I
106TH CONGRESS
1ST SESSION
H. R. 2817
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
SEPTEMBER 8, 1999
Mr. TOWNS (for himself, Mr. UPTON, Mr. MCDERMOTT, Mr. LOBIONDO, Mr.
WAXMAN, Mrs. JOHNSON of Connecticut, Mr. BROWN of Ohio, Mr.
BILBRAY, Mr. WYNN, Mr. FOLEY, Mrs. CAPPS, Mr. BOEHNER, Mr.
LEWIS of Georgia, Mr. LEACH, Mr. PALLONE, Mrs. MORELLA, Mr.
KLINK, Mrs. LOWEY, Mr. GILLMOR, Mr. ABERCROMBIE, Mr. HINCHEY,
Ms. CARSON, Mr. ACKERMAN, Ms. EDDIE BERNICE JOHNSON of Texas,
Mr. OLVER, Ms. KILPATRICK, Mr. CLYBURN, Ms. LOFGREN, Mr. THOMP-
SON of Mississippi, Mr. MORAN of Virginia, Mr. BALDACCI, Mr. WISE,
Mrs. CLAYTON, Mr. THOMPSON of California, and Ms. RIVERS) intro-
duced 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 consider-
ation 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 pro-
vide for more equitable reimbursement rates for certified
nurse-midwife services, and for other purposes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
HR 2817 IH
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Certified Nurse Mid-
wifery Medicare Services Act of 1999’’.
SEC. 2. 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:
HR 2817 IH
‘‘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—
HR 2817 IH
(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
HR 2817 IH
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 serv-
ices furnished in a hospital which has a
teaching program described in clause
(i)(II), such services may be furnished as
provided under section 1842(b)(7)(E) and
section 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—
HR 2817 IH
(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 to 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
HR 2817 IH
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 program approved as specified in
section 1861(b)(6) but which does not meet the conditions
described in section 1861(b)(8), the provisions of subpara-
graphs (A) through (C) shall apply with respect to a cer-
tified 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 shall pre-
scribe regulations to carry out the amendments
made by subparagraph (A).
SEC. 3. MEDICARE PAYMENT FOR FREESTANDING BIRTH
CENTER SERVICES.
(a) FREESTANDING
BIRTH
CENTER
SERVICES,
FREESTANDING BIRTH CENTER DEFINED.—
HR 2817 IH
(1) IN GENERAL.—(A) Section 1861(gg) of the
Social Security Act (42 U.S.C. 1395x(gg)), as
amended in section 2(a)(1), is amended by adding at
the end the following new paragraphs:
‘‘(5) The term ‘freestanding birth center services’
means items and services furnished by a freestanding
birth center (as defined in paragraph (6)) and such items
and services furnished as an incident to the freestanding
birth center’s service as would otherwise be covered if fur-
nished by a physician or as an incident to a physician’s
service.
‘‘(6) The term ‘freestanding birth center’ means a fa-
cility, institution, or site (other than a rural health clinic,
critical access hospital, or a sole community hospital) (A)
in which births are planned to occur (outside the mother’s
place of residence), (B) in which comprehensive health
care services are furnished, and (C) which has been ap-
proved by the Secretary or accredited by an organization
recognized by the Secretary for purposes of accrediting
freestanding birth centers. Such term does not include a
facility, institution, or site that is a hospital or an ambula-
tory surgical center, unless with respect to ambulatory
surgical centers, the State law or regulation that regulates
such centers also regulates freestanding birth centers in
the State.’’.
HR 2817 IH
(B) The heading in section 1861(gg) of such
Act (42 U.S.C. 1395x(gg)), as amended in section
2(b)(2), is further amended by adding at the end the
following:
‘‘; Freestanding Birth Center Services’’.
(2) MEDICAL AND OTHER SERVICES.—Section
1861(s)(2)(L) 
of 
such 
Act 
(42 
U.S.C.
1395x(s)(2)(L)), as amended in section 2(b)(1), is
further amended—
(A) by inserting ‘‘(i)’’ after ‘‘(L)’’;
(B) by adding ‘‘and’’ after the semicolon;
and
(C) by adding at the end the following new
clause:
‘‘(ii) freestanding birth center services;’’.
(b) PART B BENEFIT.—
(1) IN GENERAL.—Section 1832(a)(2)(B)(iii) of
such Act (42 U.S.C. 1395k(a)(2)(B)(iii)), as amend-
ed in section 2(b)(4), is further amended by insert-
ing ‘‘freestanding birth center services,’’ after ‘‘cer-
tified midwife services,’’.
(2) AMOUNT OF PAYMENT.—Section 1833(a)(1)
of such Act (42 U.S.C. 1395l(a)(1)) is amended—
(A) by striking ‘‘and (S)’’ and inserting in
lieu thereof ‘‘(S)’’; and
HR 2817 IH
(B) by inserting before the semicolon the
following new subparagraph: ‘‘, and (T) with
respect to freestanding birth center services
under section 1861(s)(2)(L)(ii), the amount
paid shall be made on an assignment-related
basis, and shall be 80 percent of the lesser of
(i) the actual charge for the services or (ii) an
amount established by the Secretary for pur-
poses of this subparagraph, such amount being
95 percent of the Secretary’s estimate of the
average total payment made to hospitals and
physicians during 1997 for charges for delivery
and pre-delivery visits, such amounts adjusted
to allow for regional variations in labor costs;
except that (I) such estimate shall not include
payments for diagnostic tests, drugs, or the cost
associated with the transfer of a patient to the
hospital or the physician whether or not sepa-
rate payments were made under this title for
such tests, drugs, or transfers, and (II) such
amount shall be updated by applying the single
conversion factor for 1998 under section
1848(d)(1)(C)’’.
HR 2817 IH
SEC. 4. INTERIM, FINAL REGULATIONS.
Except as provided in section 2(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