II

106TH CONGRESS

2D SESSION S. 2523

To amend title XVIII of the Social Security Act to provide for reimbursement

of certified midwife services, to provide for more equitable reimbursement

rates for certified nurse-midwife services, and for other purposes.

IN THE SENATE OF THE UNITED STATES

MAY 9, 2000

Mr. CONRAD (for himself and Mr. MURKOWSKI) introduced the following bill;

which was read twice and referred to the Committee on Finance

A BILL

To amend title XVIII of the Social Security Act to provide

for reimbursement of certified midwife services, to provide for more equitable reimbursement rates for certified

nurse-midwife services, and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

4 (a) SHORT TITLE.—This Act may be cited as the

5 ‘‘Promoting Access to Medicare Midwifery Services Act of

6 2000’’.

7 (b) TABLE OF CONTENTS.—The table of contents of

8 this Act is as follows:
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Sec. 1. Short title; table of contents.

Sec. 2. Medicare payment for certified midwife services.

Sec. 3. Increased medicare payments for certified nurse-midwife services and

certified midwife services.

Sec. 4. Clarification of hospital conditions of participation with respect to certified nurse-midwives and certified midwives.

Sec. 5. Medicare payment for freestanding birth center services.

Sec. 6. Clarification of billing rights of certified nurse-midwives and certified

midwives.

Sec. 7. Clarification regarding payments for certified nurse-midwife services

and certified midwife services furnished in teaching hospitals.

Sec. 8. Interim and final regulations.

1 SEC. 2. MEDICARE PAYMENT FOR CERTIFIED MIDWIFE

2 SERVICES.

3 (a) CERTIFIED MIDWIFE AND CERTIFIED MIDWIFE

4 SERVICES DEFINED.—Section 1861(gg) of the Social Se5 curity Act (42 U.S.C. 1395x(gg)) is amended—

6 (1) in paragraph (1)—

7 (A) by striking ‘‘(as defined in paragraph

8 (2))’’ and inserting ‘‘(as defined in subpara9 graph (B))’’; and

10 (B) by inserting ‘‘(A)’’ after ‘‘(1)’’;

11 (2) by redesignating paragraph (2) as subpara12 graph (B); and

13 (3) by adding at the end the following new

14 paragraph:

15 ‘‘(2)(A) The term ‘certified midwife services’ means

16 such services furnished by a certified midwife (as defined

17 in subparagraph (B)) and such services and supplies fur18 nished as an incident to the certified midwife’s service

19 which the certified midwife is legally authorized to perform

20 under State law (or the State regulatory mechanism pro-
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1 vided by State law) as would otherwise be payable under

2 this title if furnished by a physician or as an incident to

3 a physician’s service.

4 ‘‘(B) The term ‘certified midwife’ means an

5 individual—

6 ‘‘(i) with a bachelor’s degree from an accredited

7 educational institution who has completed a program

8 of study and clinical experience meeting guidelines

9 established by the Secretary of Education; or

10 ‘‘(ii) who has been certified in nurse-midwifery

11 or midwifery by an organization recognized by the

12 Secretary of Education.’’.

13 (b) CERTIFIED MIDWIFE BENEFIT.—

14 (1) SCOPE OF BENEFITS.—Section

15 1832(a)(2)(B)(iii) of the Social Security Act (42

16 U.S.C. 1395k(a)(2)(B)(iii)) is amended by inserting

17 ‘‘, certified midwife services’’ after ‘‘certified nurse18 midwife services’’.

19 (2) PAYMENT OF BENEFITS.—Section

20 1833(a)(1)(K) of the Social Security Act (42 U.S.C.

21 1395l(a)(1)(K)) is amended by inserting ‘‘and cer22 tified midwife services’’ after ‘‘certified nurse-mid23 wife services’’.

24 (c) CONFORMING AMENDMENTS.—
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1 (1) USE OF CARRIERS FOR ADMINISTRATION OF

2 BENEFITS.—Section 1842(b)(18)(C)(iii) of the So3 cial Security Act (42 U.S.C. 1395u(b)(18)(C)(iii)) is

4 amended by striking ‘‘(as defined in section

5 1861(gg)(2))’’ and inserting ‘‘or a certified midwife

6 (as defined in paragraph (1)(B) and (2)(B), respec7 tively, of section 1861(gg))’’.

