ACO 
professional 
described 
in 
subsection 
(h)(1)(B).’’. 
SEC. 104. EXPANDING THE AVAILABILITY OF MEDICAL NU-
TRITION THERAPY SERVICE MEDICARE PRO-
GRAM. 
Section 1861(vv)(1) of the Social Security Act (42 
U.S.C. 1395x(vv)(1)) is amended by inserting ‘‘, a nurse 
practitioner, a clinical nurse specialist, or a physician as-
sistant (as such terms are defined in subsection (aa)(5))’’ 
before the period at the end. 
SEC. 105. PRESERVING ACCESS TO HOME INFUSION THER-
APY. 
(a) ALLOWING APPLICABLE PROVIDERS TO ESTAB-
LISH
HOME
INFUSION
THERAPY
PLANS.—Section 
1861(iii)(1)(B) of the Social Security Act (42 U.S.C. 
1395x(iii)(1)(B)) is amended— 
(1) by striking ‘‘a physician (as defined in sub-
section (r)(1))’’ and inserting ‘‘an applicable pro-
vider (as defined in paragraph (3)(A))’’; and 
(2) by striking ‘‘a physician (as so defined)’’ 
and inserting ‘‘an applicable provider (as so de-
fined)’’. 
(b) CONFORMING AMENDMENT.—Section 1834(u)(6) 
of the Social Security Act (42 U.S.C. 1395m(u)(6)) is 
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amended by striking ‘‘physician’’ and inserting ‘‘applicable 
provider (as defined in section 1861(iii)(3)(A))’’. 
SEC. 106. INCREASING ACCESS TO HOSPICE CARE SERV-
ICES. 
(a) IN GENERAL.—Section 1814(a)(7)(A) of the So-
cial Security Act (42 U.S.C. 1395f(a)(7)(A)) is amend-
ed— 
(1) in clause (i)(I), by striking ‘‘a nurse practi-
tioner or’’; 
(2) in clause (i), in the matter following sub-
clause (II), by inserting ‘‘or nurse practitioner’’ after 
‘‘physician’’ and inserting ‘‘, nurse practitioner’s’’ 
after ‘‘physician’s’’; and 
(3) in clause (ii), by striking ‘‘or physician’’ and 
inserting ‘‘, physician, or nurse practitioner’’. 
(b) 
HOSPICE
CARE
DEFINITION.—Section 
1861(dd)(1)(C) of the Social Security Act (42 U.S.C. 
1395x(dd)(1)(C)) is amended by adding ‘‘or nurse practi-
tioner’’ after ‘‘physician’’. 
(c) NURSE PRACTITIONER BILLING.—Not later than 
90 days after the date of the enactment of this Act, the 
Secretary of Health and Human Services shall revise sec-
tion 418.304 of title 42, Code of Federal Regulations, to 
allow nurse practitioners to bill for services not described 
in paragraph (a) of such section in the same manner as 
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physicians may bill for such services in accordance with 
paragraph (b) of such section. Such revision shall provide 
that such services furnished by a nurse practitioner shall 
be payable at the percent of the physician fee schedule 
specified in section 1833(a)(1)(O) of the Social Security 
Act (42 U.S.C. 1395l(a)(1)(O)). 
SEC. 107. STREAMLINING CARE DELIVERY IN SKILLED 
NURSING FACILITIES AND NURSING FACILI-
TIES; AUTHORIZING MEDICARE AND MED-
ICAID INPATIENT HOSPITAL PATIENTS TO BE 
UNDER THE CARE OF A NURSE PRACTI-
TIONER. 
(a) MEDICARE.— 
(1) CERTIFICATION
OF
POST-HOSPITAL
EX-
TENDED CARE SERVICES.—Section 1814(a)(2) of the 
Social Security Act (42 U.S.C. 1395f(a)(2)) is 
amended by striking ‘‘, or a nurse practitioner,’’ and 
inserting ‘‘or a nurse practitioner (in accordance 
with State law), or’’. 
(2) CERTIFICATION
AUTHORITY
FOR
NURSE 
PRACTITIONERS.—Section 1814(a)(3) of the Social 
Security Act (42 U.S.C. 1395f(a)(3)) is amended by 
inserting ‘‘or nurse practitioner’’ after ‘‘physician’’ 
the first place that it appears. 
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(3) SUPERVISION
REQUIREMENT
IN
SKILLED 
NURSING
FACILITY
SERVICES.—Section 
1819(b)(6)(A) of the Social Security Act (42 U.S.C. 
