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<dc:title>118 S2418 IS: Improving Care and Access to Nurses Act</dc:title>
<dc:publisher>U.S. Senate</dc:publisher>
<dc:date>2023-07-20</dc:date>
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<dc:language>EN</dc:language>
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<distribution-code display="yes">II</distribution-code><congress>118th CONGRESS</congress><session>1st Session</session><legis-num>S. 2418</legis-num><current-chamber>IN THE SENATE OF THE UNITED STATES</current-chamber><action><action-date date="20230720">July 20, 2023</action-date><action-desc><sponsor name-id="S322">Mr. Merkley</sponsor> (for himself and <cosponsor name-id="S410">Ms. Lummis</cosponsor>) introduced the following bill; which was read twice and referred to the <committee-name committee-id="SSFI00">Committee on Finance</committee-name></action-desc></action><legis-type>A BILL</legis-type><official-title>To amend titles XVIII and XIX of the Social Security Act to increase access to services provided by advanced practice registered nurses under the Medicare and Medicaid programs, and for other purposes.</official-title></form><legis-body style="OLC" display-enacting-clause="yes-display-enacting-clause" id="H6FA314C2365245B084BBA8502942D951"><section section-type="section-one" id="HE3FB32588432489FBF3085F004AAF1DD"><enum>1.</enum><header>Short title; table of contents</header><subsection commented="no" display-inline="no-display-inline" id="id87a3676c1db94bc59a9296c0b0bd50fc"><enum>(a)</enum><header display-inline="yes-display-inline">Short title</header><text display-inline="yes-display-inline">This Act may be cited as the <quote><short-title>Improving Care and Access to Nurses Act</short-title></quote> or the <quote><short-title>I CAN Act</short-title></quote>.</text></subsection><subsection commented="no" display-inline="no-display-inline" id="id88fab126f1204847915dc3f8b401cd52"><enum>(b)</enum><header>Table of contents</header><text>The table of contents of this Act is as follows:</text><toc><toc-entry level="section" idref="HE3FB32588432489FBF3085F004AAF1DD">Sec. 1. Short title; table of contents.</toc-entry><toc-entry level="title" idref="H8734306F03CC4C2184D08947DA7E99DA">TITLE I—Removal of Barriers to Practice on Nurse Practitioners </toc-entry><toc-entry level="section" idref="HFF12C0632F39474EB4851749198C7093">Sec. 101. Expanding access to cardiac rehabilitation programs and pulmonary rehabilitation programs under Medicare program.</toc-entry><toc-entry level="section" idref="H66DABBEDAB2E49B8B7A991BA4FD901BF">Sec. 102. Permitting nurse practitioners to satisfy medicare documentation requirement for coverage of certain shoes for individuals with diabetes.</toc-entry><toc-entry level="section" idref="H78758BA48087418FA3A3DCC248276880">Sec. 103. Improvements to the assignment of beneficiaries under the Medicare shared savings program.</toc-entry><toc-entry level="section" idref="HD62223C5B38243E593AAF44198E2A9DD">Sec. 104. Expanding the availability of medical nutrition therapy service Medicare program.</toc-entry><toc-entry level="section" idref="H6998AC4BED0144EB8FBDBF4A2A391901">Sec. 105. Preserving access to home infusion therapy.</toc-entry><toc-entry level="section" idref="HE41C5E7209A442B0B89FE88237B6B7CF">Sec. 106. Increasing access to hospice care services.</toc-entry><toc-entry level="section" idref="HD1DD633356E0415788710829069A1DCA">Sec. 107. Streamlining care delivery in skilled nursing facilities and nursing facilities; Authorizing Medicare and Medicaid inpatient hospital patients to be under the care of a nurse practitioner.</toc-entry><toc-entry level="section" idref="H977754DA364D4B13888FB58283AE889C">Sec. 108. Improving access to Medicaid clinic services.