First Regular Session
Seventy-fourth General Assembly
STATE OF COLORADO
REVISED
This Version Includes All Amendments Adopted
on Second Reading in the Second House
LLS NO. 23-0838.02 Chelsea Princell x4335
SENATE BILL 23-288
Senate Committees House Committees
Health & Human Services Public & Behavioral Health & Human Services
Appropriations Appropriations
A BILL FOR AN ACT
C
ONCERNING MEASURES TO DETERMINE COVERAGE FOR DOULA101
SERVICES, AND, IN CONNECTION THEREWITH , MAKING AN
102
APPROPRIATION.103
Bill Summary
(Note: This summary applies to this bill as introduced and does
not reflect any amendments that may be subsequently adopted. If this bill
passes third reading in the house of introduction, a bill summary that
applies to the reengrossed version of this bill will be available at
http://leg.colorado.gov
.)
Not later than September 1, 2023, the bill requires the department
of health care policy and financing (state department) to initiate a
stakeholder process to promote the expansion and utilization of doula
services for pregnant and postpartum medicaid recipients (recipients).
The bill requires the state department to work with a maternity
HOUSE
2nd Reading Unamended
May 3, 2023
SENATE
Amended 3rd Reading
April 27, 2023
SENATE
Amended 2nd Reading
April 26, 2023
SENATE SPONSORSHIP
Fields and Buckner, Coleman, Cutter, Danielson, Exum, Ginal, Gonzales, Hansen,
Hinrichsen, Jaquez Lewis, Kolker, Marchman, Moreno, Mullica, Priola, Roberts, Rodriguez,
Sullivan, Winter F., Zenzinger
HOUSE SPONSORSHIP
English and Joseph,
Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
Capital letters or bold & italic numbers indicate new material to be added to existing law.
Dashes through the words or numbers indicate deletions from existing law. advisory committee to create a report detailing the findings and
recommendations from the stakeholder process and submit the report to
the general assembly during the state department's "SMART Act"
hearing.
Not later than July 1, 2024, the bill requires the state department
to seek federal authorization for medicaid providers to provide doula
services for pregnant and postpartum people.
The bill creates a doula scholarship program to provide financial
support to eligible individuals to pursue doula training and certification.
To be eligible for a scholarship, individuals must agree to enroll as a
doula provider and provide doula services to recipients.
The bill requires the division of insurance (division) to contract
with an independent entity to study the potential health-care costs and
benefits of providing coverage for doula services in health benefit plans.
The bill requires the division to submit a report to the general assembly
during the state department's "SMART Act" hearing detailing the results
and recommendations from the study during the state fiscal year 2024-25.
Be it enacted by the General Assembly of the State of Colorado:1
SECTION 1. Legislative declaration. (1) The general assembly2
finds and declares that:3
(a) There is strong evidence of positive maternal and infant4
outcomes associated with doula services;5
(b) Doula care is associated with a reduction in the number of low6
birth weight babies, preterm births, cesarean sections, labor inductions,7
and other medical interventions, and is associated with increased rates of8
breast-feeding;9
(c) Most pregnant persons who utilize doula services have positive10
outcomes, and the association between doula support and positive11
perinatal outcomes is even stronger for low-income people, people of12
color, and people who experience cultural or language barriers to13
accessing pregnancy care. However, individuals and families who could14
benefit the most from doula services may have the least access to it,15
financially and culturally.16
288-2- (d) The United States has the highest rate of maternal mortality1
among developed countries, with 1,205 deaths due to maternal causes in2
2021;3
(e) It is estimated that more than 80 percent of the maternal4
mortalities in the United States are preventable;5
(f) Data from the Centers for Disease Control and Prevention6
shows that nationally, Black pregnant persons are two to three times more7
likely to die from pregnancy-related causes than White pregnant persons.8
There are between 69 and 70 deaths per 100,000 live births for Black9
pregnant persons, compared to between 26 and 27 deaths per 100,000 live10