1395i–3(b)(6)(A)) is amended— 
(A) in the header, by striking ‘‘Physician 
supervision’’ and inserting ‘‘Supervision’’; and 
(B) by inserting ‘‘or a nurse practitioner, 
in accordance with State law’’ after ‘‘physi-
cian’’. 
(4) ADMINISTRATION
OF
PART
B.—Section 
1842(b)(2)(C) of the Social Security Act (42 U.S.C. 
1395u(b)(2)(C)) is amended— 
(A) by inserting ‘‘or a nurse practitioner’’ 
after ‘‘a physician’’; and 
(B) by striking ‘‘or a nurse practitioner 
working in collaboration with that physician, or 
both’’. 
(5) PROVISION
OF
MEDICAL
AND
OTHER 
HEALTH
SERVICES.—Section 1861(s)(2)(K)(ii) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395x(s)(2)(K)(ii)) is amended by striking ‘‘or clin-
ical nurse specialist (as defined in subsection 
(aa)(5)) working in collaboration (as defined in sub-
section (aa)(6)) with a physician (as defined in sub-
section (r)(1))’’ and inserting ‘‘(as defined in sub-
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section (aa)(5)(A)), or by a clinical nurse specialist 
(as defined in subsection (aa)(5)(B)) working in col-
laboration with a physician (as defined in subsection 
(r)(1)),’’. 
(6) PRIVILEGES FOR NURSE PRACTITIONERS.— 
Section 1861 of the Social Security Act (42 U.S.C. 
1395x) is amended— 
(A) in subsection (e)(4), by inserting ‘‘(or 
nurse practitioner, in accordance with State 
law)’’ after ‘‘physician’’; 
(B) in subsection (f)(1), by inserting ‘‘or 
nurse practitioner,’’ after ‘‘physician’’; and 
(C) in subsection (ee)(2), by inserting ‘‘or 
nurse practitioner,’’ after ‘‘physician’’ each 
place that it appears. 
(b) MEDICAID.— 
(1) CERTIFICATION
AUTHORITY
FOR
NURSE 
PRACTITIONERS.—Section 1902(a)(44) of the Social 
Security Act (42 U.S.C. 1396a(a)(44)) is amended 
to read as follows: 
‘‘(44) in each case for which payment for inpa-
tient hospital services, skilled nursing facility serv-
ices, services in an intermediate care facility de-
scribed in section 1905(d), or inpatient mental hos-
pital services is made under the State plan— 
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‘‘(A) a physician or nurse practitioner (or, 
in the case of skilled nursing facility services or 
intermediate care facility services, a physician 
or nurse practitioner, or a clinical nurse spe-
cialist who is not an employee of the facility but 
is working in collaboration with a physician) 
certifies at the time of admission, or, if later, 
the time the individual applies for medical as-
sistance under the State plan (and a physician 
or nurse practitioner, or a physician assistant 
under the supervision of a physician, or, in the 
case of skilled nursing facility services or inter-
mediate care facility services, a physician or 
nurse practitioner, or a clinical nurse specialist 
who is not an employee of the facility but is 
working in collaboration with a physician, recer-
tifies, where such services are furnished over a 
period of time, in such cases, at least as often 
as required under section 1903(g)(6) (or, in the 
case of services that are services provided in an 
intermediate care facility, every year), and ac-
companied by such supporting material, appro-
priate to the case involved, as may be provided 
in regulations of the Secretary), that such serv-
ices are or were required to be given on an in-
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patient basis because the individual needs or 
needed such services, and 
‘‘(B) such services were furnished under a 
plan established and periodically reviewed and 
evaluated by a physician or nurse practitioner, 
or, in the case of skilled nursing facility services 
or intermediate care facility services, by a phy-
sician or nurse practitioner, or a clinical nurse 
specialist who is not an employee of the facility 
but is working in collaboration with a physi-
cian;’’. 
(2) NURSING FACILITY SERVICES SUPERVISION 
AND CLINICAL RECORDS.—Section 1919(b)(6)(A) of 
the Social Security Act (42 U.S.C. 1396r(b)(6)(A)) 
is amended to read as follows: 
‘‘(A) require that the health care of every 
resident be provided under the supervision of a 
physician or nurse practitioner (or, at the op-
tion of a State, under the supervision of a clin-
ical nurse specialist or physician assistant who 
is not an employee of the facility but who is 
working in collaboration with a physician);’’. 
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SEC. 108. IMPROVING ACCESS TO MEDICAID CLINIC SERV-
ICES. 