</toc-entry><toc-entry level="title" idref="H6B1A6D7204B44000AA0961D0DFD4944A">TITLE II—Removal of Barriers to Practice on Certified Registered Nurse Anesthetists</toc-entry><toc-entry level="section" idref="H43A99476C61C41CDB8B3752513D19D1F">Sec. 201. Clarifying that certified registered nurse anesthetists can be reimbursed by Medicare for evaluation and management services.</toc-entry><toc-entry level="section" idref="H09D00B48AA5545BE857A793FC3DD9F63">Sec. 202. Revision of conditions of payment relating to services ordered and referred by certified registered nurse anesthetists.</toc-entry><toc-entry level="section" idref="H193220AE51254856B61BF6D3DE9C2FC7">Sec. 203. Special payment rule for teaching student registered nurse anesthetists.</toc-entry><toc-entry level="section" idref="H791023FBE50F424B8D5F73EB74664504">Sec. 204. Removing unnecessary and costly supervision of certified registered nurse anesthetists.</toc-entry><toc-entry level="section" idref="H9BA0EB1C27CE42328CE6F84D07DA800A">Sec. 205. CRNA services as a Medicaid-required benefit.</toc-entry><toc-entry level="title" idref="HDFBCAFC7506849C49417C7EA0F8C79EC">TITLE III—Removal of Barriers to Practice on Certified Nurse-Midwives</toc-entry><toc-entry level="section" idref="H0C880707C8534FDB87806A0970ACA191">Sec. 301. Improving access to training in maternity care.</toc-entry><toc-entry level="section" idref="HE1B3398AB54E46F3AC3AA01805D77F4C">Sec. 302. Improving medicare patient access to home health services provided by certified nurse-midwives.</toc-entry><toc-entry level="section" idref="H0AB05C8827CF4CC69D1C111A954A20B1">Sec. 303. Improving access to DMEPOS for Medicare beneficiaries.</toc-entry><toc-entry level="section" idref="HD21E8ADF18734380BCC81087633670A8">Sec. 304. Technical changes to qualifications and conditions with respect to the services of certified nurse-midwives.</toc-entry><toc-entry level="title" idref="HDA098BA8BA7A419FB9111628F5CC4A76">TITLE IV—Improving Federal Health Programs for All Advanced Practice Registered Nurses</toc-entry><toc-entry level="section" idref="H83BFEFAD126E4C78B2B63A4A7D6A5E95">Sec. 401. Revising the local coverage determination process under the Medicare program.</toc-entry><toc-entry level="section" idref="H649D3E1AC75844BBB84E0CBA96559014">Sec. 402. Locum tenens.</toc-entry><toc-entry level="title" idref="HFDCC1778E98C49DEB87292797E3FB1B4">TITLE V—Miscellaneous</toc-entry><toc-entry level="section" idref="H2CA558530F08404DB6238E2572B53C8A">Sec. 501. Effective date.</toc-entry></toc></subsection></section><title id="H8734306F03CC4C2184D08947DA7E99DA"><enum>I</enum><header>Removal of Barriers to Practice on Nurse Practitioners </header><section id="HFF12C0632F39474EB4851749198C7093"><enum>101.</enum><header>Expanding access to cardiac rehabilitation programs and pulmonary rehabilitation programs under Medicare program</header><subsection id="H783C3DAFB5604A6DBB258A74C896B78C"><enum>(a)</enum><header>Cardiac rehabilitation programs</header><text>Section 1861(eee) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(eee)</external-xref>) is amended—</text><paragraph id="HBE39A835838C43FE9ED41E86F2849E7C"><enum>(1)</enum><text>in paragraph (2)—</text><subparagraph id="H398FCD6D66634FB2B89114626E9BA636"><enum>(A)</enum><text>in subparagraph (A)(i), by striking <quote>a physician’s office</quote> and inserting <quote>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))</quote>; and</text></subparagraph><subparagraph id="H3691E9257C004906BC821FBB6C8CB2C6"><enum>(B)</enum><text>in subparagraph (C), by inserting <quote>(as defined in subsection (r)(1)), nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in subsection (aa)(5))</quote> after <quote>physician</quote>;</text></subparagraph></paragraph><paragraph id="H447BEBE277424611BE43AF2583519DF2"><enum>(2)</enum><text>in paragraph (3)(A), by striking <quote>physician-prescribed exercise</quote> and inserting <quote>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))</quote>; and</text></paragraph><paragraph id="H8036B5F082B542B8B264BBBF7961C48D"><enum>(3)</enum><text>in paragraph (5), in the matter preceding subparagraph (A), by inserting <quote>(as defined in subsection (r)(1)), nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in subsection (aa)(5)),</quote> after <quote>physician</quote>.