8 (2) HEALTH CARE PROFESSIONAL DEFINED.—

9 Section 1852(j)(3)(D) of the Social Security Act (42

10 U.S.C. 1395w–22(j)(3)(D)) is amended by striking

11 ‘‘and certified nurse-midwife’’ and inserting ‘‘cer12 tified nurse-midwife, and certified midwife’’.

13 (3) INPATIENT HOSPITAL SERVICES.—Section

14 1861(b)(4) of the Social Security Act (42 U.S.C.

15 1395x(b)(4)) is amended by inserting ‘‘, certified

16 midwife services,’’ after ‘‘certified nurse-midwife

17 services’’.

18 (4) MEDICAL AND OTHER HEALTH SERVICES.—

19 Section 1861(s)(2)(L) of the Social Security Act (42

20 U.S.C. 1395x(s)(2)(L)) is amended by inserting

21 ‘‘and certified midwife services’’ before the semicolon

22 at the end.

23 (5) RURAL HEALTH CLINIC SERVICES AND FED24 ERALLY QUALIFIED HEALTH CLINIC SERVICES.—
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1 Section 1861(aa) of the Social Security Act (42

2 U.S.C. 1395x(aa)) is amended—

3 (A) in paragraph (2)(J), by striking ‘‘, or

4 a certified nurse-midwife (as defined in sub5 section (gg))’’ and inserting ‘‘, a certified nurse6 midwife (as defined in subsection (gg)(1)(B)),

7 or a certified midwife (as defined in subsection

8 (gg)(2)(B))’’; and

9 (B) in paragraph (7)(A), by striking ‘‘or

10 certified nurse midwife’’ and inserting ‘‘, cer11 tified nurse-midwife, or certified midwife’’.

12 (6) CERTIFIED NURSE-MIDWIFE SERVICES.—

13 The heading of section 1861(gg) of the Social Secu14 rity Act (42 U.S.C. 1395x(gg)) is amended by add15 ing at the end the following:

16 ‘‘; Certified Midwife Services’’.

17 (7) EXCLUSIONS FROM COVERAGE AND MEDI18 CARE AS SECONDARY PAYER.—Section 1862(a)(14)

19 of the Social Security Act (42 U.S.C. 1395y(a)(14))

20 is amended by inserting ‘‘, certified midwife serv21 ices’’ after ‘‘certified nurse-midwife services’’.

22 (8) AGREEMENTS WITH PROVIDERS OF SERV23 ICES.—Section 1866(a)(1)(H)(i) (42 U.S.C.

24 1395cc(a)(1)(H)(i)) is amended by inserting ‘‘, cer-
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1 tified midwife services’’ after ‘‘certified nurse-mid2 wife services’’.

3 (9) EXCLUSION FROM PAYMENT TO SKILLED

4 NURSING FACILITIES FOR ROUTINE SERVICE

5 COSTS.—Section 1888(e)(2)(A)(ii) of the Social Se6 curity Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amend7 ed by inserting ‘‘, certified midwife services’’ after

8 ‘‘certified nurse-midwife services’’.

9 (10) MEDICAID DEFINITIONS.—Section 1905 of

10 the Social Security Act (42 U.S.C. 1396d) is

11 amended—

12 (A) in subsection (a)(17)—

13 (i) by striking ‘‘a nurse-midwife (as

14 defined in section 1861(gg)) which the

15 nurse-midwife is’’ and inserting ‘‘a cer16 tified nurse-midwife or a certified midwife

17 (as defined in paragraphs (1)(B) and

18 (2)(B), respectively, of section 1861(gg))

19 which the certified nurse-midwife or cer20 tified midwife, as the case may be, is’’; and

21 (ii) by striking ‘‘whether or not the

22 nurse-midwife’’ and inserting ‘‘whether or

23 not the certified nurse-midwife or certified

24 midwife, as the case may be,’’; and
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1 (B) in subsection (t)(2)(B)(ii), by striking

2 ‘‘(as defined in section 1861(gg))’’ and insert3 ing ‘‘or a certified midwife (as defined in para4 graphs (1)(B) and (2)(B), respectively, of sec5 tion 1861(gg)(2)(B))’’.

