II 

109TH CONGRESS 

1ST SESSION S. 911 

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 

APRIL 27, 2005 

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-Midwifery Care Act of 2005’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds the following: 
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1 (1) Since 1988, Congress has authorized cer2 tified nurse-midwives (in this section referred to as 

3 ‘‘CNMs’’) to provide maternity-related services to 

4 Medicare-eligible women who are of childbearing age. 

5 Approximately 3,000,000 disabled women are Medi6 care-eligible beneficiaries. In 1993, Congress author7 ized CNMs to also provide additional services out8 side the maternity cycle. Medicare reimburses CNMs 

9 for primary care services if those services are part 

10 of the practitioner’s State-regulated scope of prac11 tice. 

12 (2) In its June 2002 report to Congress, the 

13 Medicare Payment Advisory Commission (MedPAC) 

14 unanimously recommended that the percentage of 

15 part B reimbursement for certified nurse-midwife 

16 services to be increased. 

17 (3) In this same report, MedPAC also stated 

18 that research shows the quality of care and out19 comes for services provided by CNMs are at least 

20 comparable to obstetricians and gynecologists. 

21 (4) A 1998 study from the National Center for 

22 Health Statistics published Journal of Epidemiology 

23 and Community Health found the risk of experi24 encing an infant death was 19 percent lower for 

25 births attended by CNMs than for births attended 
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1 by physicians. The risk of neonatal mortality (an in2 fant death occurring in the first 28 days of life) was 

3 33 percent lower, and the risk of delivering a low 

4 birth weight infant was 31 percent lower. Mean 

5 birth weight was 37 grams heavier for the CNM-at6 tended than for the physician-attended births. Low 

7 birth weight is a major predictor of infant mortality, 

8 subsequent disease, or developmental disabilities. 

9 (5) The study also found that CNMs attended 

10 a greater proportion of women who are at higher 

11 risk for poor birth outcome: African Americans, 

12 American Indians, teenagers, unmarried women, and 

13 those with less than a high school education. Physi14 cians attended a slightly higher proportion of births 

15 with medical complications. However, birth outcomes 

16 for CNMs were better even after socio-demographic 

17 and medical risk factors were controlled for in statis18 tical analyses. 

19 (6) Medicare covers 3,000,000 women with dis20 abilities that are of childbearing age. These women 

21 give birth to approximately 50,000 infants annually 

22 within the program. 

23 (7) CNMs and certified midwives (in this sec24 tion referred to as ‘‘CMs’’) are highly educated 

25 health professionals. Completion of a post-bacca-
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1 laureate educational program, licensure, and passage 

2 of a national certification examination are required 

3 to become CNMs and CMs. 

4 (8) Inequitable reimbursement for obstetrical 

5 and gynecological services provided by CNMs or 

6 CMs jeopardizes access for women (particularly 

7 those covered by Medicare) to the health care pro8 vider of their choice. 

9 SEC. 3. MEDICARE PAYMENT FOR CERTIFIED NURSE-MID10 WIFE AND MIDWIFE SERVICES. 

11 (a) CERTIFIED MIDWIFE, CERTIFIED MIDWIFE

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

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

14 at the end the following new paragraphs: 

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

16 services furnished by a certified midwife (as defined in 

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

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

19 certified midwife is legally authorized to perform under 

20 State law (or the State regulatory mechanism provided by 

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

22 if furnished by a physician or as an incident to a physi23 cian’s service. 

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

25 who has successfully completed a bachelor’s degree from 
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1 an accredited educational institution and a program of 

2 study and clinical experience meeting guidelines prescribed 

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

4 recognized by the Secretary.’’. 

5 (2) The heading in section 1861(gg) of the Social Se6 curity Act (42 U.S.C. 1395x(gg)) is amended to read as 

7 follows: 

8 ‘‘Certified Nurse-Midwife Services; Certified Midwife 

9 Services’’. 

10 (b) CERTIFIED MIDWIFE SERVICE BENEFIT.— 

11 (1) MEDICAL AND OTHER SERVICES.—Section 

12 1861(s)(2)(L) of the Social Security Act (42 U.S.C. 

13 1395x(s)(2)(L)) is amended by inserting ‘‘and cer14 tified midwife services’’ before the semicolon. 