</text></paragraph></subsection><subsection id="HAF2F5BFC9E404A4793C461715CFD9550"><enum>(b)</enum><header>Pulmonary rehabilitation programs</header><text>Section 1861(fff) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(fff)</external-xref>) is amended—</text><paragraph id="H9FD0903FD04944C6970C1C00598F29A3"><enum>(1)</enum><text>in paragraph (2)(A), by striking <quote>physician-prescribed exercise</quote> and inserting <quote>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))</quote>; and</text></paragraph><paragraph id="H4AF4CF93C2F64CEA93E4B36C1A0443AA"><enum>(2)</enum><text>in paragraph (3), in the matter preceding subparagraph (A), by inserting after <quote>physician</quote> the following: <quote>(as defined in subsection (r)(1)), nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in subsection (aa)(5)),</quote>. </text></paragraph></subsection></section><section id="H66DABBEDAB2E49B8B7A991BA4FD901BF"><enum>102.</enum><header>Permitting nurse practitioners to satisfy Medicare documentation requirement for coverage of certain shoes for individuals with diabetes</header><text display-inline="no-display-inline">Section 1861(s)(12) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(s)(12)</external-xref>) is amended—</text><paragraph id="H44EB8721334C4158BEE7A9609EE16890"><enum>(1)</enum><text>in subparagraph (A), by inserting <quote>, nurse practitioner, or physician assistant</quote> after <quote>physician</quote>; and</text></paragraph><paragraph id="H405B31D1E1C0472283090B2BFA58434D"><enum>(2)</enum><text>in subparagraph (C), by inserting <quote>, nurse practitioner, or physician assistant</quote> after <quote>physician</quote> each place it appears.</text></paragraph></section><section id="H78758BA48087418FA3A3DCC248276880"><enum>103.</enum><header>Improvements to the assignment of beneficiaries under the Medicare shared savings program</header><text display-inline="no-display-inline">Section 1899(c)(1) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395jjj">42 U.S.C. 1395jjj(c)(1)</external-xref>) is amended—</text><paragraph id="H31E81C9E50C0471CA4E9E70F726B8DB8"><enum>(1)</enum><text>in subparagraph (A), by striking <quote>and</quote> at the end;</text></paragraph><paragraph id="HE233C9CC61284CB7A32658B2BC5ADAA6"><enum>(2)</enum><text>in subparagraph (B), by striking the period at the end and inserting <quote>; and</quote>; and</text></paragraph><paragraph id="HC060F5A701CB4FE48229759236399D41"><enum>(3)</enum><text>by adding at the end the following new subparagraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="HFE98273DFC1E43699E23DC6E5C5C288C"><subparagraph id="HC5C726F6EBF94A95ADE75D219CA14D20"><enum>(C)</enum><text display-inline="yes-display-inline">in the case of performance years beginning on or after January 1, 2024, primary care services provided under this title by an ACO professional described in subsection (h)(1)(B).</text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></section><section id="HD62223C5B38243E593AAF44198E2A9DD"><enum>104.</enum><header>Expanding the availability of medical nutrition therapy service Medicare program</header><text display-inline="no-display-inline">Section 1861(vv)(1) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(vv)(1)</external-xref>) is amended by inserting <quote>, a nurse practitioner, a clinical nurse specialist, or a physician assistant (as such terms are defined in subsection (aa)(5))</quote> before the period at the end.</text></section><section id="H6998AC4BED0144EB8FBDBF4A2A391901"><enum>105.