans. If you are due next year, think about your doula fee when you pick your FSA amount. Check whether your plan covers doula care at all, and if you have a choice of plans, look at that too.

Most families have never heard any of this. Nobody told them, and you can be the one who does.

What can a client's FSA pay a doula for?

An FSA pays for care given during the plan year. The date that counts is the day the care happens, not the day you are paid.

IRS Publication 969 says it directly: distributions from a health FSA are only for qualified medical expenses "incurred during the period of coverage," and "the FSA can't make advance reimbursements of future or projected expenses." Under the IRS's proposed rules, which plans are allowed to follow, an expense is incurred when the care is provided.

For a doula package, each piece counts on its own date. A prenatal visit counts the day you meet. The birth counts the day of the birth. Postpartum visits count on the days you visit.

One rule works in your client's favor. The full amount a client elects for the year is available from the first day of the plan year, no matter how little has come out of their paycheck so far. A client due in February can use the whole year's FSA amount for a February birth.

If you want the whole picture of how insurance, HSA, and FSA money reach a doula, my Insurance Basics for Doulas class walks through it in an hour for $9, and it counts toward your DONA recertification.

Can a client due next year use this year's FSA to pay a doula?

Paying in December for an April birth generally cannot come out of this year's FSA, because the birth hasn't happened yet. The card might go through. FSA card charges are checked against receipts afterward, and a charge for care that hasn't happened can be denied, with the client asked to pay it back.

There is a better path, and it fits with how I handle my own fee. A family can sign and pay now with other money, which keeps this year's rate. Once the birth happens in the new plan year, they send your receipt to next year's FSA, because that is when the care took place. I wrote more about locking in a rate before January in how to tell clients your doula fee is going up in January.

If you bill each prenatal visit separately, the visits you do before the plan year ends can come out of this year's FSA. Those visits already happened.

Two more things to check with the plan:

• Grace period. Some plans allow up to two and a half months after the plan year ends to use leftover money for care given in that window.
• Carryover. Other plans let a set amount roll into next year, up to $680 for 2026.

A plan can offer one or the other, never both. Many also give a window, often around 90 days, to file claims for care that already happened. Your client finds out which by asking their plan administrator.

Do HSA funds have a year-end deadline for doula care?

A Health Savings Account (HSA) works differently. The money doesn't expire. A client can pay you from it or pay another way and reimburse themselves later, with no deadline, as long as the care happened after the HSA was opened. The money doesn't even have to be in the account yet on the day of the care.

So for an HSA client, there is nothing to rush. The question is only how they want to pay.

What should a doula's receipt include for HSA or FSA reimbursement?

Most HSA and FSA payments are simple. The client runs the card, or pays me and submits my receipt for reimbursement. There are usually no forms for me to fill out. If the plan wants forms, that is generally on the client.

What makes it go smoothly is the receipt. Mine includes:

• My name and certification
• The client's name and due date
• Each service provided, with its own date
• The amount paid and payment confirmation
• My National Provider Identifier (NPI)
• My EIN

If you are a sole proprietor without an EIN, your Social Security number goes there instead.

The dates matter more than ever with an FSA, because the plan is checking when the care happened. If a client pays in more than one installment, I send an updated receipt as each payment lands, not one receipt at the end.

Some plans also want a letter of medical necessity from the client's own physician or midwife. The client requests it. I don't write it, because I am not their medical provider. My clients check with their plan before they count on it, and every plan makes its own call. More on accepting the payment itself is in how to accept HSA and FSA funds as a doula, and a client handout is in how to create an HSA and FSA coverage handout.

Frequently Asked Questions

Is doula care an FSA-eligible expense?
Often, but not automatically. IRS Publication 502 does not list doulas by name, so each plan administrator decides, and some ask for a letter of medical necessity from the client's own provider. The client should check with their plan before counting on it.

Can a client use a dependent care FSA or a limited-purpose FSA for a doula?
No. Doula care is a health expense, so it would come from a regular health FSA. A dependent care FSA covers child and dependent care, and a limited-purpose FSA usually covers only dental and vision.

Can a client use this year's FSA for a deposit on a birth next year?
Generally not. An FSA pays for care on the date it happens, and it cannot reimburse care that hasn't happened yet. The client can pay the deposit another way and submit the receipt to next year's FSA after the birth.

Does the client need the full amount in their FSA before they can pay me?
No. The full amount a client elects for the year is available from the first day of the plan year, even if only a little has come out of their paycheck so far.

Do I need an NPI number to accept HSA or FSA money?
Not always, but some plans ask for one on the receipt. A National Provider Identifier is free, and any doula can get one, certified or not.

Who decides whether the plan pays?
The plan does. Your job is a clear, dated receipt. Whether the money is approved is between the client and their plan administrator.

Sources

Internal Revenue Service. (2025). Publication 969: Health savings accounts and other tax-favored health plans. https://www.irs.gov/publications/p969

Internal Revenue Service. (2025). Publication 502: Medical and dental expenses. https://www.irs.gov/publications/p502

Employee benefit plans; cafeteria plans (proposed rule). (2007, August 6). Federal Register, 72(150), 43938. https://www.govinfo.gov/content/pkg/FR-2007-08-06/pdf/E7-14827.pdf

Want the rest of the money side?

Open enrollment is one piece of getting paid by more than the family's checking account. My Insurance Basics for Doulas class covers HSA, FSA, insurance, and the NPI in one hour. It is $9 and counts toward your DONA recertification. Everything else I've written about insurance is in my doula insurance guide.