[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8812 Introduced in House (IH)]

<DOC>






117th CONGRESS
  2d Session
                                H. R. 8812

   To amend titles XVIII and XIX of the Social Security Act and the 
 Bipartisan Budget Act of 2018 to increase access to services provided 
by advanced practice registered nurses under the Medicare and Medicaid 
                   programs, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 13, 2022

Ms. Roybal-Allard (for herself, Mr. Joyce of Ohio, Mr. Blumenauer, and 
    Mr. Smith of Nebraska) introduced the following bill; which was 
 referred to the Committee on Energy and Commerce, and in addition to 
   the Committee on Ways and Means, for a period to be subsequently 
   determined by the Speaker, in each case for consideration of such 
 provisions as fall within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
   To amend titles XVIII and XIX of the Social Security Act and the 
 Bipartisan Budget Act of 2018 to increase access to services provided 
by advanced practice registered nurses under the Medicare and Medicaid 
                   programs, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Improving Care and Access to Nurses 
Act'' or the ``I CAN Act''.

    TITLE I--REMOVAL OF BARRIERS TO PRACTICE ON NURSE PRACTITIONERS

SEC. 101. EXPANDING ACCESS TO CARDIAC REHABILITATION PROGRAMS AND 
              PULMONARY REHABILITATION PROGRAMS UNDER MEDICARE PROGRAM.

    (a) Cardiac Rehabilitation Programs.--Section 1861(eee) of the 
Social Security Act (42 U.S.C. 1395x(eee)) is amended--
            (1) in paragraph (2)--
                    (A) in subparagraph (A)(i), by striking ``a 
                physician's office'' and inserting ``the office of a 
                physician (as defined in subsection (r)(1)) or the 
                office of a nurse practitioner, clinical nurse 
                specialist, or physician assistant (as those terms are 
                defined in subsection (aa)(5))''; and
                    (B) in subparagraph (C), by inserting ``(as defined 
                in subsection (r)(1)), nurse practitioner, clinical 
                nurse specialist, or physician assistant (as those 
                terms are defined in subsection (aa)(5))'' after 
                ``physician'';
            (2) in paragraph (3)(A), by striking ``physician-prescribed 
        exercise'' and inserting ``exercise prescribed by a physician 
        (as defined in subsection (r)(1)), nurse practitioner, clinical 
        nurse specialist, or physician assistant (as those terms are 
        defined in subsection (aa)(5))''; and
            (3) in paragraph (5), by inserting ``(as defined in 
        subsection (r)(1)), nurse practitioner, clinical nurse 
        specialist, or physician assistant (as those terms are defined 
        in subsection (aa)(5)),'' after ``physician''.
    (b) Pulmonary Rehabilitation Programs.--Section 1861(fff) of the 
Social Security Act (42 U.S.C. 1395x(fff)) is amended--
            (1) in paragraph (2)(A), by striking ``physician-prescribed 
        exercise'' and inserting ``exercise prescribed by a physician 
        (as defined in subsection (r)(1)), nurse practitioner, clinical 
        nurse specialist, or physician assistant (as those terms are 
        defined in subsection (aa)(5))''; and
            (2) in paragraph (3), by inserting after ``physician'' the 
        following: ``(as defined in subsection (r)(1)), nurse 
        practitioner, clinical nurse specialist, or physician assistant 
        (as those terms are defined in subsection (aa)(5)),''.
    (c) Effective Date.--
            (1) In general.--The amendments made by subsections (a) and 
        (b) shall apply to items and services furnished on or after the 
        date that is three months after the date of enactment of this 
        Act.
            (2) Expediting implementation of supervision authority.--
        Section 51008(c) of the Bipartisan Budget Act of 2018 (Public 
        Law 115-123; 42 U.S.C. 1395x note) is amended by striking 
        ``January 1, 2024'' and inserting ``January 1, 2023''.

SEC. 102. PERMITTING NURSE PRACTITIONERS TO SATISFY MEDICARE 
              DOCUMENTATION REQUIREMENT FOR COVERAGE OF CERTAIN SHOES 
              FOR INDIVIDUALS WITH DIABETES.

    (a) In General.--Section 1861(s)(12) of the Social Security Act (42 
U.S.C. 1395x(s)(12)) is amended--
            (1) in subparagraph (A), by inserting ``, nurse 
        practitioner, or physician assistant'' after ``physician''; and
            (2) in subparagraph (C), by inserting ``, nurse 
        practitioner, or physician assistant'' after each occurrence of 
        ``physician''.
    (b) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2023.

SEC. 103. IMPROVEMENTS TO THE ASSIGNMENT OF BENEFICIARIES UNDER THE 
              MEDICARE SHARED SAVINGS PROGRAM.

    Section 1899(c)(1) of the Social Security Act (42 U.S.C. 
1395jjj(c)(1)) is amended--
            (1) in subparagraph (A), by striking ``and'' at the end;
            (2) in subparagraph (B), by striking the period at the end 
        and inserting ``; and''; and
            (3) by adding at the end the following new subparagraph:
                    ``(C) in the case of performance years beginning on 
                or after January 1, 2023, primary care services 
                provided under this title by an ACO professional 
                described in subsection (h)(1)(B).''.