</enum><header>Preserving access to home infusion therapy</header><subsection id="HFE63E5BB1CE74FE288AFB4451C350791"><enum>(a)</enum><header>Allowing applicable providers To establish home infusion therapy plans</header><text>Section 1861(iii)(1)(B) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(iii)(1)(B)</external-xref>) is amended—</text><paragraph id="H847D4ECC2DDE45BE917BEC756FD27083"><enum>(1)</enum><text>by striking <quote>a physician (as defined in subsection (r)(1))</quote> and inserting <quote>an applicable provider (as defined in paragraph (3)(A))</quote>; and</text></paragraph><paragraph id="HA9BB0B4987D2409C8177F5C3C27636A2"><enum>(2)</enum><text>by striking <quote>a physician (as so defined)</quote> and inserting <quote>an applicable provider (as so defined)</quote>.</text></paragraph></subsection><subsection id="HD2C89C8C56F940BBA5DBD7986FB05675"><enum>(b)</enum><header>Conforming amendment</header><text>Section 1834(u)(6) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395m">42 U.S.C. 1395m(u)(6)</external-xref>) is amended by striking <quote>physician</quote> and inserting <quote>applicable provider (as defined in section 1861(iii)(3)(A))</quote>.</text></subsection></section><section id="HE41C5E7209A442B0B89FE88237B6B7CF"><enum>106.</enum><header>Increasing access to hospice care services</header><subsection id="H49E4F74452C140108694348A980D2F03"><enum>(a)</enum><header>In general</header><text>Section 1814(a)(7)(A) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395f">42 U.S.C. 1395f(a)(7)(A)</external-xref>) is amended—</text><paragraph id="H6775FDE318254BA6955D8984107E2575"><enum>(1)</enum><text>in clause (i)—</text><subparagraph commented="no" display-inline="no-display-inline" id="id4ce4ef2b27d04db18c6b9bbc1454741e"><enum>(A)</enum><text display-inline="yes-display-inline">in subclause (I), by striking <quote>a nurse practitioner or</quote>; </text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="idac740273b15d46c5941e23698064376e"><enum>(B)</enum><text display-inline="yes-display-inline">in subclause (II), by inserting <quote>or nurse practitioner</quote> after <quote>physician</quote>; and</text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="id4b89b15d66da4190957c8d337dad1059"><enum>(C)</enum><text>in the flush matter following subclause (II), by inserting <quote>, nurse practitioner’s,</quote> after <quote>physician’s</quote>; and</text></subparagraph></paragraph><paragraph id="H37A8C209F6C24A6A9618C655C1536F53"><enum>(2)</enum><text>in clause (ii), by striking <quote>or physician</quote> and inserting <quote>, physician, or nurse practitioner</quote>.</text></paragraph></subsection><subsection id="H24B5C0D61E574A7D9E6F9833FFCC0B41"><enum>(b)</enum><header>Hospice care definition</header><text>Section 1861(dd)(1)(C) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(dd)(1)(C)</external-xref>) is amended by inserting <quote>or nurse practitioner</quote> after <quote>physician</quote>.</text></subsection><subsection id="H65079CEA395543F994B092AF5F98C2C6"><enum>(c)</enum><header>Nurse practitioner billing</header><text>Not later than 90 days after the date of the enactment of this Act, the Secretary of Health and Human Services shall revise section 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 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 (<external-xref legal-doc="usc" parsable-cite="usc/42/1395l">42 U.S.C. 1395l(a)(1)(O)</external-xref>).</text></subsection></section><section commented="no" id="HD1DD633356E0415788710829069A1DCA"><enum>107.</enum><header>Streamlining care delivery in skilled nursing facilities and nursing facilities; Authorizing Medicare and Medicaid inpatient hospital patients to be under the care of a nurse practitioner</header><subsection commented="no" id="H8F2AA3E488EB4C218BCD2DEA990AD86B"><enum>(a)</enum><header>Medicare</header><paragraph commented="no" id="H023FB3892B02412D9AED90423D3EE29A"><enum>(1)</enum><header>Certification of post-hospital extended care services</header><text display-inline="yes-display-inline">Section 1814(a)(2) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395f">42 U.S.C. 1395f(a)(2)</external-xref>) is amended, in the matter preceding subparagraph (A), by striking <quote>, or a nurse practitioner,</quote> and inserting <quote>or a nurse practitioner (in accordance with State law), or</quote>.