15 (2) PAYMENT TO HOSPITAL FOR PATIENTS

16 UNDER CARE OF CERTIFIED NURSE-MIDWIFE OR

17 CERTIFIED MIDWIFE.—Section 1861(e)(4) of the So18 cial Security Act (42 U.S.C. 1395x(e)(4)) is amend19 ed— 

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

21 and 

22 (B) by inserting before the semicolon the 

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

24 nurse-midwife services or certified midwife serv25 ices (as defined in paragraphs (1) and (3), re-
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1 spectively, of subsection (gg)) may be under the 

2 care of a certified nurse-midwife or certified 

3 midwife with respect to such services to the ex4 tent permitted under State law’’. 

5 (3) INPATIENT HOSPITAL SERVICE AT TEACH6 ING HOSPITALS.—Section 1861(b) of the Social Se7 curity Act (42 U.S.C. 1395x(b)) is amended— 

8 (A) in paragraph (4), by inserting ‘‘cer9 tified midwife services,’’ after ‘‘certified nurse10 midwife services,’’; 

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

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

13 hospital or osteopathic hospital by an intern or 

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

15 gynecology, nothing in this paragraph shall be 

16 construed to preclude a certified nurse-midwife 

17 or certified midwife (as defined in paragraphs 

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

19 from teaching or supervising such intern or 

20 resident-in-training, to the extent permitted 

21 under State law and as may be authorized by 

22 the hospital; or’’; 

23 (C) in paragraph (7), by striking the pe24 riod at the end and inserting ‘‘; or’’; and 
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1 (D) 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 (A) the 

6 hospital elects to receive any payment due under this 

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

8 all certified nurse-midwives or certified midwives in 

9 such hospital agree not to bill charges for profes10 sional services rendered in such hospital to individ11 uals covered under the insurance program estab12 lished by this title.’’. 

13 (4) BENEFIT UNDER PART B.—Section 

14 1832(a)(2)(B)(iii) of the Social Security Act (42 

15 U.S.C. 1395k(a)(2)(B)(iii)) is amended— 

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

17 (B) by inserting ‘‘certified midwife serv18 ices,’’ after ‘‘certified nurse-midwife services,’’, 

19 and 

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

21 subclause: 

22 ‘‘(II) in the case of certified 

23 nurse-midwife services or certified 

24 midwife services furnished in a hos25 pital which has a teaching program 
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1 described in clause (i)(II), such serv2 ices may be furnished as provided 

3 under section 1842(b)(7)(E) and sec4 tion 1861(b)(8);’’. 

5 (5) AMOUNT OF PAYMENT.—Section 

6 1833(a)(1)(K) of the Social Security Act (42 U.S.C. 

7 1395l(a)(1)(K)) is amended— 

8 (A) by inserting ‘‘and certified midwife 

9 services’’ after ‘‘certified nurse-midwife serv10 ices’’, and 

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

12 appears and inserting ‘‘100 percent’’. 

13 (6) ASSIGNMENT OF PAYMENT.—The first sen14 tence of section 1842(b)(6) of the Social Security 

15 Act (42 U.S.C. 1395u(b)(6)) is amended— 

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

17 ‘‘(F)’’; and 

18 (B) by inserting before the period the fol19 lowing: ‘‘, and (G) in the case of certified 

20 nurse-midwife services or certified midwife serv21 ices under section 1861(s)(2)(L), payment may 

22 be made in accordance with subparagraph (A), 

23 except that payment may also be made to such 

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

25 entity) as the certified nurse-midwife or cer-
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1 tified midwife may designate under an agree2 ment between the certified nurse-midwife or 

3 certified midwife and such person or entity (or 

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

5 (7) CLARIFICATION REGARDING PAYMENTS

6 UNDER PART B FOR SUCH SERVICES FURNISHED IN

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

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

9 amended— 

10 (i) in subparagraphs (A) and (C), by in11 serting ‘‘or, for purposes of subparagraph (E), 

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

13 after ‘‘section 1861(b)(7),’’; and 

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

15 subparagraph: 

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

17 services or certified midwife services furnished 

18 to a patient in a hospital with a teaching pro19 gram approved as specified in section 

20 1861(b)(6) but which does not meet the condi21 tions described in section 1861(b)(8), the provi22 sions of subparagraphs (A) through (C) shall 

23 apply with respect to a certified nurse-midwife 

24 or a certified midwife respectively under this 
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1 subparagraph as they apply to a physician 

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

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

4 the enactment of this Act, the Secretary of Health 

5 and Human Services shall prescribe regulations to 

6 carry out the amendments made by subparagraph 

7 (A). 

8 SEC. 4. INTERIM, FINAL REGULATIONS. 

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

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

11 manner, the Secretary of Health and Human Services may 

12 first promulgate regulations, that take effect on an interim 

13 basis, after notice and pending opportunity for public com14 ment, by not later than 6 months after the date of the 

15 enactment of this Act. 

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