Section 1905(a)(9) of the Social Security Act (42 
U.S.C. 1396d(a)(9)) is amended by adding ‘‘or nurse 
practitioner’’ after ‘‘physician’’ in both places that it ap-
pears. 
TITLE 
II—REMOVAL 
OF 
BAR-
RIERS TO PRACTICE ON CER-
TIFIED REGISTERED NURSE 
ANESTHETISTS 
SEC. 201. CLARIFYING THAT CERTIFIED REGISTERED 
NURSE ANESTHETISTS CAN BE REIMBURSED 
BY MEDICARE FOR EVALUATION AND MAN-
AGEMENT SERVICES. 
Section 1861(bb)(1) of the Social Security Act (42 
U.S.C. 1395x(bb)(1)) is amended by inserting ‘‘, including 
pre-anesthesia evaluation and management services,’’ 
after ‘‘and related care’’. 
SEC. 202. REVISION OF CONDITIONS OF PAYMENT RELAT-
ING TO SERVICES ORDERED AND REFERRED 
BY CERTIFIED REGISTERED NURSE ANES-
THETISTS. 
Not later than 3 months after the date of enactment 
of this Act, the Secretary of Health and Human Services 
shall revise section 410.69 of title 42, Code of Federal 
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Regulations, to clarify that, for purposes of payment 
under part B of title XVIII of the Social Security Act— 
(1) certified registered nurse anesthetists are 
authorized to order, certify, and refer services to the 
extent allowed under the law of the State in which 
the services are furnished; and 
(2) payment shall be made under such part for 
such services so ordered, certified, or referred by 
certified registered nurse anesthetists. 
SEC. 203. SPECIAL PAYMENT RULE FOR TEACHING STU-
DENT REGISTERED NURSE ANESTHETISTS. 
Section 1848(a)(6) of the Social Security Act (42 
U.S.C. 1395w–4(a)(6)) is amended in the matter pre-
ceding subparagraph (A), by inserting ‘‘or student reg-
istered nurse anesthetists’’ after ‘‘physician residents’’. 
SEC. 204. REMOVING UNNECESSARY AND COSTLY SUPER-
VISION OF CERTIFIED REGISTERED NURSE 
ANESTHETISTS. 
Section 1861(bb)(2) of the Social Security Act (42 
U.S.C. 1395x(bb)(2)) is amended— 
(1) in the second sentence, by inserting ‘‘, but 
may not require that certified registered nurse anes-
thetists provide services under the supervision of a 
physician’’ after ‘‘certification of nurse anes-
thetists’’; and 
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(2) in the third sentence, by inserting ‘‘under 
the supervision of an anesthesiologist’’ after ‘‘an an-
esthesiologist assistant’’. 
SEC. 205. CRNA SERVICES AS A MEDICAID-REQUIRED BEN-
EFIT. 
(a) IN GENERAL.—Section 1905(a)(5) of the Social 
Security Act (42 U.S.C. 1396d(a)(5)) is amended— 
(1) by striking ‘‘and (B)’’ and inserting ‘‘(B)’’; 
and 
(2) by inserting before the semicolon at the end 
the following: ‘‘, and (C) services furnished by a cer-
tified registered nurse anesthetist (as defined in sec-
tion 1861(bb)(2)), which such certified registered 
nurse anesthetist is authorized to perform under 
State law (or the State regulatory mechanism as 
provided by State law)’’. 
(b) PAYMENT.—Section 1902(a) of the Social Secu-
rity Act (42 U.S.C. 1396d(a)) is amended— 
(1) in paragraph (86), by striking ‘‘and’’ at the 
end; 
(2) in paragraph (87), by striking the period 
and inserting ‘‘; and’’; and 
(3) by inserting after paragraph (87) the fol-
lowing new paragraph: 
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‘‘(88) provide for payment for the services of a 
certified registered nurse anesthetist (as defined in 
section 1861(bb)(1)) in amounts no lower than the 
amounts, using the same methodology, used for pay-
ment for amounts under section 1833(a)(1)(H).’’. 
TITLE III—REMOVAL OF BAR-
RIERS TO PRACTICE ON CER-
TIFIED NURSE-MIDWIVES 
SEC. 301. IMPROVING ACCESS TO TRAINING IN MATERNITY 
CARE. 