</text></paragraph><paragraph id="HEE2DC55EB5D544C1A866BB05CFB0B159"><enum>(2)</enum><header>Certification authority for nurse practitioners</header><text>Section 1814(a)(3) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395f">42 U.S.C. 1395f(a)(3)</external-xref>) is amended by inserting <quote>or nurse practitioner</quote> after <quote>physician</quote>.</text></paragraph><paragraph commented="no" id="HC76DAA1B6A5948A1A4792A01AE377AC1"><enum>(3)</enum><header>Supervision requirement in skilled nursing facility services</header><text>Section 1819(b)(6) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(b)(6)</external-xref>) is amended—</text><subparagraph id="H75AD2B96C74648F681D76B7E63B56BF5"><enum>(A)</enum><text>in the heading, by striking <quote><header-in-text style="OLC" level="paragraph">Physician supervision</header-in-text></quote> and inserting <quote><header-in-text style="OLC" level="paragraph">Supervision</header-in-text></quote>; and </text></subparagraph><subparagraph id="H3AD820B9BCFA46B9AAD29DDEDC8778C2"><enum>(B)</enum><text>in subparagraph (A), by inserting <quote>or a nurse practitioner, in accordance with State law</quote> after <quote>physician</quote>.</text></subparagraph></paragraph><paragraph commented="no" id="HB639590CF0554018810528C26E281B3E"><enum>(4)</enum><header>Administration of part B</header><text>Section 1842(b)(2)(C) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395u">42 U.S.C. 1395u(b)(2)(C)</external-xref>) is amended, in the second sentence—</text><subparagraph display-inline="no-display-inline" id="HAF30BE6CD2D84E1084080D25266C6C35"><enum>(A)</enum><text>by inserting <quote>or a nurse practitioner</quote> after <quote>a physician</quote>; and</text></subparagraph><subparagraph display-inline="no-display-inline" id="HE4C9DE89CA5841C5BBD894297F830679"><enum>(B)</enum><text>by striking <quote>or a nurse practitioner working in collaboration with that physician, or both</quote>. </text></subparagraph></paragraph><paragraph commented="no" id="HCDDDC68660BE447E8A31BFA9AF09ACC3"><enum>(5)</enum><header>Provision of medical and other health services</header><text>Section 1861(s)(2)(K)(ii) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(s)(2)(K)(ii)</external-xref>) is amended by striking <quote>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))</quote> and inserting <quote>(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)),</quote>.</text></paragraph><paragraph commented="no" id="H15F7C5DE3682446DB3542FF21C4DC724"><enum>(6)</enum><header>Privileges for nurse practitioners</header><text>Section 1861 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x</external-xref>) is amended—</text><subparagraph commented="no" id="H5A77FE71A9814FB882E4D8C6A202CC5F"><enum>(A)</enum><text display-inline="yes-display-inline">in subsection (e)(4), by inserting <quote>(or nurse practitioner, in accordance with State law)</quote> after <quote>physician</quote>;</text></subparagraph><subparagraph commented="no" id="H8F7A045491924E51AB0C5248F5F06A05"><enum>(B)</enum><text display-inline="yes-display-inline">in subsection (f)(1), by inserting <quote>or nurse practitioner</quote> after <quote>physician</quote>; and</text></subparagraph><subparagraph commented="no" id="H76B99F1808E74584A110A7671DE396D2"><enum>(C)</enum><text display-inline="yes-display-inline">in each of subparagraphs (B) and (F) of subsection (ee)(2), by inserting <quote>or nurse practitioner</quote> after <quote>physician</quote>. </text></subparagraph></paragraph></subsection><subsection commented="no" id="H7ABA42EA75BA4886BA6EF50E9951CA20"><enum>(b)</enum><header>Medicaid</header><paragraph