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March 8, 2023 SB 23-167
Legislative Council Staff
Nonpartisan Services for Colorado’s Legislature
Fiscal Note
Drafting Number:
Prime Sponsors:
LLS 23-0840
Sen. Winter F.; Will
Rep. Gonzales-Gutierrez
Date:
Bill Status:
Fiscal Analyst:
March 8, 2023
Senate Health & Human Services
Shukria Maktabi | 303-866-4720
shukria.maktabi@coleg.gov
Bill Topic: BOARD OF NURSING REGULATE CERTIFIED MIDWIVES
Summary of
Fiscal Impact:
☒ State Revenue
☒ State Expenditure
☐ State Transfer
☒ TABOR Refund
☐ Local Government
☐ Statutory Public Entity
The bill requires the Board of Nursing in the Department of Regulatory
Agencies to regulate certified midwives. The bill increases state expenditures starting
FY 2023-24, and increases state revenue starting in FY 2024-25.
Appropriation
Summary:
For FY 2023-24, the bill requires an appropriation of $15,393 to the Department of
Public Health and Environment.
Fiscal Note
Status:
The fiscal note reflects the introduced bill.
Table 1
State Fiscal Impacts Under SB 23-167
Budget Year
FY 2023-24
Out Year
FY 2024-25
Out Year
FY 2025-26
Revenue Cash Funds - $70,000 $10,000
Total Revenue - $70,000 $10,000
Expenditures General Fund $15,393 - -
Cash Funds - $54,135 $34,005
Centrally Appropriated $3,645 $3,227 $1,614
Total Expenditures $19,038 $57,362 $35,619
Total FTE 0.2 FTE 0.5 FTE 0.3 FTE
Other Budget Impacts TABOR Refund - $70,000 Not estimated
General Fund Reserve $2,309 - -
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March 8, 2023 SB 23-167
Summary of Legislation
Starting July 1, 2024, the bill requires midwives who are certified by the American Midwifery
Certification Board to obtain a license from the State Board of Nursing in the Department of
Regulatory Agencies (DORA) to practice as a certified midwife. This licensure also requires payment
of a required fee and submission of a criminal history record check. Once licensed, a certified midwife
can apply to obtain provisional and full prescriptive authority if certain experience and liability
insurance requirements are met.
The bill also adds certified midwives to the list of professions subject to a class 2 misdemeanor for
practicing without an active license and makes it a class 6 felony for a person to intentionally
misrepresent themselves as a licensed certified midwife. The bill also authorizes certified midwives
to report data into the immunization tracking system and be a medical supervisor in clinical settings.
The bill expands the duties of the State Board of Nursing to include the regulation of certified
midwives, including enforcing disciplinary actions and investigating complaints. It also adds a
member to the State Board of Nursing and updates its membership requirements to include a certified
midwife.
Background and Assumptions.
Currently, direct-entry midwives and certified nurse midwives are regulated by DORA. Certified
midwives are not currently licensed by the State Board of Nursing in Colorado. The fiscal note
assumes that around 175 individuals will be licensed as certified midwifes in FY 2024-25, and around
25 per year thereafter will enter the profession.
Comparable Crime Analysis
Legislative Council Staff is required to include certain information in the fiscal note for any bill that
creates a new crime, changes the classification of an existing crime, or creates a new factual basis for
an existing crime. Using Judicial Department data, the following section outlines crimes that are
comparable to the offense in this bill and discusses assumptions on future rates of criminal convictions
resulting from the bill.
Prior conviction data. This bill adds practicing as a certified midwife without a license to the list of
unauthorized practices, a class 2 misdemeanor. To form an estimate on the prevalence of this new
crime, the fiscal note analyzed the existing offense of unauthorized practice of acupuncturists as a
comparable crime. From FY 2019-20 to FY 2021-22, one offender (white, male) has been sentenced and
convicted for this existing offense.
The bill also makes fraudulently representing oneself and practicing as a licensed certified midwife a
class 6 felony. To form an estimate of the prevalence of this new crime, the fiscal note analyzed the
existing offense of practicing medicine as a physician assistant or anesthesiologist assistant using false
or forged evidence to obtain a license as a comparable crime. From FY 2019-20 to FY 2021-22, zero
offenders have been sentenced and convicted for this existing offense.
