I

105TH CONGRESS

2D SESSION H. R. 4872

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 HOUSE OF REPRESENTATIVES

OCTOBER 20, 1998

Mr. TOWNS (for himself, Mrs. MORELLA, Mr. MCDERMOTT, Mr. LOBIONDO,

Mrs. LOWEY, Mr. CARDIN, Mr. LEVIN, Mr. BROWN of Ohio, Mr. WAXMAN, Mr. KLINK, Mr. WYNN, Mr. SCHUMER, Mr. ABERCROMBIE, and

Mrs. CAPPS) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Commerce, for a period to be subsequently determined by the Speaker, in

each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

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.

4 This Act may be cited as the ‘‘Certified Nurse Mid5 wifery Medicare Services Act of 1998’’.
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1 SEC. 2. MEDICARE PAYMENT FOR CERTIFIED NURSE-MID2 WIFE AND MIDWIFE SERVICES.

3 (a) CERTIFIED MIDWIFE, CERTIFIED MIDWIFE

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

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

6 at the end the following new paragraphs:

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

8 services furnished by a certified midwife (as defined in

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

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

11 certified midwife is legally authorized to perform under

12 State law (or the State regulatory mechanism provided by

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

14 if furnished by a physician or as an incident to a physi15 cian’s service.

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

17 who has successfully completed a bachelor’s degree from

18 an accredited educational institution and a program of

19 study and clinical experience meeting guidelines prescribed

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

21 recognized by the Secretary.’’.

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

23 U.S.C. 1395x(gg)) is amended to read as follows:

24 ‘‘Certified Nurse-Midwife Services; Certified Midwife

25 Services’’.

26 (b) CERTIFIED MIDWIFE SERVICE BENEFIT.—
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1 (1) MEDICAL AND OTHER SERVICES.—Section

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

3 1395x(s)(2)(L)) is amended by inserting ‘‘and cer4 tified midwife services’’ before the semicolon.

5 (2) PAYMENT TO HOSPITAL FOR PATIENTS

6 UNDER CARE OF CERTIFIED NURSE-MIDWIFE OR

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

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

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

10 and

11 (B) by inserting before the semicolon the

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

13 nurse-midwife services or certified midwife serv14 ices (as defined in paragraphs (1) and (3), re15 spectively, of subsection (gg)) may be under the

16 care of a certified nurse-midwife or certified

17 midwife with respect to such services to the ex18 tent permitted under State law’’.

19 (3) INPATIENT HOSPITAL SERVICE AT TEACH20 ING HOSPITALS.—Section 1861(b) of such Act (42

21 U.S.C. 1395x(b)) is amended—

22 (A) in paragraph (4), by inserting ‘‘cer23 tified midwife services,’’ after ‘‘certified nurse24 midwife services,’’;
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1 (B) in paragraph (6), by striking ‘‘; or’’

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

3 hospital or osteopathic hospital by an intern or

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

5 gynecology, nothing in this paragraph shall be

6 construed to preclude a certified nurse-midwife

7 or certified midwife (as defined in paragraphs

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

9 from teaching or supervising such intern or

10 resident-in-training, to the extent permitted

11 under State law and as may be authorized by

12 the hospital; or’’;

13 (C) in paragraph (7), by striking the pe14 riod at the end and inserting ‘‘; or’’; and

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

16 paragraph:

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

18 midwife where the hospital has a teaching program

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

20 hospital elects to receive any payment due under this

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

22 all certified nurse-midwives or certified midwives in

23 such hospital agree not to bill charges for profes24 sional services rendered in such hospital to individ-
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1 uals covered under the insurance program estab2 lished by this title.’’.

3 (4) BENEFIT UNDER PART B.—Section

4 1832(a)(2)(B)(iii) of such Act (42 U.S.C.

5 1395k(a)(2)(B)(iii)) is amended—

6 (A) by inserting ‘‘(I)’’ after ‘‘(iii)’’;

7 (B) by inserting ‘‘certified midwife serv8 ices,’’ after ‘‘certified nurse-midwife services,’’;

9 and

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

11 subclause:

12 ‘‘(II) in the case of certified nurse13 midwife services or certified midwife serv14 ices furnished in a hospital which has a

15 teaching program described in clause

16 (i)(II), such services may be furnished as

17 provided under section 1842(b)(7)(E) and

18 section 1861(b)(8);’’.

19 (5) AMOUNT OF PAYMENT.—Section

20 1833(a)(1)(K) of such Act (42 U.S.C.

21 1395l(a)(1)(K)) is amended—

22 (A) by inserting ‘‘and certified midwife

23 services’’ after ‘‘certified nurse-midwife serv24 ices’’; and
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1 (B) by striking ‘‘65 percent’’ each place it

2 appears and inserting ‘‘95 percent’’.

3 (6) ASSIGNMENT OF PAYMENT.—The first sen4 tence of section 1842(b)(6) of such Act (42 U.S.C.