SEC. 104. EXPANDING THE AVAILABILITY OF MEDICAL NUTRITION THERAPY 
              SERVICE MEDICARE PROGRAM.

    Section 1861(vv)(1) of the Social Security Act (42 U.S.C. 
1395x(vv)(1)) is amended by inserting ``, a nurse practitioner, or a 
clinical nurse specialist (as such terms are defined in subsection 
(aa)(5))'' before the period at the end.

SEC. 105. PRESERVING ACCESS TO HOME INFUSION THERAPY.

    (a) Allowing Applicable Providers To Establish 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 subsection 
        (r)(1))'' and inserting ``an applicable provider (as defined in 
        paragraph (3)(A))''; and
            (2) by striking ``a physician (as so defined)'' and 
        inserting ``an applicable provider (as so defined)''.
    (b) Conforming Amendment.--Section 1834(u)(6) of the Social 
Security Act (42 U.S.C. 1395m(u)(6)) is amended by striking 
``physician'' and inserting ``applicable provider (as defined in 
section 1861(iii)(3)(A))''.

SEC. 106. INCREASING ACCESS TO HOSPICE CARE SERVICES.

    (a) In General.--Section 1814(a)(7)(A) of the Social Security Act 
(42 U.S.C. 1395f(a)(7)(A)) is amended--
            (1) in clause (i)(I), by striking ``a nurse practitioner 
        or'';
            (2) in clause (i)(II), by inserting ``or nurse 
        practitioner'' after ``physician''; 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 practitioner'' after ``physician''.

SEC. 107. STREAMLINING CARE DELIVERY IN SKILLED NURSING FACILITIES AND 
              NURSING FACILITIES.

    (a) Medicare.--
            (1) Certification of post-hospital extended 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) 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 by inserting ``or a nurse 
        practitioner, in accordance with State law'' after 
        ``physician''.
            (3) Administration of part b.--Section 1842(b)(2)(C) of the 
        Social Security Act (42 U.S.C. 1395u(b)(2)(C)) is amended by 
        striking ``working in collaboration with that physician''.
            (4) 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 clinical nurse 
        specialist (as defined in subsection (aa)(5)) working in 
        collaboration (as defined in subsection (aa)(6)) with a 
        physician (as defined in subsection (r)(1))'' and inserting 
        ``(as defined in subsection (aa)(5)(A)), or by a clinical nurse 
        specialist (as defined in subsection (aa)(5)(B)) working in 
        collaboration with a physician (as defined in subsection 
        (r)(1)),''.
    (b) Medicaid.--
            (1) Certification of skilled nursing facility services and 
        intermediate care facility services.--Section 1902(a)(44) of 
        the Social Security Act (42 U.S.C. 1396a(a)(44)) is amended--
                    (A) in subparagraph (A)--
                            (i) by striking ``a physician (or, in the 
                        case of skilled nursing facility services or'' 
                        and inserting ``a physician (or, in the case of 
                        skilled nursing facility services, a physician 
                        or nurse practitioner; and, in the case of''; 
                        and
                            (ii) by striking ``or, in the case of 
                        skilled nursing facility services or'' and 
                        inserting ``or, in the case of skilled nursing 
                        facility services, a physician or nurse 
                        practitioner; and, in the case of''; and
                    (B) in subparagraph (B), by striking ``a physician, 
                or a nurse practitioner or clinical nurse specialist'' 
                and inserting ``a physician or nurse practitioner, or a 
                clinical nurse specialist''.
            (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 option of a 
                State, under the supervision of a clinical nurse 
                specialist or physician assistant who is not an 
                employee of the facility but who is working in 
                collaboration with a physician);''.

SEC. 108. AUTHORIZING MEDICARE AND MEDICAID INPATIENT HOSPITAL PATIENTS 
              TO BE UNDER THE CARE OF A NURSE PRACTITIONER.

    (a) Medicare.--
            (1) Certifications.--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.
            (2) 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.--Section 1902(a)(44) of the Social Security Act (42 
U.S.C. 1396a(a)(44)) is amended--
            (1) in paragraph (A), by inserting ``or nurse 
        practitioner'' after ``physician'' the first place that it 
        appears; and
            (2) in paragraph (B), by inserting ``or nurse 
        practitioner'' after ``physician'' the first place that it 
        appears.

SEC. 109. IMPROVING ACCESS TO MEDICAID CLINIC SERVICES.

    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 appears.

TITLE II--REMOVAL OF BARRIERS TO PRACTICE ON CERTIFIED REGISTERED NURSE 
                              ANESTHETISTS

SEC. 201. CLARIFYING THAT CERTIFIED REGISTERED NURSE ANESTHETISTS CAN 
              BE REIMBURSED BY MEDICARE FOR EVALUATION AND MANAGEMENT 
              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 RELATING TO SERVICES 
              ORDERED AND REFERRED BY CERTIFIED REGISTERED NURSE 
              ANESTHETISTS.