births for White pregnant persons, and 28 deaths per 100,000 live births11
for Hispanic pregnant persons.12
(g) High rates of maternal mortality among Black pregnant13
persons span income and education levels; moreover, risk factors such as14
a lack of access to prenatal care and physical health conditions do not15
fully explain the racial disparity in maternal mortality;16
(h) A growing body of evidence indicates that stress from racism17
can result in conditions such as hypertension and preeclampsia that18
contribute to poor maternal health outcomes among Black pregnant19
persons;20
(i) In the United States, one in three births is a cesarean section,21
which costs about 50 percent more than vaginal births. Studies suggest22
that having a doula reduces the need for a cesarean section by 25 percent.23
(j) Currently, 11 states provide medicaid reimbursement for doula24
services. Studies in Oregon, Minnesota, and Wisconsin have shown that25
when pregnant individuals use a doula, it can save the state money.26
(2) Therefore, the general assembly finds that providing doula27
288
-3- services for medicaid recipients in Colorado would significantly improve1
health outcomes for pregnant and postpartum individuals and would help2
lower the maternal mortality rate in the state.3
SECTION 2. In Colorado Revised Statutes, add 25.5-4-506 as4
follows:5
25.5-4-506. Coverage for doula services - stakeholder process6
- federal authorization - scholarship program - training - report -7
definitions - repeal. (1) AS USED IN THIS SECTION, UNLESS THE CONTEXT8
OTHERWISE REQUIRES:9
(a) "D
OULA" MEANS A TRAINED BIRTH COMPANION WHO PROVIDES10
PERSONAL, NONMEDICAL SUPPORT TO PREGNANT AND POSTPARTUM11
PEOPLE AND THEIR FAMILIES PRIOR TO CHILDBIRTH , DURING LABOR AND12
DELIVERY, AND DURING THE POSTPARTUM PERIOD .13
(b) "M
ATERNITY ADVISORY COMMITTEE " MEANS THE COMMITTEE14
FACILITATED BY THE STATE DEPARTMENT COMPOSED PREDOMINANTLY OF15
B
LACK, INDIGENOUS, AND OTHER PEOPLE OF COLOR WITH MATERNITY16
CARE EXPERIENCE AS RECIPIENTS.17
(2) N
O LATER THAN SEPTEMBER 1, 2023, THE STATE DEPARTMENT18
SHALL INITIATE A STAKEHOLDER PROCESS TO PROMOTE THE EXPANSION19
AND UTILIZATION OF DOULA SERVICES FOR PREGNANT AND POSTPARTUM20
RECIPIENTS IN THE STATE. IN CONDUCTING THE STAKEHOLDER PROCESS ,21
THE STATE DEPARTMENT SHALL :22
(a) D
ESIGN AN OUTREACH STRATEGY THAT INCLUDES BEST23
PRACTICES IN COMMUNITY ENGAGEMENT , INCLUDING, BUT NOT LIMITED24
TO:25
(I) E
NGAGING TRUSTED COMMUNITY PARTNERS TO SUPPORT THE26
WORK;27
288
-4- (II) REIMBURSEMENT OF PARTICIPATION COSTS FOR INDIVIDUALS1
WHO ARE NOT OTHERWISE PAID TO PARTICIPATE ;2
(III) R
EIMBURSEMENT OF CHILD CARE COSTS FOR INDIVIDUALS3
WHO PARTICIPATE; AND4
(IV) T
RANSLATION SERVICES AND MEETING TIMES THAT ALLOW5
DIVERSE AND INCLUSIVE PARTICIPATION;6
(b) S
OLICIT FEEDBACK RELATED TO:7
(I) A
N APPROVED DOULA CERTIFICATION PROCESS THAT
8
INCORPORATES NATIONAL AND LOCAL TRAINING PROGRAMS ;9
(II) A
BILLING PROCESS FOR DOULA SERVICES; 10
(III) W
AYS TO RECRUIT DOULAS AND INTEGRATE THEM INTO11
HOSPITAL DELIVERIES;12
(IV) S
UPPORT NEEDED TO BUILD AND RETAIN A DOULA13
WORKFORCE;14
(V) C
OMMUNITY OUTREACH TO DETERMINE HOW TO BEST15
PROMOTE DOULA SERVICES; AND16
(VI) T
HE DOULA SCHOLARSHIP PROGRAM CREATED IN SUBSECTION17
(7)
OF THIS SECTION.18
(3) S
TAKEHOLDERS MUST BE DIVERSE WITH REGARD TO RACE ,19
ETHNICITY, IMMIGRATION STATUS, SEXUAL ORIENTATION, AND GENDER,20
AND MUST REPRESENT OTHER POPULATIONS THAT EXPERIENCE GREATER21
HEALTH DISPARITIES AND INEQUITIES . THE STATE DEPARTMENT MAY22
INCLUDE THE FOLLOWING IN THE STAKEHOLDER PROCESS :23
(a) D
OULAS AND POTENTIAL DOULAS WHO MAY SERVE RECIPIENTS24
WHO INCLUDE, BUT ARE NOT LIMITED TO, BLACK, INDIGENOUS, AND OTHER25
PEOPLE OF COLOR, REFUGEES, NON-ENGLISH SPEAKERS, PEOPLE LIVING IN26
RURAL AREAS, AND PEOPLE WHO WERE RECENTLY INCARCERATED ;27
288
-5- (b) INDIVIDUALS INDIRECTLY INVOLVED IN THE DELIVERY OF1
DOULA SERVICES, INCLUDING, BUT NOT LIMITED TO, CLINICAL PROVIDERS,2
HOSPITALS, MANAGED CARE ENTITIES, AND STATE PARTNERS, INCLUDING,3
BUT NOT LIMITED TO , THE DEPARTMENT OF PUBLIC HEALTH AND4
ENVIRONMENT, DEPARTMENT OF HUMAN SERVICES , DEPARTMENT OF5
EARLY CHILDHOOD, AND DEPARTMENT OF REGULATORY AGENCIES ;6
(c) R
EPRESENTATIVES FROM THE DIVISION OF INSURANCE WITH7
SUBJECT MATTER EXPERTISE; AND8
(d) R
EPRESENTATIVES FROM THE MATERNITY ADVISORY9
COMMITTEE;
10
(e) C
ONSUMER ADVOCATES ; AND
11
(f) E
XPERTS ON PERINATAL CARE AND QUALITY .