6 (11) MEDICAID MANAGED CARE.—Section

7 1932(b)(3)(C) of the Social Security Act (42 U.S.C.

8 1396u–2(b)(3)(C)) is amended by striking ‘‘and cer9 tified nurse-midwife’’ and inserting ‘‘certified nurse10 midwife, and certified midwife’’.

11 (d) EFFECTIVE DATE.—The amendments made by

12 this section shall apply to payment for certified nurse-mid13 wife services and certified midwife services furnished on

14 or after the date of enactment of this Act.

15 SEC. 3. INCREASED MEDICARE PAYMENTS FOR CERTIFIED

16 NURSE-MIDWIFE SERVICES AND CERTIFIED

17 MIDWIFE SERVICES.

18 (a) AMOUNT OF PAYMENT.—Section 1833(a)(1)(K)

19 of the Social Security Act (42 U.S.C. 1395l(a)(1)(K)) is

20 amended by striking ‘‘65 percent of the prevailing charge

21 that would be allowed for the same service performed by

22 a physician, or, for services furnished on or after January

23 1, 1992, 65 percent’’ and inserting ‘‘95 percent’’.

24 (b) EFFECTIVE DATE.—The amendments made by

25 subsection (a) shall apply to certified nurse-midwife serv-
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1 ices and certified midwife services furnished on or after

2 the date of enactment of this Act.

3 SEC. 4. CLARIFICATION OF HOSPITAL CONDITIONS OF PAR4 TICIPATION WITH RESPECT TO CERTIFIED

5 NURSE-MIDWIVES AND CERTIFIED MIDWIVES.

6 (a) PAYMENT TO HOSPITAL FOR PATIENTS UNDER

7 CARE OF CERTIFIED NURSE-MIDWIFE OR CERTIFIED

8 MIDWIFE.—Section 1861(e)(4) of the Social Security Act

9 (42 U.S.C. 1395x(e)(4)) is amended to read as follows:

10 ‘‘(4) has a requirement that every patient with

11 respect to whom payment may be made under this

12 title must be under the care of a physician, except

13 that—

14 ‘‘(A) a patient receiving qualified psycholo15 gist services (as defined in subsection (B)) may

16 be under the care of a clinical psychologist with

17 respect to such services to the extent permitted

18 under State law; and

19 ‘‘(B) a patient receiving certified nurse20 midwife services or certified midwife services

21 (as defined in paragraphs (1)(B) and (2)(B),

22 respectively, of subsection (gg)) may be under

23 the care of a certified nurse-midwife or certified

24 midwife, as the case may be, with respect to
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1 such services to the extent permitted under

2 State law;’’.

3 (b) EFFECTIVE DATE.—The amendment made by

4 subsection (a) shall take effect on the date of enactment

5 of this Act.

6 SEC. 5. MEDICARE PAYMENT FOR FREESTANDING BIRTH

7 CENTER SERVICES.

8 (a) FREESTANDING BIRTH CENTER SERVICES AND

9 FREESTANDING BIRTH CENTER DEFINED.—Section

10 1861(gg) of the Social Security Act (42 U.S.C. 1395x(gg))

11 (as amended by section 2(a)) is amended by adding at the

12 end the following new paragraph:

13 ‘‘(3)(A) The term ‘freestanding birth center services’

14 means items and services furnished by a freestanding

15 birth center (as defined in subparagraph (B)) as would

16 otherwise be covered if furnished by a hospital.

17 ‘‘(B)(i) The term ‘freestanding birth center’ means

18 a facility or institution—

19 ‘‘(I) in which births are planned to occur (out20 side the mother’s place of residence);

21 ‘‘(II) in which comprehensive health care serv22 ices are furnished; and

23 ‘‘(III) which has been approved by the Sec24 retary or accredited by an organization recognized
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1 by the Secretary for purposes of accrediting free2 standing birth centers.

