First Regular Session
Seventy-fourth General Assembly
STATE OF COLORADO
ENGROSSED
This Version Includes All Amendments Adopted
on Second Reading in the House of Introduction
LLS NO. 23-0838.02 Chelsea Princell x4335
SENATE BILL 23-288
Senate Committees House Committees
Health & Human Services
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
SENATE
Amended 2nd Reading
April 26, 2023
SENATE SPONSORSHIP
Fields and Buckner,
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, Oregon and Minnesota permit medicaid coverage24
for doula services, and New York City has launched a doula pilot25
program. Studies in Oregon, Minnesota, and Wisconsin have shown that26
when pregnant individuals use a doula, it can save the state money.27
288
-3- (2) Therefore, the general assembly finds that providing doula1
services for medicaid recipients in Colorado would significantly improve2
health outcomes for pregnant and postpartum individuals and would help3
lower the maternal mortality rate in the state.4
SECTION 2. In Colorado Revised Statutes, add 25.5-4-506 as5
follows:6
25.5-4-506. Coverage for doula services - stakeholder process7
- federal authorization - scholarship program - training - report -8
definitions. (1) A
S USED IN THIS SECTION, UNLESS THE CONTEXT9
OTHERWISE REQUIRES:10
(a) "D
OULA" MEANS A TRAINED BIRTH COMPANION WHO PROVIDES11
PERSONAL, NONMEDICAL SUPPORT TO PREGNANT AND POSTPARTUM12
PEOPLE AND THEIR FAMILIES PRIOR TO CHILDBIRTH , DURING LABOR AND13
DELIVERY, AND DURING THE POSTPARTUM PERIOD .14
(b) "M
ATERNITY ADVISORY COMMITTEE " MEANS THE COMMITTEE15
FACILITATED BY THE STATE DEPARTMENT COMPOSED PREDOMINANTLY OF16
B
LACK, INDIGENOUS, AND OTHER PEOPLE OF COLOR WITH MATERNITY17
CARE EXPERIENCE AS RECIPIENTS.18
(2) N
O LATER THAN SEPTEMBER 1, 2023, THE STATE DEPARTMENT19
SHALL INITIATE A STAKEHOLDER PROCESS TO PROMOTE THE EXPANSION20
AND UTILIZATION OF DOULA SERVICES FOR PREGNANT AND POSTPARTUM21
RECIPIENTS IN THE STATE. IN CONDUCTING THE STAKEHOLDER PROCESS ,22
THE STATE DEPARTMENT SHALL :23
(a) D
ESIGN AN OUTREACH STRATEGY THAT INCLUDES BEST24
PRACTICES IN COMMUNITY ENGAGEMENT , INCLUDING, BUT NOT LIMITED25
TO:26
(I) E
NGAGING TRUSTED COMMUNITY PARTNERS TO SUPPORT THE27
288
-4- WORK;1
(II) R
EIMBURSEMENT OF PARTICIPATION COSTS FOR INDIVIDUALS2
WHO ARE NOT OTHERWISE PAID TO PARTICIPATE ;3
(III) R
EIMBURSEMENT OF CHILD CARE COSTS FOR INDIVIDUALS4
WHO PARTICIPATE; AND5
(IV) T
RANSLATION SERVICES AND MEETING TIMES THAT ALLOW6
DIVERSE AND INCLUSIVE PARTICIPATION;7
(b) S
OLICIT FEEDBACK RELATED TO:8
(I) I
NCLUDED TRAININGS OR CERTIFICATIONS FOR DOULAS ;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
(4) F
OR STATE FISCAL YEAR 2024-25, THE STATE DEPARTMENT11
SHALL SUBMIT A REPORT TO THE GENERAL ASSEMBLY AS PART OF THE12
STATE DEPARTMENT 'S "SMART ACT" PRESENTATION REQUIRED BY13
SECTION 2-7-203. THE REPORT MUST INCLUDE FINDINGS AND14
RECOMMENDATIONS FROM THE STAKEHOLDER PROCESS AS DESCRIBED IN15
SUBSECTION (2) OF THIS SECTION. THE STATE DEPARTMENT SHALL WORK16
WITH THE MATERNITY ADVISORY COMMITTEE TO CREATE THE REPORT .17
(5) I
N CARRYING OUT THE STAKEHOLDER PROCESS DESCRIBED IN18
SUBSECTION (2) OF THIS SECTION, THE STATE DEPARTMENT IS EXEMPT19
FROM THE "PROCUREMENT CODE", ARTICLES 101 TO 112 OF TITLE 24.20
(6) N
OT LATER THAN JULY 1, 2024, THE STATE DEPARTMENT21
SHALL SEEK FEDERAL AUTHORIZATION TO PROVIDE DOULA SERVICES FOR22
PREGNANT AND POSTPARTUM PEOPLE TO IMPROVE HEALTH OUTCOMES OF23
PREGNANT AND POSTPARTUM PEOPLE WHO FACE A DISPROPORTIONATELY24
GREATER RISK OF POOR BIRTH OUTCOMES .25
(7) (a) N
OT LATER THAN JULY 1, 2024, THE STATE DEPARTMENT26
SHALL CREATE A DOULA SCHOLARSHIP PROGRAM THAT GRANTS FUNDS TO27
288
-6- INDIVIDUALS WITHOUT SUFFICIENT FINANCIAL RESOURCES TO COMPLETE1
DOULA TRAINING AND CERTIFICATION PROGRAMS NECESSARY TO PROVIDE2
DOULA SERVICES.3
(b) I
