I 
109TH CONGRESS 
1ST SESSION 
H. R. 872
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 
FEBRUARY 16, 2005
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 ‘‘Improving Access to 
Nurse-Midwifery Care Act of 2005’’. 
SEC. 2. FINDINGS. 
Congress finds the following:
(1) Since 1988, Congress has authorized cer-
tified nurse-midwives (in this section referred to as 
‘‘CNMs’’) to provide maternity-related services to 
Medicare-eligible women who are of childbearing age. 
Approximately 3,000,000 disabled women are Medi-
care-eligible beneficiaries. In 1993, Congress author-
ized CNMs to also provide additional services out-
side the maternity cycle. Medicare reimburses CNMs 
for primary care services if those services are part 
of the practitioner’s State-regulated scope of prac-
tice. 
(2) In its June 2002 report to Congress, the 
Medicare Payment Advisory Commission (MedPAC) 
unanimously recommended that the percentage of 
part B reimbursement for certified nurse-midwife 
services to be increased. 
(3) In this same report, MedPAC also stated 
that research shows the quality of care and out-
comes for services provided by CNMs are at least 
comparable to obstetricians and gynecologists. 
(4) A 1998 study from the National Center for 
Health Statistics published Journal of Epidemiology 
and Community Health found the risk of experi-
encing an infant death was 19 percent lower for 
births attended by CNMs than for births attended
by physicians. The risk of neonatal mortality (an in-
fant death occurring in the first 28 days of life) was 
33 percent lower, and the risk of delivering a low 
birth weight infant was 31 percent lower. Mean 
birth weight was 37 grams heavier for the CNM-at-
tended than for the physician-attended births. Low 
birth weight is a major predictor of infant mortality, 
subsequent disease, or developmental disabilities. 
(5) The study also found that CNMs attended 
a greater proportion of women who are at higher 
risk for poor birth outcome: African Americans, 
American Indians, teenagers, unmarried women, and 
those with less than a high school education. Physi-
cians attended a slightly higher proportion of births 
with medical complications. However, birth outcomes 
for CNMs were better even after socio-demographic 
and medical risk factors were controlled for in statis-
tical analyses. 
(6) Medicare covers 3,000,000 women with dis-
abilities that are of childbearing age. These women 
give birth to approximately 50,000 infants annually 
within the program. 
(7) CNMs and certified midwives (in this sec-
tion referred to as ‘‘CMs’’) are highly educated 
health professionals. Completion of a post-bacca-
laureate educational program, licensure, and passage 
of a national certification examination are required 
to become CNMs and CMs. 
(8) Inequitable reimbursement for obstetrical 
and gynecological services provided by CNMs or 
CMs jeopardizes access for women (particularly 
those covered by Medicare) to the health care pro-
vider of their choice. 
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 the Social Se-
curity 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 the Social Security 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 the So-
cial Security Act (42 U.S.C. 1395x(e)(4)) is amend-
ed—
(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 the Social Se-
curity 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 the Social Security 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 the Social Security 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 ‘‘100 percent’’. 
(6) ASSIGNMENT OF PAYMENT.—The first sen-
tence of section 1842(b)(6) of the Social Security 
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 
the Social Security 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.
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