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