12
(4) F
OR STATE FISCAL YEAR 2024-25, THE STATE DEPARTMENT13
SHALL SUBMIT A REPORT TO THE GENERAL ASSEMBLY AS PART OF THE14
STATE DEPARTMENT'S "SMART ACT" PRESENTATION REQUIRED BY15
SECTION 2-7-203. THE REPORT MUST INCLUDE FINDINGS AND16
RECOMMENDATIONS FROM THE STAKEHOLDER PROCESS AS DESCRIBED IN17
SUBSECTION (2) OF THIS SECTION. THE STATE DEPARTMENT SHALL WORK18
WITH THE MATERNITY ADVISORY COMMITTEE TO CREATE THE REPORT .19
(5) I
N CARRYING OUT THE STAKEHOLDER PROCESS DESCRIBED IN20
SUBSECTION (2) OF THIS SECTION, THE STATE DEPARTMENT IS EXEMPT21
FROM THE "PROCUREMENT CODE", ARTICLES 101 TO 112 OF TITLE 24.22
(6) N
OT LATER THAN JULY 1, 2024, THE STATE DEPARTMENT23
SHALL SEEK FEDERAL AUTHORIZATION TO PROVIDE DOULA SERVICES FOR24
PREGNANT AND POSTPARTUM PEOPLE TO IMPROVE HEALTH OUTCOMES OF25
PREGNANT AND POSTPARTUM PEOPLE WHO FACE A DISPROPORTIONATELY26
GREATER RISK OF POOR BIRTH OUTCOMES .27
288
-6- (7) (a) NOT LATER THAN JULY 1, 2024, THE STATE DEPARTMENT1
SHALL CREATE A DOULA SCHOLARSHIP PROGRAM THAT GRANTS FUNDS TO2
INDIVIDUALS WITHOUT SUFFICIENT FINANCIAL RESOURCES TO COMPLETE3
DOULA TRAINING AND CERTIFICATION PROGRAMS NECESSARY TO PROVIDE4
DOULA SERVICES.5
(b) I
N DESIGNING THE DOULA SCHOLARSHIP PROGRAM , THE STATE6
DEPARTMENT SHALL SOLICIT INPUT FROM GROUPS IDENTIFIED IN7
SUBSECTION (3) OF THIS SECTION.8
(c) T
HE STATE DEPARTMENT SHALL DEFINE ELIGIBILITY CRITERIA9
FOR THE DOULA SCHOLARSHIP PROGRAM THAT INCLUDES , BUT IS NOT10
LIMITED TO, THE FOLLOWING:11
(I) P
ROOF OF FINANCIAL HARDSHIP;12
(II) P
ROOF OF STATE RESIDENCY; AND13
(III) A
STATEMENT OF INTENT TO SERVE AS A DOULA PROVIDER IN14
C
OLORADO FOR PREGNANT AND POSTPARTUM RECIPIENTS .15
(d) T
HE STATE DEPARTMENT SHALL DEFINE CRITERIA FOR16
ORGANIZATIONS TO CONDUCT TRAINING AND CERTIFICATION PROGRAMS17
FOR DOULAS THAT INCLUDE, BUT ARE NOT LIMITED TO:18
(I) A
N APPROVED CERTIFICATION PROCESS FOR DOULAS ;19
(II) A
N EQUITABLE APPROACH TO DOULA RECRUITMENT AND20
TRAINING; AND21
(III) A
N APPROVED BUDGET TO PROVIDE FREE TRAINING TO22
ATTENDEES.23
(e) T
HE STATE DEPARTMENT MAY REQUIRE INDIVIDUALS WHO24
RECEIVE SCHOLARSHIP MONEY PURSUANT TO THE DOULA SCHOLARSHIP25
PROGRAM DESCRIBED IN THIS SUBSECTION (7) TO SUBMIT TO THE STATE26
DEPARTMENT, NOT LATER THAN SIX MONTHS AFTER THE INDIVIDUAL 'S27
288
-7- COMPLETION OF DOULA TRAINING OR CERTIFICATION , DOCUMENTATION1
THAT THE INDIVIDUAL IS SERVING AS A DOULA FOR RECIPIENTS OR IS2
WORKING TOWARD ENROLLMENT AS A DOULA FOR RECIPIENTS . IF AN3
INDIVIDUAL DOES NOT COMPLETE THE DOCUMENTATION , THE STATE4