5 1395u(b)(6)) is amended—

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

7 ‘‘(F)’’; and

8 (B) by inserting before the period the fol9 lowing: ‘‘, and (G) in the case of certified

10 nurse-midwife services or certified midwife serv11 ices under section 1861(s)(2)(L), payment may

12 be made in accordance with subparagraph (A),

13 except that payment may also be made to such

14 person or entity (or to the agent of such person

15 or entity) as the certified nurse-midwife or cer16 tified midwife may designate under an agree17 ment between the certified nurse-midwife or

18 certified midwife and such person or entity (or

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

20 (7) CLARIFICATION REGARDING PAYMENTS

21 UNDER PART B FOR SUCH SERVICES FURNISHED IN

22 TEACHING HOSPITALS.—(A) Section 1842(b)(7) of

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

24 (i) in subparagraphs (A) and (C), by in25 serting ‘‘or, for purposes of subparagraph (E),
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1 the conditions described in section 1861(b)(8),’’

2 after ‘‘section 1861(b)(7),’’; and

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

4 subparagraph:

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

6 or certified midwife services furnished to a patient in a

7 hospital with a teaching program approved as specified in

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

9 described in section 1861(b)(8), the provisions of subpara10 graphs (A) through (C) shall apply with respect to a cer11 tified nurse-midwife or a certified midwife respectively

12 under this subparagraph as they apply to a physician

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

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

15 the enactment of this Act, the Secretary shall pre16 scribe regulations to carry out the amendments

17 made by subparagraph (A).

18 SEC. 3. MEDICARE PAYMENT FOR FREESTANDING BIRTH

19 CENTER SERVICES.

20 (a) FREESTANDING BIRTH CENTER SERVICES,

21 FREESTANDING BIRTH CENTER DEFINED.—

22 (1) IN GENERAL.—(A) Section 1861(gg) of the

23 Social Security Act (42 U.S.C. 1395x(gg)), as

24 amended in section 2(a)(1), is amended by adding at

25 the end the following new paragraphs:
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1 ‘‘(5) The term ‘freestanding birth center services’

2 means items and services furnished by a freestanding

3 birth center (as defined in paragraph (6)) and such items

4 and services furnished as an incident to the freestanding

5 birth center’s service as would otherwise be covered if fur6 nished by a physician or as an incident to a physician’s

7 service.

8 ‘‘(6) The term ‘freestanding birth center’ means a fa9 cility, institution, or site (other than a rural health clinic,

10 critical access hospital, or a sole community hospital) (A)

11 in which births are planned to occur (outside the mother’s

12 place of residence), (B) in which comprehensive health

13 care services are furnished, and (C) which has been ap14 proved by the Secretary or accredited by an organization

15 recognized by the Secretary for purposes of accrediting

16 freestanding birth centers. Such term does not include a

17 facility, institution, or site that is a hospital or an ambula18 tory surgical center, unless with respect to ambulatory

19 surgical centers, the State law or regulation that regulates

20 such centers also regulates freestanding birth centers in

21 the State.’’.

22 (B) The heading in section 1861(gg) of such

23 Act (42 U.S.C. 1395x(gg)), as amended in section

24 2(b)(2), is further amended by adding at the end the

25 following:
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1 ‘‘; Freestanding Birth Center Services’’.

2 (2) MEDICAL AND OTHER SERVICES.—Section

3 1861(s)(2)(L) of such Act (42 U.S.C.

4 1395x(s)(2)(L)), as amended in section 2(b)(1), is

5 further amended—

6 (A) by inserting ‘‘(i)’’ after ‘‘(L)’’;

7 (B) by adding ‘‘and’’ after the semicolon;

8 and

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

10 clause:

11 ‘‘(ii) freestanding birth center services;’’.

12 (b) PART B BENEFIT.—

13 (1) IN GENERAL.—Section 1832(a)(2)(B)(iii) of

14 such Act (42 U.S.C. 1395k(a)(2)(B)(iii)), as amend15 ed in section 2(b)(4), is further amended by insert16 ing ‘‘freestanding birth center services,’’ after ‘‘cer17 tified midwife services,’’.

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

19 of such Act (42 U.S.C. 1395l(a)(1)) is amended—

20 (A) by striking ‘‘and (S)’’ and inserting in

21 lieu thereof ‘‘(S)’’; and

22 (B) by inserting before the semicolon the

23 following new subparagraph: ‘‘, and (T) with

24 respect to freestanding birth center services

25 under section 1861(s)(2)(L)(ii), the amount
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1 paid shall be made on an assignment-related

2 basis, and shall be 80 percent of the lesser of

3 (i) the actual charge for the services or (ii) an

4 amount established by the Secretary for pur5 poses of this subparagraph, such amount being

6 95 percent of the Secretary’s estimate of the

7 average total payment made to hospitals and

8 physicians during 1997 for charges for delivery

9 and pre-delivery visits, such amounts adjusted

10 to allow for regional variations in labor costs;

11 except that (I) such estimate shall not include

12 payments for diagnostic tests, drugs, or the cost

13 associated with the transfer of a patient to the

14 hospital or the physician whether or not sepa15 rate payments were made under this title for

16 such tests, drugs, or transfers, and (II) such

17 amount shall be updated by applying the single

18 conversion factor for 1998 under section

19 1848(d)(1)(C)’’.

20 SEC. 4. INTERIM, FINAL REGULATIONS.

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

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

23 manner, the Secretary of Health and Human Services may

24 first promulgate regulations, that take effect on an interim

25 basis, after notice and pending opportunity for public com-
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1 ment, by not later than 6 months after the date of the

2 enactment of this Act.

Æ