    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 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 STUDENT 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 preceding subparagraph (A), by 
inserting ``or student registered nurse anesthetists'' after 
``physician residents''.

SEC. 204. REMOVING UNNECESSARY AND COSTLY SUPERVISION 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 anesthetists provide 
        services under the supervision of a physician'' after 
        ``certification of nurse anesthetists''; and
            (2) in the third sentence, by inserting ``under the 
        supervision of an anesthesiologist'' after ``an 
        anesthesiologist assistant''.

SEC. 205. CRNA SERVICES AS A MEDICAID-REQUIRED BENEFIT.

    (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 certified 
        registered nurse anesthetist (as defined in section 
        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 Security 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 following new 
        paragraph:
            ``(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 payment for amounts under section 
        1833(a)(1)(H).''.

 TITLE III--REMOVAL OF BARRIERS TO PRACTICE ON CERTIFIED 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 
                        legally authorized to perform under State law 
                        (or the State regulatory mechanism provided by 
                        State law) as would otherwise be covered if 
                        furnished by a physician;
                            ``(ii) are furnished under the supervision 
                        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 certified 
                        nurse-midwife; and
                            ``(iv) would otherwise be covered if 
                        furnished under the supervision of a 
                        physician.''.
    (b) Clarifying Permissibility of Using Certain Grants for Clinical 
Training by Certified Nurse-Midwives.--Section 811(a)(1) of the Public 
Health Service 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 CERTIFIED NURSE-MIDWIVES.

    (a) In General.--Section 1835(a) of the Social Security Act (42 
U.S.C. 1395n(a)) is amended--
            (1) in paragraph (2)--
                    (A) by inserting ``or a certified nurse-midwife (as 
                defined in section 1861(gg)),'' after ``or 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.
    (b) Conforming Amendments.--Section 1895 of the Social Security Act 
(42 U.S.C. 1395(fff)) is amended--
            (1) in subsection (c)(1), by inserting ``a certified 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 physician a 
        nurse practitioner or clinical nurse specialist,'' and 
        inserting ``a physician, a nurse practitioner, 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 section 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 specialist 
                (as those terms are defined in section 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 inserting 
                ``specialist, or nurse-midwife''.

SEC. 304. TECHNICAL CHANGES TO QUALIFICATIONS AND CONDITIONS WITH 
              RESPECT TO THE SERVICES 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 Secretary'' and inserting ``and has been 
certified by the American Midwifery Certification Board (or a successor 
organization)''.

 TITLE IV--IMPROVING FEDERAL HEALTH PROGRAMS FOR ALL ADVANCED PRACTICE 
                           REGISTERED NURSES

SEC. 401. REVISING THE LOCAL COVERAGE DETERMINATION PROCESS UNDER THE 
              MEDICARE PROGRAM.

    (a) In General.--Section 1862(l)(5) of the Social Security Act (42 
U.S.C. 1395y(l)(5)) is amended--
            (1) in subparagraph (D), by adding at the end the following 
        new clauses:
                            ``(vi) Identification of any medical or 
                        scientific experts whose advice was obtained by 
                        such contractor during the development of such 
                        determination, whether or not such contractor 
                        relied on such advice in developing such 
                        determination.
                            ``(vii) A hyperlink to any written 
                        communication between such contractor and 
                        another entity that such contractor relied on 
                        when developing such determination.
                            ``(viii) A hyperlink to any rule, 
                        guideline, protocol, or other criterion that 
                        such contractor relied on when developing such 
                        determination.''; and
            (2) by adding at the end the following new subparagraphs:
                    ``(E) Prohibition on imposition of practitioner 
                qualifications.--The Secretary shall prohibit a 
                Medicare administrative contractor that develops a 
                local coverage determination from imposing such 
                determination on any coverage limitation with respect 
                to the qualifications of a physician (as defined in 
                section 1861(r)) or a practitioner described in section 
                1842(b)(18)(C) who may furnish the item or service that 
                is the subject of such determination.
                    ``(F) Civil monetary penalty.--A Medicare 
                administrative contractor that develops 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 subparagraph (A) with 
                respect to a local coverage determination on or after 
                the date that such determination is posted, in 
                accordance with section 1862(l)(5)(D), on the Internet 
                website of the Medicare administrative contractor 
                making such determination, whether or not such 
                determination 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 administrative contractor and on the Medicare 
internet website on or after the date of the enactment of this Act.

SEC. 402. LOCUM TENENS.

    (a) In General.--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 practitioner, or clinical nurse 
        specialist (as defined in section 1861(aa)(5)), or a certified 
        nurse midwife (as defined in section 1861(gg)(2))'' after ``(as 
        defined in section 1886(d)(2)(D))''.
    (b) Implementation.--Not later than 90 days after the date of the 
enactment of this Act, the Secretary of Health and Human Services shall 
update all applicable regulations and subregulatory guidance necessary 
to carry out this section.
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