(a) MEDICARE PAYMENTS
FOR SUPERVISION
BY 
CERTIFIED NURSE-MIDWIVES.—Paragraph (1) of section 
1861(gg) of the Social Security Act (42 U.S.C. 1395x(gg)) 
is amended to read as follows: 
‘‘(1) The term ‘certified nurse-midwife services’ 
means— 
‘‘(A) such services furnished by a certified 
nurse-midwife (as defined in paragraph (2)); 
and 
‘‘(B) such services (and such supplies and 
services furnished as an incident to the nurse- 
midwife’s service) which— 
‘‘(i) the certified nurse-midwife is le-
gally authorized to perform under State 
law (or the State regulatory mechanism 
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provided by State law) as would otherwise 
be covered if furnished by a physician; 
‘‘(ii) are furnished under the super-
vision of a certified-nurse midwife by an 
intern or resident-in-training (as described 
in subsection (b)(6)); 
‘‘(iii) would otherwise be described in 
subparagraph (A) if furnished by a cer-
tified nurse-midwife; and 
‘‘(iv) would otherwise be covered if 
furnished under the supervision of a physi-
cian.’’. 
(b) CLARIFYING PERMISSIBILITY OF USING CERTAIN 
GRANTS FOR CLINICAL TRAINING BY CERTIFIED NURSE- 
MIDWIVES.—Section 811(a)(1) of the Public Health Serv-
ice Act (42 U.S.C. 296j(a)(1)) is amended by inserting 
‘‘, including clinical training,’’ after ‘‘projects’’. 
SEC. 302. IMPROVING MEDICARE PATIENT ACCESS TO 
HOME HEALTH SERVICES PROVIDED BY CER-
TIFIED NURSE-MIDWIVES. 
(a) IN GENERAL.—Section 1835(a) of the Social Se-
curity Act (42 U.S.C. 1395n(a)) is amended— 
(1) in paragraph (2)— 
(A) by inserting ‘‘or a certified nurse-mid-
wife (as defined in section 1861(gg)),’’ after ‘‘or 
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a physician assistant (as defined in section 
1861(aa)(5)) who is working in accordance with 
State law,’’; and 
(B) in subparagraph (A)— 
(i) in each of clauses (ii) and (iii), by 
striking ‘‘or a physician assistant (as the 
case may be)’’ and inserting ‘‘a physician 
assistant, or a certified nurse-midwife (as 
the case may be)’’; and 
(ii) in clause (iv), by— 
(I) inserting ‘‘or by a certified 
nurse-midwife (as defined in section 
1861(gg))’’ after ‘‘(but in no case 
later than the date that is 6 months 
after the date of the enactment of the 
CARES Act)’’; and 
(II) by striking ‘‘(as defined in 
section 1861(gg))’’; and 
(2) in the matter following paragraph (2), by 
striking ‘‘or physician assistant (as the case may 
be)’’ and inserting ‘‘physician assistant, or certified 
nurse-midwife (as the case may be)’’ each place it 
appears. 
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(b) CONFORMING AMENDMENTS.—Section 1895 of 
the Social Security Act (42 U.S.C. 1395(fff)) is amend-
ed— 
(1) in subsection (c)(1), by inserting ‘‘a cer-
tified 
nurse-midwife 
(as 
defined 
in 
section 
1861(gg)),’’ after ‘‘clinical nurse specialist (as those 
terms are defined in section 1861(aa)(5)),’’; and 
(2) in subsection (e)(1)(A), by striking ‘‘a phy-
sician a nurse practitioner or clinical nurse spe-
cialist,’’ and inserting ‘‘a physician, a nurse practi-
tioner, a clinical nurse specialist, a certified nurse- 
midwife,’’. 
SEC. 303. IMPROVING ACCESS TO DMEPOS FOR MEDICARE 
BENEFICIARIES. 
Section 1834(a) of the Social Security Act (42 U.S.C. 
1395m(a)) is amended— 
(1) in paragraph (1)(E)(ii) by striking ‘‘or a 
clinical nurse specialist (as those terms are defined 
in section 1861(aa)(5))’’ and inserting ‘‘, a clinical 
nurse specialist (as those terms are defined in sec-
tion 1861(aa)(5)), or a certified nurse-midwife (as 
defined in section 1861(gg))’’; and 
(2) in paragraph (11)(B)(ii)— 
(A) by striking ‘‘or a clinical nurse spe-
cialist (as those terms are defined in section 
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1861(aa)(5))’’ and inserting ‘‘a clinical nurse 
specialist (as those terms are defined in section 
1861 (aa)(5)), or a certified nurse-midwife (as 
defined in 1861(gg))’’; and 
(B) by striking ‘‘or specialist’’ and insert-
ing ‘‘specialist, or nurse-midwife’’. 
SEC. 304. TECHNICAL CHANGES TO QUALIFICATIONS AND 
CONDITIONS WITH RESPECT TO THE SERV-
ICES OF CERTIFIED NURSE-MIDWIVES. 
