SB 44 - HB 295
FISCAL NOTE
Fiscal Review Committee
Tennessee General Assembly
February 16, 2025
Fiscal Analyst: Chris Higgins | Email: chris.higgins@capitol.tn.gov | Phone: 615-741-2564
SB 44 - HB 295
SUMMARY OF BILL: Requires the Commissioner of the Department of Health (DOH) to
utilize the findings of the Doula Services Advisory Committee to establish, by rule, a process by
which the department issues a verification of certification to a person who has demonstrated the
required knowledge and understanding of pregnancy and doula services.
Authorizes doula services offered by an individual with a verification of certification by DOH to be
made an available medical service to TennCare recipients.
FISCAL IMPACT:
STATE GOVERNMENT
REVENUE Division of Health-Related Boards
FY25-26 & Subsequent Years $281,900
EXPENDITURES General Fund Division of Health-Related Boards
FY25-26 NET $839,200 $281,900
FY26-27 & Subsequent Years NET $1,678,500 $281,900
Total Positions Required: 3
FEDERAL GOVERNMENT
EXPENDITURES
FY25-26 NET $1,513,100
FY26-27 & Subsequent Years NET $3,026,100
OTHER FISCAL IMPACT
The Division of Health-Related Boards had an annual deficit of $596,709 in FY22-23, an annual
deficit of $973,243 in FY23-24, and a cumulative reserve balance of $35,530,690 on June 30, 2024.
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Assumptions:
Department of Health
• The proposed legislation allows for DOH to set the process for doula certification. It is
assumed that the certification will be handled under the Division of Health-Related Boards
(HRBs) in a similar manner to other health providers, such as nurse midwives.
• According to the U.S. Bureau of Labor Statistics, in May 2023 there were 170 nurse
midwives in Tennessee. Since prior to the proposed legislation there was no state
certification for doulas, this analysis assumes that the number of doulas is equal to nurse
midwives.
• The DOH cannot accommodate the proposed legislation utilizing existing resources.
• The HRBs will require three additional positions (two Administrative Services Assistant-4
positions and one Public Health Nursing Consultant-2 position) beginning in FY25-26.
Title Salary Benefits # Positions Total
Admin. Services
Assistant-4 $60,336 $18,038 2 $156,748
Public Health
Nursing Con.-2 $100,440 $24,691 1 $125,131
Total: $281,879
• Pursuant to Tenn. Code Ann. § 4-29-121, all health-related boards are required to be self-
supporting over a two-year period.
• It is assumed that the licensing certification fees for doula providers will be set at an
amount sufficient to cover any increase in expenditures.
• Therefore, there will be a corresponding increase in revenue to the HRBs of at least
$281,879 in FY25-26 and subsequent years.
• The HRBs had an annual deficit of $596,709 in FY22-23, an annual deficit of $973,243 in
FY23-24, and a cumulative reserve balance of $35,530,690 on June 30, 2024.
Division of TennCare:
• It is assumed the Division of TennCare (TennCare) will add doula services coverage as a
result of the proposed legislation.
• Between 2021 and 2023, TennCare covered an average of 39,207 births. This number is
assumed to remain consistent.
• This estimate assumes 20 percent of all covered pregnant women, or 7,841 (39,207 x 20%),
will receive doula services.
• Based on current doula reimbursement rates from other state Medicaid programs, the cost
of coverage per doula is estimated to be $1,100. This would lead to an increase in
expenditures of $8,625,100 (7,841 x $1,100) annually.
• Medicaid expenditures receive matching funds at a rate of 64.323 percent federal funds to
35.677 percent state funds. Of this amount, $3,077,177 ($8,625,100 x 35.677%) will be in
state funds and $5,547,923 ($8,625,100 x 64.323%) will be in federal funds.
• Based on lower preterm and cesarean birth rates associated with women who receive doula
support, the average savings per birth using a doula is estimated to be about $500. This
could mean a potential decrease in total expenditures of $3,920,500 (7,841 x $500).
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• Of this amount, $1,398,717 ($3,920,500 x 35.677%) will be in state funds and $2,521,783
($3,920,500 x 64.323%) will be in federal funds.
• Due to the time to establish the certification verification process, the first-year impact
(FY25-26) is assumed to be half of the full-year impact.
• Therefore, the net increase in state expenditures is estimated to be $839,230 [($3,077,177 -
$1,398,717) x 50%] in FY25-26 and $1,678,460 ($3,077,177- $1,398,717) in FY26-27 and
subsequent years.
• The net increase in federal expenditures is estimated to be $1,513,070 [($5,547,923 -
$2,521,783) x 50%] in FY25-26 and $3,026,140 ($5,547,923 - $2,521,783) in FY26-27 and
subsequent years.
IMPACT TO COMMERCE:
BUSINESS IMPACT
FISCAL YEAR REVENUE EXPENSES
FY25-26 NET $2,352,300 <$2,352,300
FY26-27 & Subsequent Years NET $4,704,600 <$4,704,600
Assumptions:
• Individuals who provide doula services will experience an increase in business revenue for
providing additional services of approximately $8,625,100 per year.
• Hospitals and healthcare providers will experience a decrease in business revenue from
TennCare expenditures of approximately $3,920,500 per year due to a decrease in preterm
and cesarean birth rates.
• There will be a net increase in business revenue of $4,704,600 ($8,625,100 - $3,920,500).
• Due to the time of implementation, the net increase in business revenue is estimated to be
$2,352,300 ($4,704,600 x 50%) in FY25-26, and $4,704,600 in FY26-27 and subsequent
years.
• For companies to retain solvency, any increased expenditures will be less than the amount
of increased revenues collected. Therefore, the net increase in business expenditures is
estimated to be less than $2,352,300 in FY25-26 and less than $4,704,600 in FY26-27 and
subsequent years.
CERTIFICATION:
The information contained herein is true and correct to the best of my knowledge.
Bojan Savic, Executive Director
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