II 

108TH CONGRESS 

2D SESSION S. 2492

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

of certified midwife services and to provide for more equitable reimbursement rates for certified nurse-midwife services. 

IN THE SENATE OF THE UNITED STATES 

JUNE 2, 2004

Mr. CONRAD 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 and to 

provide for more equitable reimbursement rates for certified nurse-midwife services.

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. 

4 This Act may be cited as the ‘‘Improving Access to 

5 Nurse-Midwife Care Act of 2004’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds the following: 
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1 (1) Medicare covers approximately 2 million 

2 women with disabilities that are of childbearing age. 

3 (2) Women with disabilities give birth to 50,000 

4 children annually. 

5 (3) The Agency for Healthcare Policy and Re6 search reports that these women are without appro7 priate access to primary care services. 

8 (4) Their average time between gynecological 

9 visits was 10–12 years. 

10 (5) They were less likely to have received a re11 cent mammogram. 

12 (6) The medicare program reimburses Certified 

13 Nurse Midwives (CNMs) at 65 percent of the physi14 cian fee schedule, on average, only $14 per annual 

15 exam. 

16 (7) CNMs who serve these women are forced to 

17 subsidize care with their own money or turn away 

18 patients because they cannot afford to operate at a 

19 financial loss. 

20 (8) Professional liability premiums for CNMs 

21 are skyrocketing, leaving no monies to subsidize 

22 care. 

23 (9) CNMs are forced to leave the marketplace 

24 as other public and private payers adopt Medicare 

25 payment policies. 
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1 (10) Midwives are highly educated and available 

2 to serve this special population. 

3 SEC. 3. MEDICARE PAYMENT FOR CERTIFIED NURSE-MID4 WIFE AND MIDWIFE SERVICES. 

5 (a) CERTIFIED MIDWIFE, CERTIFIED MIDWIFE

6 SERVICES DEFINED.—(1) Section 1861(gg) of the Social 

7 Security Act (42 U.S.C. 1395x(gg)) is amended by adding 

8 at the end the following new paragraphs: 

9 ‘‘(3) The term ‘certified midwife services’ means such 

10 services furnished by a certified midwife (as defined in 

11 paragraph (4)) and such services and supplies furnished 

12 as an incident to the certified midwife’s service which the 

13 certified midwife is legally authorized to perform under 

14 State law (or the State regulatory mechanism provided by 

15 State law) as would otherwise be payable under this title 

16 if furnished by a physician or as an incident to a physi17 cian’s service. 

18 ‘‘(4) The term ‘certified midwife’ means an individual 

19 who has successfully completed a bachelor’s degree from 

20 an accredited educational institution and a program of 

21 study and clinical experience meeting guidelines prescribed 

22 by the Secretary, or has been certified by an organization 

23 recognized by the Secretary.’’. 

24 (2) The heading in section 1861(gg) of such Act (42 

25 U.S.C. 1395x(gg)) is amended to read as follows: 
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1 ‘‘Certified Nurse-Midwife Services; Certified Midwife 

2 Services’’. 

3 (b) CERTIFIED MIDWIFE SERVICE BENEFIT.—

4 (1) MEDICAL AND OTHER SERVICES.—Section 

5 1861(s)(2)(L) of such Act (42 U.S.C. 

6 1395x(s)(2)(L)) is amended by inserting ‘‘and cer7 tified midwife services’’ before the semicolon. 

8 (2) PAYMENT TO HOSPITAL FOR PATIENTS

9 UNDER CARE OF CERTIFIED NURSE-MIDWIFE OR

10 CERTIFIED MIDWIFE.—Section 1861(e)(4) of such 

11 Act (42 U.S.C. 1395x(e)(4)) is amended—

12 (A) by inserting ‘‘(i)’’ after ‘‘except that’’; 

13 and 

14 (B) by inserting before the semicolon the 

15 following: ‘‘and (ii) a patient receiving certified 

16 nurse-midwife services or certified midwife serv17 ices (as defined in paragraphs (1) and (3), re18 spectively, of subsection (gg)) may be under the 

19 care of a certified nurse-midwife or certified 

20 midwife with respect to such services to the ex21 tent permitted under State law’’. 