DEPARTMENT MAY SEEK REPAYMENT OF THE FUNDS AWARDED TO THE5
INDIVIDUAL THROUGH THE DOULA SCHOLARSHIP PROGRAM .6
(f) (I) ANY MONEY APPROPRIATED TO THE DOULA SCHOLARSHIP7
PROGRAM AND NOT EXPENDED PRIOR TO JULY 1, 2024, IS FURTHER8
APPROPRIATED TO THE STATE DEPARTMENT THROUGH JUNE 30, 2025, TO9
BE USED FOR THE SAME PURPOSE.10
(II) T
HIS SUBSECTION (7)(f) IS REPEALED, EFFECTIVE JULY 1, 2026.
11
(g) N
OTWITHSTANDING SECTION 24-1-136 (11)(a)(I), THE STATE12
DEPARTMENT SHALL REPORT ANNUALLY BEGINNING IN 2025 TO THE13
GENERAL ASSEMBLY AS PART OF THE STATE DEPARTMENT 'S "SMART14
A
CT" PRESENTATION, AS REQUIRED BY SECTION 2-7-203, ON THE15
UTILIZATION AND OUTCOMES OF THE DOULA SCHOLARSHIP PROGRAM .16
SECTION 3. In Colorado Revised Statutes, add 10-16-155.5 as17
follows:18
10-16-155.5. Actuarial review of doula services - report -19
definition. (1) T
HE DIVISION SHALL CONTRACT WITH AN INDEPENDENT20
ENTITY TO CONDUCT AN ACTUARIAL REVIEW OF THE POTENTIAL21
HEALTH-CARE COSTS AND BENEFITS OF INCLUDING COVERAGE FOR DOULA22
SERVICES FOR PREGNANT AND POSTPARTUM PERSONS COVERED BY HEALTH23
BENEFIT PLANS.24
(2) T
HE DIVISION SHALL PRESENT THE RESULTS FROM THE25
ACTUARIAL REVIEW CONDUCTED PURSUANT TO SUBSECTION (1) OF THIS26
SECTION TO THE GENERAL ASSEMBLY AS PART OF THE DIVISION 'S "SMART27
288
-8- ACT" PRESENTATION REQUIRED BY SECTION 2-7-203 DURING STATE FISCAL1
YEAR 2024-25.2
(3) A
S USED IN THIS SECTION, UNLESS THE CONTEXT OTHERWISE3
REQUIRES, "DOULA" MEANS A TRAINED BIRTH COMPANION WHO PROVIDES4
PERSONAL, NONMEDICAL SUPPORT TO PREGNANT AND POSTPARTUM5
PEOPLE AND THEIR FAMILIES PRIOR TO CHILDBIRTH , DURING LABOR AND6
DELIVERY, AND DURING THE POSTPARTUM PERIOD .7
SECTION 4. Appropriation. (1) For the 2023-24 state fiscal
8
year, $100,000 is appropriated to the department of health care policy and9
financing for use by the other medical services division. This10
appropriation is from the general fund. To implement this act, the division11
may use this appropriation for the doula scholarship program.12
(2) For the 2023-24 state fiscal year, $100,000 is appropriated to13
the department of regulatory agencies for use by the division of insurance.14
This appropriation is from the division of insurance cash fund created in15
section 10-1-103 (3), C.R.S. To implement this act, the division may use16
this appropriation for personal services.17
SECTION 5. Safety clause. The general assembly hereby finds,18
determines, and declares that this act is necessary for the immediate19
preservation of the public peace, health, or safety.20
288
-9-