commented="no" id="H3FBA99A75B594C4B9BED23520CA3212E"><enum>(1)</enum><header>Certification authority for nurse practitioners</header><text display-inline="yes-display-inline">Section 1902(a)(44) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396a">42 U.S.C. 1396a(a)(44)</external-xref>) is amended to read as follows:</text><quoted-block style="OLC" display-inline="no-display-inline" id="HD4E9706776A84565A793FF4F53261EC4"><paragraph id="HCF9056E2AD844AB289F23B58FB9A8F67"><enum>(44)</enum><text display-inline="yes-display-inline">in each case for which payment for inpatient hospital services, skilled nursing facility services, services in an intermediate care facility described in section 1905(d), or inpatient mental hospital services is made under the State plan—</text><subparagraph id="HDE1C2BD7AB6847FD8CBC517AD2C75B3C"><enum>(A)</enum><text display-inline="yes-display-inline">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 specialist 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 assistance 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 intermediate 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, recertifies, 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 accompanied by such supporting material, appropriate to the case involved, as may be provided in regulations of the Secretary), that such services are or were required to be given on an inpatient basis because the individual needs or needed such services, and</text></subparagraph><subparagraph id="H3EA50A787F9643AB9899E651C5C5EBCD"><enum>(B)</enum><text display-inline="yes-display-inline">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 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;</text></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph><paragraph commented="no" id="H2BAF2189BF5E4C02B1284FA631294300"><enum>(2)</enum><header>Nursing facility services supervision and clinical records</header><text>Section 1919(b)(6)(A) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r">42 U.S.C. 1396r(b)(6)(A)</external-xref>) is amended to read as follows:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H52593E0F0B14402F9479ECDD542AD53D"><subparagraph commented="no" id="H9E24E9A4BCB44632974CE68CDCB7BE9F"><enum>(A)</enum><text display-inline="yes-display-inline">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);</text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section><section id="H977754DA364D4B13888FB58283AE889C"><enum>108.</enum><header>Improving access to Medicaid clinic services</header><text display-inline="no-display-inline">Section 1905(a)(9) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396d">42 U.S.C. 1396d(a)(9)</external-xref>) is amended by adding <quote>or nurse practitioner</quote> after <quote>physician</quote> in both places that it appears.</text></section></title><title id="H6B1A6D7204B44000AA0961D0DFD4944A"><enum>II</enum><header>Removal of Barriers to Practice on Certified Registered Nurse Anesthetists</header><section commented="no" id="H43A99476C61C41CDB8B3752513D19D1F"><enum>201.</enum><header>Clarifying that certified registered nurse anesthetists can be reimbursed by Medicare for evaluation and management services</header><text display-inline="no-display-inline">Section 1861(bb)(1) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(bb)(1)</external-xref>) is amended by inserting <quote>, including pre-anesthesia evaluation and management services,</quote> after <quote>and related care</quote>.</text></section><section commented="no" id="H09D00B48AA5545BE857A793FC3DD9F63"><enum>202.</enum><header>Revision of conditions of payment relating to services ordered and referred by certified registered nurse anesthetists</header><text display-inline="no-display-inline">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—</text><paragraph commented="no" id="H217A8FD30C2B4735917EEE96CAD1E24E"><enum>(1)</enum><text>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</text></paragraph><paragraph commented="no" id="H08C4EFA4348940B08DC31DB4339F8042"><enum>(2)</enum><text>payment shall be made under such part for such services so ordered, certified, or referred by certified registered nurse anesthetists.