3 ‘‘(ii) Such term does not include—

4 ‘‘(I) a rural health clinic, critical access hos5 pital, or a sole community hospital; or

6 ‘‘(II) a facility or institution that is a hospital

7 or an ambulatory surgical center, unless with respect

8 to ambulatory surgical centers, the State law or reg9 ulation that regulates such centers also regulates

10 freestanding birth centers in the State.’’.

11 (b) FREESTANDING BIRTH CENTER BENEFIT.—

12 (1) SCOPE OF BENEFITS.—Section 1832(a)(2)

13 of the Social Security Act (42 U.S.C. 1395l(a)(2))

14 is amended—

15 (A) in subparagraph (I), by striking ‘‘and’’

16 at the end;

17 (B) in subparagraph (J), by striking the

18 period at the end and inserting ‘‘; and’’; and

19 (C) by adding at the end the following new

20 subparagraph:

21 ‘‘(K) freestanding birth center services per22 formed in a freestanding birth center if the cen23 ter has an agreement in effect with the Sec24 retary by which the center agrees to accept the

25 amount of payment determined under section
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1 1833(u) as full payment for such services, and

2 to accept assignment described in section

3 1842(b)(3)(B)(ii) with respect to payment for

4 all such services furnished by the center to indi5 viduals enrolled under this part.’’.

6 (2) PAYMENT OF BENEFITS.—Section 1833 of

7 the Social Security Act (42 U.S.C. 1395l) is amend8 ed by adding at the end the following new sub9 section:

10 ‘‘(u) PAYMENT FOR FREESTANDING BIRTH CENTER

11 SERVICES.—The Secretary shall establish by regulation

12 the amount of payment to be made for facility services

13 furnished in connection with freestanding birth center

14 services and furnished to an individual in a freestanding

15 birth center under this title.’’.

16 (c) CONFORMING AMENDMENTS.—

17 (1) MEDICAL AND OTHER HEALTH SERVICES.—

18 Section 1861(s)(2)(L) of the Social Security Act (42

19 U.S.C. 1395x(s)(2)(L)) is amended—

20 (A) by adding ‘‘and’’ at the end;

21 (B) by inserting ‘‘(i)’’ after ‘‘(L)’’; and

22 (C) by adding at the end the following new

23 clause:

24 ‘‘(ii) freestanding birth center services;’’.
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1 (2) CERTIFIED NURSE-MIDWIFE SERVICES;

2 CERTIFIED MIDWIFE SERVICES.—The heading of

3 section 1861(gg) of the Social Security Act (42

4 U.S.C. 1395x(gg)) (as amended by section 2(c)(6))

5 is amended by adding at the end the following:

6 ‘‘; Freestanding Birth Center Services’’.

7 (d) EFFECTIVE DATE.—The amendments made by

8 this section shall apply to freestanding birth center serv9 ices furnished on or after the date of enactment of this

10 Act.

11 SEC. 6. CLARIFICATION OF BILLING RIGHTS OF CERTIFIED

12 NURSE-MIDWIVES AND CERTIFIED MIDWIVES.

13 (a) USE OF CARRIERS FOR ADMINISTRATION OF

14 BENEFITS.—The first sentence of section 1842(b)(6) of

15 the Social Security Act (42 U.S.C. 1395u(b)(6)) is

16 amended—

17 (1) by striking ‘‘and’’ before ‘‘(F)’’; and

18 (2) by inserting before the period at the end the

19 following: ‘‘, and (G) in the case of certified nurse20 midwife services or certified midwife services de21 scribed in section 1861(s)(2)(L), payment may be

22 made in accordance with subparagraph (A), except

23 that payment may also be made to such individual

24 or entity (or to the agent of such individual or enti25 ty) as the certified nurse-midwife or certified mid-
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1 wife, as the case may be, may designate under an

2 agreement between the certified nurse-midwife or

3 certified midwife, as the case may be, and such indi4 vidual or entity (or the agent of such individual or

5 entity)’’.

6 (b) EFFECTIVE DATE.—The amendment made by

7 subsection (a) shall apply to payment for certified nurse8 midwife services and certified midwife services furnished

9 on or after the date of enactment of this Act.