Section 1861(gg)(2) of the Social Security Act (42 
U.S.C. 1395x(gg)(2)) is amended by striking ‘‘, or has 
been certified by an organization recognized by the Sec-
retary’’ and inserting ‘‘and has been certified by the Amer-
ican Midwifery Certification Board (or a successor organi-
zation)’’. 
TITLE IV—IMPROVING FEDERAL 
HEALTH PROGRAMS FOR ALL 
ADVANCED 
PRACTICE 
REG-
ISTERED NURSES 
SEC. 401. REVISING THE LOCAL COVERAGE DETERMINA-
TION PROCESS UNDER THE MEDICARE PRO-
GRAM. 
(a) IN GENERAL.—Section 1862(l)(5) of the Social 
Security Act (42 U.S.C. 1395y(l)(5)) is amended— 
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(1) in subparagraph (D), by adding at the end 
the following new clauses: 
‘‘(vi) Identification of any medical or 
scientific experts whose advice was ob-
tained by such contractor during the devel-
opment of such determination, whether or 
not such contractor relied on such advice 
in developing such determination. 
‘‘(vii) A hyperlink to any written com-
munication between such contractor and 
another entity that such contractor relied 
on when developing such determination. 
‘‘(viii) A hyperlink to any rule, guide-
line, protocol, or other criterion that such 
contractor relied on when developing such 
determination.’’; and 
(2) by adding at the end the following new sub-
paragraphs: 
‘‘(E) PROHIBITION
ON
IMPOSITION
OF 
PRACTITIONER
QUALIFICATIONS.—The 
Sec-
retary shall prohibit a Medicare administrative 
contractor that develops a local coverage deter-
mination from imposing such determination on 
any coverage limitation with respect to the 
qualifications of a physician (as defined in sec-
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tion 1861(r)) or a practitioner described in sec-
tion 1842(b)(18)(C) who may furnish the item 
or service that is the subject of such determina-
tion. 
‘‘(F) 
CIVIL
MONETARY
PENALTY.—A 
Medicare administrative contractor that devel-
ops a local coverage determination that fails to 
make information described in subparagraph 
(D) available as required by the Secretary 
under such subparagraph or comply with the 
prohibition under subparagraph (E) is subject 
to a civil monetary penalty of not more than 
$10,000 for each such failure. The provisions of 
section 1128A (other than subsections (a) and 
(b)) shall apply to a civil money penalty under 
the previous sentence in the same manner as 
such provisions apply to a penalty or proceeding 
under section 1128A(a).’’. 
(b) TIMING OF REVIEW.—Section 1869(f)(2) of the 
Social Security Act (42 U.S.C. 1395ff(f)(2)) is amended 
by adding at the end the following new subparagraph: 
‘‘(D) TIMING OF REVIEW.—An aggrieved 
party may file a complaint described in sub-
paragraph (A) with respect to a local coverage 
determination on or after the date that such de-
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termination is posted, in accordance with sec-
tion 1862(l)(5)(D), on the Internet website of 
the Medicare administrative contractor making 
such determination, whether or not such deter-
mination has taken effect.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to local coverage determinations 
made available on the internet website of a Medicare ad-
ministrative contractor and on the Medicare internet 
website on or after the date of the enactment of this Act. 
SEC. 402. LOCUM TENENS. 
Section 1842(b)(6) of the Social Security Act (42 
U.S.C. 1395u(b)(6)) is amended— 
(1) by striking ‘‘and (J)’’ and inserting ‘‘, (J)’’; 
and 
(2) by adding ‘‘, and (K) in the case of services 
furnished by a certified registered nurse anesthetist 
(as defined in section 1861(bb)(2)), nurse practi-
tioner, or clinical nurse specialist (as defined in sec-
tion 1861(aa)(5)), or a certified nurse midwife (as 
defined in section 1861(gg)(2))’’ after ‘‘(as defined 
in section 1886(d)(2)(D))’’. 
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TITLE V—MISCELLANEOUS 
SEC. 501. EFFECTIVE DATE. 
The provisions of, including amendments made by, 
this Act (other than sections 103 and 401) shall apply 
with respect to items and services furnished on or after 
the date that is 90 days after the date of the enactment 
of this Act. Notwithstanding any other provision of law, 
the Secretary of Health and Human Services shall imple-
ment such provisions, including such amendments, 
through interim final rule or subregulatory guidance if the 
Secretary determines such implementation to be necessary 
for purposes of complying with the preceding sentence or 
with any other effective date provided in this Act. 
Æ 
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