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March 8, 2023 SB 23-167
Assumptions. Based on the low number of sentences for each offense, the fiscal note assumes that
there will be minimal or no additional case filings or convictions for the new offense under the bill.
Because the bill is not expected to have a tangible impact on criminal justice-related expenditures or
revenue at the state or local levels, these potential impacts are not discussed further in this fiscal note.
State Revenue
State revenue to the Professions and Occupations Cash Fund in DORA is estimated to increase by
$70,000 in FY 2024-25 and $10,000 in FY 2025-26. Revenue to the Professions and Occupation Cash
Fund is subject to the state’s TABOR limit.
Fee impact on certified midwives. Colorado law requires legislative service agency review of
measures which create or increase any fee collected by a state agency. These fee amounts are estimates
only, based on the assumed costs and regulated population in this fiscal note, which will result in fees
of $400 for a two-year license for certified midwifes. However, actual fees will be set administratively
by DORA based on cash fund balance, program costs, and the number of persons seeking licensure
under the bill. The table below identifies the fee impact of this bill through FY 2026-27
Table 2
Fee Impact on Certified Midwives
Fiscal Year
Type of
Fee
Proposed
Fee
Number
Affected
Total Fee
Impact
FY 2023-24 - - -
FY 2024-25 Initial License $400 175 $70,000
FY 2024-25 Total $70,000
FY 2025-26 Initial License $400 25 $10,000
FY 2025-26 Total $10,000
FY 2026-27 Initial License $400 25 $10,000
Renewal $400 175 $70,000
FY 2026-27 Total $80,000
Fee impact on direct-entry midwives and certified nurse midwives. Preliminarily, the fiscal note
assumes that certified midwifes under the bill will be new professionals in the state who have relevant
experience and education and who will seek a license under the bill. However, some people who
qualify for the new license type may currently be practicing as a direct entry-midwife. Others who
are certified nurse midwives may choose to switch to the new license if it allows them to practice
midwifery while no longer meeting other requirements of being a registered nurse. On an ongoing
basis, some persons interested in practicing as a midwife may forego becoming a certified nurse
midwife once the new license type is available. To the extent midwives shift to the new license type
away from these other licenses, the population of direct entry midwives and certified nurse midwives
may decrease, which could result in higher fees on the remaining population to cover the costs of
regulation. These impacts cannot be estimated at this time. The fiscal note may be updated if
additional information on the interaction between the three types of midwife credentials become
available. Page 4
March 8, 2023 SB 23-167
Background check fees. The bill will also increase cash fund revenue to the Department of Public
Safety by a minimal amount for additional background checks for less than 50 certified midwife
applicants starting in FY 2024-25. The current fee for a finger-print based background check is $39.50,
of which $12 is passed through to the federal government.
State Expenditures
In FY 2023-24, the bill increases state expenditures in Department of Public Health and Environment
(CDPHE) by about $19,000, paid from the General Fund. After implementation of the new license
type, the bill increases expenditures in DORA by $57,000 in FY 2024-25 and $36,000 in FY 2025-26 and
future years, paid from the Professions and Occupations Cash Fund. Expenditures are shown in
Table 3 and detailed below. In addition, workload to the Judicial Department and Department of
Public Safety will increase, as described below.
Table 3
Expenditures Under SB 23-167
Budget Year
FY 2023-24
Out Year
FY 2024-25
Out Year
FY 2025-26
Department of Regulatory Agencies
Personal Services - $10,939 $5,470
Legal Services - $42,296 $26,435
Board Member Reimbursement - $900 $900
Consultant Costs - - $1,200
Centrally Appropriated Costs
1
- $3,227 $1,614
FTE – Personal Services - 0.2 FTE 0.1 FTE
FTE – Legal Services - 0.3 FTE 0.2 FTE
DORA Subtotal - $57,362 $35,619
Dept. of Public Health & Environment
Personal Services $15,393 - -
Centrally Appropriated Costs
1
$3,645 - -
FTE – Personal Services 0.2 FTE - -
CDPHE Subtotal $19,038 - -
Total $19,038 $57,362 $35,619
Total FTE 0.2 FTE 0.5 FTE 0.3 FTE
1
Centrally appropriated costs are not included in the bill's appropriation.
