I 
108TH CONGRESS 
1ST SESSION H. R. 2980
To amend title XVIII of the Social Security Act to provide for reimbursement 
of certified midwife services and to provide for more equitable reimburse-
ment rates for certified nurse-midwife services. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 25, 2003
Mr. TOWNS (for himself and Mr. UPTON) introduced the following bill; which 
was referred to the Committee on Ways and Means, and in addition to 
the Committee on Energy and Commerce, for a period to be subsequently 
determined by the Speaker, in each case for consideration of such provi-
sions 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 and to 
provide for more equitable reimbursement rates for cer-
tified nurse-midwife services.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare Payment Up-
date for Certified Nurse-Midwives Act’’. 
SEC. 2. FINDINGS. 
Congress finds the following:
(1) Medicare covers approximately 2 million 
women with disabilities that are of childbearing age. 
(2) Women with disabilities give birth to 50,000 
children annually. 
(3) The Agency for Healthcare Policy and Re-
search reports that these women are without appro-
priate access to primary care services. 
(4) Their average time between gynecological 
visits was 10–12 years. 
(5) They were less likely to have received a re-
cent mammogram. 
(6) The medicare program reimburses Certified 
Nurse Midwives (CNMs) at 65 percent of the physi-
cian fee schedule, on average, only $14 per annual 
exam. 
(7) CNMs who serve these women are forced to 
subsidize care with their own money or turn away 
patients because they cannot afford to operate at a 
financial loss. 
(8) Professional liability premiums for CNMs 
are skyrocketing, leaving no monies to subsidize 
care. 
(9) CNMs are forced to leave the marketplace 
as other public and private payers adopt Medicare 
payment policies.
(10) Midwives are highly educated and available 
to serve this special population. 
SEC. 3. MEDICARE PAYMENT FOR CERTIFIED NURSE-MID-
WIFE AND MIDWIFE SERVICES. 
(a) CERTIFIED
MIDWIFE, CERTIFIED
MIDWIFE 
SERVICES DEFINED.—(1) Section 1861(gg) of the Social 
Security Act (42 U.S.C. 1395x(gg)) is amended by adding 
at the end the following new paragraphs: 
‘‘(3) The term ‘certified midwife services’ means such 
services furnished by a certified midwife (as defined in 
paragraph (4)) and such services and supplies furnished 
as an incident to the certified midwife’s service which the 
certified midwife is legally authorized to perform under 
State law (or the State regulatory mechanism provided by 
State law) as would otherwise be payable under this title 
if furnished by a physician or as an incident to a physi-
cian’s service. 
‘‘(4) The term ‘certified midwife’ means an individual 
who has successfully completed a bachelor’s degree from 
an accredited educational institution and a program of 
study and clinical experience meeting guidelines prescribed 
by the Secretary, or has been certified by an organization 
recognized by the Secretary.’’. 
(2) The heading in section 1861(gg) of such Act (42 
U.S.C. 1395x(gg)) is amended to read as follows:
‘‘Certified Nurse-Midwife Services; Certified Midwife 
Services’’. 
(b) CERTIFIED MIDWIFE SERVICE BENEFIT.—
(1) MEDICAL AND OTHER SERVICES.—Section 
1861(s)(2)(L) 
of 
such 
Act 
(42 
U.S.C. 
1395x(s)(2)(L)) is amended by inserting ‘‘and cer-
tified midwife services’’ before the semicolon. 
(2) PAYMENT
TO
HOSPITAL
FOR
PATIENTS 
UNDER
CARE
OF
CERTIFIED
NURSE-MIDWIFE
OR 
CERTIFIED
MIDWIFE.—Section 1861(e)(4) of such 
Act (42 U.S.C. 1395x(e)(4)) is amended—
(A) by inserting ‘‘(i)’’ after ‘‘except that’’; 
and 
(B) by inserting before the semicolon the 
following: ‘‘and (ii) a patient receiving certified 
nurse-midwife services or certified midwife serv-
ices (as defined in paragraphs (1) and (3), re-
spectively, of subsection (gg)) may be under the 
care of a certified nurse-midwife or certified 
midwife with respect to such services to the ex-
tent permitted under State law’’. 