22 (3) INPATIENT HOSPITAL SERVICE AT TEACH23 ING HOSPITALS.—Section 1861(b) of such Act (42 

24 U.S.C. 1395x(b)) is amended—
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1 (A) in paragraph (4), by inserting ‘‘cer2 tified midwife services,’’ after ‘‘certified nurse3 midwife services,’’;

4 (B) in paragraph (6), by striking ‘‘; or’’ 

5 and inserting ‘‘or in the case of services in a 

6 hospital or osteopathic hospital by an intern or 

7 resident-in-training in the field of obstetrics and 

8 gynecology, nothing in this paragraph shall be 

9 construed to preclude a certified nurse-midwife 

10 or certified midwife (as defined in paragraphs 

11 (1) and (3), respectively, of subsection (gg)) 

12 from teaching or supervising such intern or 

13 resident-in-training, to the extent permitted 

14 under State law and as may be authorized by 

15 the hospital; or’’; 

16 (C) in paragraph (7), by striking the pe17 riod at the end and inserting ‘‘; or’’; and 

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

19 paragraph: 

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

21 midwife where the hospital has a teaching program 

22 approved as specified in paragraph (6), if (A) the 

23 hospital elects to receive any payment due under this 

24 title for reasonable costs of such services, and (B) 

25 all certified nurse-midwives or certified midwives in 
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1 such hospital agree not to bill charges for profes2 sional services rendered in such hospital to individ3 uals covered under the insurance program estab4 lished by this title.’’. 

5 (4) BENEFIT UNDER PART B.—Section 

6 1832(a)(2)(B)(iii) of such Act (42 U.S.C. 

7 1395k(a)(2)(B)(iii)) is amended—

8 (A) by inserting ‘‘(I)’’ after ‘‘(iii)’’, 

9 (B) by inserting ‘‘certified midwife serv10 ices,’’ after ‘‘certified nurse-midwife services,’’, 

11 and 

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

13 subclause: 

14 ‘‘(II) in the case of certified 

15 nurse-midwife services or certified 

16 midwife services furnished in a hos17 pital which has a teaching program 

18 described in clause (i)(II), such serv19 ices may be furnished as provided 

20 under section 1842(b)(7)(E) and sec21 tion 1861(b)(8);’’. 

22 (5) AMOUNT OF PAYMENT.—Section 

23 1833(a)(1)(K) of such Act (42 U.S.C. 

24 1395l(a)(1)(K)) is amended—
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1 (A) by inserting ‘‘and certified midwife 

2 services’’ after ‘‘certified nurse-midwife serv3 ices’’, and 

4 (B) by striking ‘‘65 percent’’ each place it 

5 appears and inserting ‘‘95 percent’’. 

6 (6) ASSIGNMENT OF PAYMENT.—The first sen7 tence of section 1842(b)(6) of such Act (42 U.S.C. 

8 1395u(b)(6)) is amended—

9 (A) by striking ‘‘and (F)’’ and inserting 

10 ‘‘(F)’’; and 

11 (B) by inserting before the period the fol12 lowing: ‘‘, and (G) in the case of certified 

13 nurse-midwife services or certified midwife serv14 ices under section 1861(s)(2)(L), payment may 

15 be made in accordance with subparagraph (A), 

16 except that payment may also be made to such 

17 person or entity (or the agent of such person or 

18 entity) as the certified nurse-midwife or cer19 tified midwife may designate under an agree20 ment between the certified nurse-midwife or 

21 certified midwife and such person or entity (or 

22 the agent of such person or entity)’’. 

23 (7) CLARIFICATION REGARDING PAYMENTS

24 UNDER PART B FOR SUCH SERVICES FURNISHED IN
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1 TEACHING HOSPITALS.—(A) Section 1842(b)(7) of 

2 such Act (42 U.S.C. 1395u(b)(7)) is amended—

3 (i) in subparagraphs (A) and (C), by in4 serting ‘‘or, for purposes of subparagraph (E), 

5 the conditions described in section 1861(b)(8),’’ 

6 after ‘‘section 1861(b)(7),’’; and 

7 (ii) by adding at the end the following new 

8 subparagraph: 

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

10 services or certified midwife services furnished 

11 to a patient in a hospital with a teaching pro12 gram approved as specified in section 

13 1861(b)(6) but which does not meet the condi14 tions described in section 1861(b)(8), the provi15 sions of subparagraphs (A) through (C) shall 

16 apply with respect to a certified nurse-midwife 

17 or a certified midwife respectively under this 

18 subparagraph as they apply to a physician 

19 under subparagraphs (A) through (C).’’. 

20 (B) Not later than 180 days after the date of 

21 the enactment of this Act, the Secretary of Health 

22 and Human Services shall prescribe regulations to 

23 carry out the amendments made by subparagraph 

24 (A). 
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1 SEC. 4. INTERIM, FINAL REGULATIONS. 

2 Except as provided in section 3(b)(7)(B), in order to 

3 carry out the amendments made by this Act in a timely 

4 manner, the Secretary of Health and Human Services may 

5 first promulgate regulations, that take effect on an interim 

6 basis, after notice and pending opportunity for public com7 ment, by not later than 6 months after the date of the 

8 enactment of this Act.

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