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March 8, 2023 SB 23-167
Department of Regulatory Agencies. Starting in FY 2024-25, DORA will have increased expenditures
to regulate certified midwifes, as described below.
Staffing costs. DORA will require 0.2 FTE in FY 2024-25 and 0.1 FTE in following fiscal years to
create application forms and update interfaces, provide outreach to certified midwife licensees,
assist the board in promulgating rules, respond to complaints, process applications, and answer
any questions when it comes to licenses. Any initial workload occurring in FY 2023-24 is assumed
to be absorbable.
Legal services. DORA will require 150 hours of legal services for rulemaking in FY 2024-25 only,
and 250 hours annually for legal counsel regarding complaints and investigations starting in
FY 2024-25. This assumes there will be one additional case referred to the Attorney General Office
every year. Legal services are provided by the Department of Law at a rate of $105.74 per hour.
Consultant costs. Starting in FY 2025-26, expenditures will increase for DORA to contract with
an expert consultant to assist in cases that enter formal investigation. The fiscal note assumes that
20 hours of contract work is required annually at $60 per hour.
Board member reimbursement. Starting in FY 2024-25, expenditures in DORA will increase to
provide per diem and travel reimbursements for an additional board member. The fiscal note
assumes a per diem of $50 per day for 16 meetings a year, and mileage and travel costs of $100 per
year.
Department of Public Health and Environment. In FY 2023-24 only, CDPHE will require 0.2 FTE to
update regulations for birth centers and Emergency Medical Services to allow certified midwives to
provide medical supervision in clinical settings, as allowed by the bill. This includes preparing,
facilitating, and providing subject matter expertise for stakeholder and board hearings.
Workload will also increase to provide onboarding to certified midwives reporting immunization and
exemption data into the Immunization Information System. The fiscal note assumes this workload is
absorbable; however, depending on the number of certified midwives that require onboarding and
impact on workload, additional funding may be required and will be requested through the budget
process.
Judicial Department. Starting in FY 2024-25, workload to the trial courts may increase to the extent
certified midwives appeal any disciplinary decisions by the Board. The fiscal note assumes any
workload will be minimal and does not require a change in appropriations.
Department of Public Safety. The bill increases workload for the Department of Public Safety to
handle additional criminal history checks. No change in appropriations is required.
Centrally appropriated costs. Pursuant to a Joint Budget Committee policy, certain costs associated
with this bill are addressed through the annual budget process and centrally appropriated in the Long
Bill or supplemental appropriations bills, rather than in this bill. These costs, which include employee
insurance and supplemental employee retirement payments, are shown in Table 2. Page 6
March 8, 2023 SB 23-167
Other Budget Impacts
TABOR refunds. The bill is expected to increase the amount of state revenue required to be refunded
to taxpayers by the amounts shown in the State Revenue section above. This estimate assumes the
December 2022 LCS revenue forecast. A forecast of state revenue subject to TABOR is not available
beyond FY 2024-25. Because TABOR refunds are paid from the General Fund, increased cash fund
revenue will reduce the amount of General Fund available to spend or save.
General Fund reserve. Under current law, an amount equal to 15 percent of General Fund
appropriations must be set aside in the General Fund statutory reserve. Based on this fiscal note, the
bill is expected to increase the amount of General Fund held in reserve by the amounts shown in
Table 1, decreasing the amount of General Fund available for other purposes.
Effective Date
The bill takes effect upon signature of the Governor, or upon becoming law without his signature,
except that changes to the State Board of Nursing take effect July 1, 2024.
State Appropriations
For FY 2023-24, the bill requires a General Fund appropriation of $15,393 to the Department of Public
Health and Environment, and 0.2 FTE.
State and Local Government Contacts
Human Services Information Technology Law
Public Health and Environment Public Safety Regulatory Agencies
The revenue and expenditure impacts in this fiscal note represent changes from current law under the bill for each
fiscal year. For additional information about fiscal notes, please visit: leg.colorado.gov/fiscalnotes..