(3) INPATIENT HOSPITAL SERVICE AT TEACH-
ING HOSPITALS.—Section 1861(b) of such Act (42 
U.S.C. 1395x(b)) is amended—
(A) in paragraph (4), by inserting ‘‘cer-
tified midwife services,’’ after ‘‘certified nurse-
midwife services,’’;
(B) in paragraph (6), by striking ‘‘; or’’ 
and inserting ‘‘or in the case of services in a 
hospital or osteopathic hospital by an intern or 
resident-in-training in the field of obstetrics and 
gynecology, nothing in this paragraph shall be 
construed to preclude a certified nurse-midwife 
or certified midwife (as defined in paragraphs 
(1) and (3), respectively, of subsection (gg)) 
from teaching or supervising such intern or 
resident-in-training, to the extent permitted 
under State law and as may be authorized by 
the hospital; or’’; 
(C) in paragraph (7), by striking the pe-
riod at the end and inserting ‘‘; or’’; and 
(D) by adding at the end the following new 
paragraph: 
‘‘(8) a certified nurse-midwife or a certified 
midwife where the hospital has a teaching program 
approved as specified in paragraph (6), if (A) the 
hospital elects to receive any payment due under this 
title for reasonable costs of such services, and (B) 
all certified nurse-midwives or certified midwives in
such hospital agree not to bill charges for profes-
sional services rendered in such hospital to individ-
uals covered under the insurance program estab-
lished by this title.’’. 
(4) 
BENEFIT
UNDER
PART
B.—Section 
1832(a)(2)(B)(iii) 
of 
such 
Act 
(42 
U.S.C. 
1395k(a)(2)(B)(iii)) is amended—
(A) by inserting ‘‘(I)’’ after ‘‘(iii)’’, 
(B) by inserting ‘‘certified midwife serv-
ices,’’ after ‘‘certified nurse-midwife services,’’, 
and 
(C) by adding at the end the following new 
subclause: 
‘‘(II) in the case of certified 
nurse-midwife services or certified 
midwife services furnished in a hos-
pital which has a teaching program 
described in clause (i)(II), such serv-
ices may be furnished as provided 
under section 1842(b)(7)(E) and sec-
tion 1861(b)(8);’’. 
(5) 
AMOUNT
OF
PAYMENT.—Section 
1833(a)(1)(K) 
of 
such 
Act 
(42 
U.S.C. 
1395l(a)(1)(K)) is amended—
(A) by inserting ‘‘and certified midwife 
services’’ after ‘‘certified nurse-midwife serv-
ices’’, and 
(B) by striking ‘‘65 percent’’ each place it 
appears and inserting ‘‘95 percent’’. 
(6) ASSIGNMENT OF PAYMENT.—The first sen-
tence of section 1842(b)(6) of such Act (42 U.S.C. 
1395u(b)(6)) is amended—
(A) by striking ‘‘and (F)’’ and inserting 
‘‘(F)’’; and 
(B) by inserting before the period the fol-
lowing: ‘‘, and (G) in the case of certified 
nurse-midwife services or certified midwife serv-
ices under section 1861(s)(2)(L), payment may 
be made in accordance with subparagraph (A), 
except that payment may also be made to such 
person or entity (or the agent of such person or 
entity) as the certified nurse-midwife or cer-
tified midwife may designate under an agree-
ment between the certified nurse-midwife or 
certified midwife and such person or entity (or 
the agent of such person or entity)’’. 
(7) CLARIFICATION
REGARDING
PAYMENTS 
UNDER PART B FOR SUCH SERVICES FURNISHED IN
TEACHING HOSPITALS.—(A) Section 1842(b)(7) of 
such Act (42 U.S.C. 1395u(b)(7)) is amended—
(i) in subparagraphs (A) and (C), by in-
serting ‘‘or, for purposes of subparagraph (E), 
the conditions described in section 1861(b)(8),’’ 
after ‘‘section 1861(b)(7),’’; and 
(ii) by adding at the end the following new 
subparagraph: 
‘‘(E) In the case of certified nurse-midwife 
services or certified midwife services furnished 
to a patient in a hospital with a teaching pro-
gram 
approved 
as 
specified 
in 
section 
1861(b)(6) but which does not meet the condi-
tions described in section 1861(b)(8), the provi-
sions of subparagraphs (A) through (C) shall 
apply with respect to a certified nurse-midwife 
or a certified midwife respectively under this 
subparagraph as they apply to a physician 
under subparagraphs (A) through (C).’’. 
(B) Not later than 180 days after the date of 
the enactment of this Act, the Secretary of Health 
and Human Services shall prescribe regulations to 
carry out the amendments made by subparagraph 
(A).
SEC. 4. INTERIM, FINAL REGULATIONS. 
Except as provided in section 3(b)(7)(B), in order to 
carry out the amendments made by this Act in a timely 
manner, the Secretary of Health and Human Services may 
first promulgate regulations, that take effect on an interim 
basis, after notice and pending opportunity for public com-
ment, by not later than 6 months after the date of the 
enactment of this Act.
Æ