10 SEC. 7. CLARIFICATION REGARDING PAYMENTS FOR CER11 TIFIED NURSE-MIDWIFE SERVICES AND CER12 TIFIED MIDWIFE SERVICES FURNISHED IN

13 TEACHING HOSPITALS.

14 (a) SCOPE OF BENEFITS.—Section

15 1832(a)(2)(B)(iii) of the Social Security Act (42 U.S.C.

16 1395k(a)(2)(B)(iii)) is amended—

17 (1) by inserting ‘‘(I)’’ after ‘‘(iii)’’; and

18 (2) by adding at the end the following new sub19 clause:

20 ‘‘(II) in the case of certified nurse21 midwife services or certified midwife serv22 ices furnished in a hospital which has a

23 teaching program described in clause

24 (i)(II), such services may be furnished as
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1 provided under sections 1842(b)(7)(E) and

2 1861(b)(8);’’.

3 (b) CLARIFICATION REGARDING PAYMENTS UNDER

4 PART B FOR SUCH SERVICES FURNISHED IN TEACHING

5 HOSPITALS.—

6 (1) IN GENERAL.—Section 1842(b)(7) of the

7 Social Security Act (42 U.S.C. 1395u(b)(7)) is

8 amended—

9 (A) in subparagraph (A), in the matter

10 preceding clause (i), by inserting ‘‘or, for pur11 poses of subparagraph (E), the conditions de12 scribed in section 1861(b)(8),’’ after ‘‘section

13 1861(b)(7),’’;

14 (B) in subparagraph (C), by inserting ‘‘or,

15 for purposes of subparagraph (E), the condi16 tions described in section 1861(b)(8),’’ after

17 ‘‘section 1861(b)(7),’’; and

18 (C) by adding at the end the following new

19 subparagraph:

20 ‘‘(E) In the case of certified nurse-midwife services

21 or certified midwife services furnished to a patient in a

22 hospital with a teaching program approved as specified in

23 section 1861(b)(6) but which does not meet the conditions

24 described in section 1861(b)(8), the provisions of subpara25 graphs (A) through (C) shall apply with respect to a cer-
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1 tified nurse-midwife or a certified midwife, as the case

2 may be, under this subparagraph as such provisions apply

3 to a physician under such subparagraphs.’’.

4 (2) REGULATIONS.—Not later than 6 months

5 after the date of enactment of this Act, the Sec6 retary shall promulgate regulations to carry out the

7 amendments made by paragraph (1).

8 (c) INPATIENT HOSPITAL SERVICES.—Section

9 1861(b) of the Social Security Act (42 U.S.C. 1395x(b))

10 is amended—

11 (1) in paragraph (6)—

12 (A) by inserting ‘‘(A)’’ after ‘‘(6)’’; and

13 (B) by adding at the end the following new

14 subparagraph:

15 ‘‘(B) in the case of services in a hospital or os16 teopathic hospital, an intern or resident-in-training

17 in the field of obstetrics and gynecology taught or

18 supervised by a certified nurse-midwife or certified

19 midwife (as defined in paragraphs (1)(B) and

20 (2)(B), respectively, of subsection (gg)) to the extent

21 permitted under State law and as may be authorized

22 by the hospital;’’;

23 (2) in paragraph (7), by striking the period at

24 the end and inserting ‘‘; or’’; and
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1 (3) by adding at the end the following new

2 paragraph:

3 ‘‘(8) a certified nurse-midwife or a certified

4 midwife where the hospital has a teaching program

5 approved as specified in paragraph (6), if—

6 ‘‘(A) the hospital elects to receive any pay7 ment due under this title for reasonable costs of

8 such services; and

9 ‘‘(B) all certified nurse-midwives and cer10 tified midwives in such hospital agree not to bill

11 charges for professional services rendered in

12 such hospital to individuals covered under the

13 insurance program established by this title.’’.

14 SEC. 8. INTERIM AND FINAL REGULATIONS.

15 Except with respect to the amendments made by sec16 tion 7(b), in order to carry out the amendments made by

17 this Act in a timely manner, the Secretary of Health and

18 Human Services may first promulgate regulations that

19 take effect on an interim basis after notice and pending

20 opportunity for public comment by not later than 1 year

21 after the date of enactment of this Act.

Æ