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.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Improving Access to Nurse-Midwife 
Care Act of 2004''.

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 Research reports 
        that these women are without appropriate 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 recent 
        mammogram.
            (6) The medicare program reimburses Certified Nurse 
        Midwives (CNMs) at 65 percent of the physician 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-MIDWIFE 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 physician'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 certified 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 services 
                (as defined in paragraphs (1) and (3), respectively, of 
                subsection (gg)) may be under the care of a certified 
                nurse-midwife or certified midwife with respect to such 
                services to the extent permitted under State law''.
            (3) Inpatient hospital service at teaching hospitals.--
        Section 1861(b) of such Act (42 U.S.C. 1395x(b)) is amended--
                    (A) in paragraph (4), by inserting ``certified 
                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 period 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 
        professional services rendered in such hospital to individuals 
        covered under the insurance program established 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 services,'' 
                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 
                                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--
                    (A) by inserting ``and certified midwife services'' 
                after ``certified nurse-midwife services'', and
                    (B) by striking ``65 percent'' each place it 
                appears and inserting ``95 percent''.
            (6) Assignment of payment.--The first sentence 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 following: 
                ``, and (G) in the case of certified nurse-midwife 
                services or certified midwife services 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 certified 
                midwife may designate under an agreement 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 inserting 
                ``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 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 
comment, by not later than 6 months after the date of the enactment of 
this Act.

Summary: Improving Access to Nurse-Midwife Care Act of 2004 - Amends title XVIII (Medicare) of the Social Security Act to provide for the coverage of and payment for certified midwife services (currently only certified nurse-midwife services are covered) under Medicare part B (Supplementary Medical Insurance). Declares that nothing precludes certified nurse-midwives and certified midwives from teaching or supervising an intern or resident-in-training.

Authorizes payment for such services to a person or entity (or the agent of such person or entity) the certified nurse-midwife (CNM) or certified midwife (CM) may designate under an agreement between the CNM or CM and such person or entity (by implication, including a free-standing birth center).