N DESIGNING THE DOULA SCHOLARSHIP PROGRAM , THE STATE4
DEPARTMENT SHALL SOLICIT INPUT FROM GROUPS IDENTIFIED IN5
SUBSECTION (3) OF THIS SECTION.6
(c) T
HE STATE DEPARTMENT SHALL DEFINE ELIGIBILITY CRITERIA7
FOR THE DOULA SCHOLARSHIP PROGRAM THAT INCLUDES , BUT IS NOT8
LIMITED TO, THE FOLLOWING:9
(I) P
ROOF OF FINANCIAL HARDSHIP;10
(II) P
ROOF OF STATE RESIDENCY; AND11
(III) A
STATEMENT OF INTENT TO SERVE AS A DOULA PROVIDER IN12
C
OLORADO FOR PREGNANT AND POSTPARTUM RECIPIENTS .13
(d) T
HE STATE DEPARTMENT SHALL DEFINE CRITERIA FOR14
ORGANIZATIONS TO CONDUCT TRAINING AND CERTIFICATION PROGRAMS15
FOR DOULAS THAT INCLUDE, BUT ARE NOT LIMITED TO:16
(I) A
N APPROVED CERTIFICATION PROCESS FOR DOULAS ;17
(II) A
N EQUITABLE APPROACH TO DOULA RECRUITMENT AND18
TRAINING; AND19
(III) A
N APPROVED BUDGET TO PROVIDE FREE TRAINING TO20
ATTENDEES.21
(e) T
HE STATE DEPARTMENT MAY REQUIRE INDIVIDUALS WHO22
RECEIVE SCHOLARSHIP MONEY PURSUANT TO THE DOULA SCHOLARSHIP23
PROGRAM DESCRIBED IN THIS SUBSECTION (7) TO SUBMIT TO THE STATE24
DEPARTMENT, NOT LATER THAN SIX MONTHS AFTER THE INDIVIDUAL 'S25
COMPLETION OF DOULA TRAINING OR CERTIFICATION , DOCUMENTATION26
THAT THE INDIVIDUAL IS SERVING AS A DOULA FOR RECIPIENTS OR IS27
288
-7- WORKING TOWARD ENROLLMENT AS A DOULA MEDICAL ASSISTANCE1
PROVIDER. IF AN INDIVIDUAL DOES NOT COMPLETE THE DOCUMENTATION ,2
THE STATE DEPARTMENT MAY SEEK REPAYMENT OF THE FUNDS AWARDED3
TO THE INDIVIDUAL THROUGH THE DOULA SCHOLARSHIP PROGRAM .4
(f) A
NY MONEY APPROPRIATED TO THE DOULA SCHOLARSHIP5
PROGRAM AND NOT EXPENDED PRIOR TO JULY 1, 2024, IS FURTHER6
APPROPRIATED TO THE STATE DEPARTMENT THROUGH JUNE 30, 2025, TO7
BE USED FOR THE SAME PURPOSE.8
(g) N
OTWITHSTANDING SECTION 24-1-136 (11)(a)(I), THE STATE9
DEPARTMENT SHALL REPORT ANNUALLY BEGINNING IN 2025 TO THE10
GENERAL ASSEMBLY AS PART OF THE STATE DEPARTMENT 'S "SMART11
A
CT" PRESENTATION, AS REQUIRED BY SECTION 2-7-203, ON THE12
UTILIZATION AND OUTCOMES OF THE DOULA SCHOLARSHIP PROGRAM .13
SECTION 3. In Colorado Revised Statutes, add 10-16-155.5 as14
follows:15
10-16-155.5. Actuarial review of doula services - report -16
definition. (1) T
HE DIVISION SHALL CONTRACT WITH AN INDEPENDENT17
ENTITY TO CONDUCT AN ACTUARIAL REVIEW OF THE POTENTIAL18
HEALTH-CARE COSTS AND BENEFITS OF INCLUDING COVERAGE FOR DOULA19
SERVICES FOR PREGNANT AND POSTPARTUM PERSONS COVERED BY HEALTH20
BENEFIT PLANS.21
(2) T
HE DIVISION SHALL PRESENT THE RESULTS FROM THE22
ACTUARIAL REVIEW CONDUCTED PURSUANT TO SUBSECTION (1) OF THIS23
SECTION TO THE GENERAL ASSEMBLY AS PART OF THE DIVISION 'S "SMART24
A
CT" PRESENTATION REQUIRED BY SECTION 2-7-203 DURING STATE FISCAL25
YEAR 2024-25.26
(3) A
S USED IN THIS SECTION, UNLESS THE CONTEXT OTHERWISE27
288
-8- REQUIRES, "DOULA" MEANS A TRAINED BIRTH COMPANION WHO PROVIDES1
PERSONAL, NONMEDICAL SUPPORT TO PREGNANT AND POSTPARTUM2
PEOPLE AND THEIR FAMILIES PRIOR TO CHILDBIRTH , DURING LABOR AND3
DELIVERY, AND DURING THE POSTPARTUM PERIOD .4
SECTION 4. Appropriation. (1) For the 2023-24 state fiscal5
year, $100,000 is appropriated to the department of health care policy and6
financing for use by the other medical services division. This7
appropriation is from the general fund. To implement this act, the division8
may use this appropriation for the doula scholarship program.9
(2) For the 2023-24 state fiscal year, $100,000 is appropriated to10
the department of regulatory agencies for use by the division of insurance.11
This appropriation is from the division of insurance cash fund created in12
section 10-1-103 (3), C.R.S. To implement this act, the division may use13
this appropriation for personal services.14
SECTION 5. Safety clause. The general assembly hereby finds,15
determines, and declares that this act is necessary for the immediate16
preservation of the public peace, health, or safety.17
288
-9-