</text></paragraph></section><section id="H193220AE51254856B61BF6D3DE9C2FC7"><enum>203.</enum><header>Special payment rule for teaching student registered nurse anesthetists</header><text display-inline="no-display-inline">Section 1848(a)(6) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395w-4">42 U.S.C. 1395w–4(a)(6)</external-xref>) is amended in the matter preceding subparagraph (A), by inserting <quote>or student registered nurse anesthetists</quote> after <quote>physician residents</quote>.</text></section><section commented="no" id="H791023FBE50F424B8D5F73EB74664504"><enum>204.</enum><header>Removing unnecessary and costly supervision of certified registered nurse anesthetists</header><text display-inline="no-display-inline">Section 1861(bb)(2) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(bb)(2)</external-xref>) is amended—</text><paragraph commented="no" id="H8B6E6075C69B46EF8DE5D59DCCF2D033"><enum>(1)</enum><text>in the second sentence, by inserting <quote>, but may not require that certified registered nurse anesthetists provide services under the supervision of a physician</quote> after <quote>certification of nurse anesthetists</quote>; and</text></paragraph><paragraph commented="no" id="H6E42A11116DC4D4A9963BBC2CF4E13EB"><enum>(2)</enum><text>in the third sentence, by inserting <quote>under the supervision of an anesthesiologist</quote> after <quote>an anesthesiologist assistant</quote>.</text></paragraph></section><section commented="no" id="H9BA0EB1C27CE42328CE6F84D07DA800A"><enum>205.</enum><header>CRNA services as a Medicaid-required benefit</header><subsection commented="no" id="HC8543A84AF4E41AAA48DABC59CF56F10"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Section 1905(a)(5) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396d">42 U.S.C. 1396d(a)(5)</external-xref>) is amended—</text><paragraph commented="no" id="HBA88016AD1AB4693B008077C91FCC288"><enum>(1)</enum><text>by striking <quote>and (B)</quote> and inserting <quote>(B)</quote>; and </text></paragraph><paragraph commented="no" id="HC7BCB6262AC44E5C89FC507E2FB323EB"><enum>(2)</enum><text>by inserting before the semicolon at the end the following: <quote>, 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)</quote>.</text></paragraph></subsection><subsection commented="no" id="HDD57DF58AF78439ABA9F0F7A8D888793"><enum>(b)</enum><header>Payment</header><text>Section 1902(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396d">42 U.S.C. 1396d(a)</external-xref>) is amended—</text><paragraph commented="no" id="HE6488CCF42D44A818726D37DF27201C0"><enum>(1)</enum><text>in paragraph (86), by striking <quote>and</quote> at the end;</text></paragraph><paragraph commented="no" id="H7FC2AA539E124D388DF6984B9A9A3B14"><enum>(2)</enum><text>in paragraph (87), by striking the period and inserting <quote>; and</quote>; and</text></paragraph><paragraph commented="no" id="H44464CBE95EF4707B92BF70271C9418C"><enum>(3)</enum><text>by inserting after paragraph (87) the following new paragraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H6D68958E995E484BAEF33F49E46D2F6E"><paragraph commented="no" id="H75C0B00E063A44BCAD57850D98E9CF29"><enum>(88)</enum><text display-inline="yes-display-inline">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).</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section></title><title id="HDFBCAFC7506849C49417C7EA0F8C79EC"><enum>III</enum><header>Removal of Barriers to Practice on Certified Nurse-Midwives</header><section section-type="subsequent-section" id="H0C880707C8534FDB87806A0970ACA191"><enum>301.</enum><header>Improving access to training in maternity care</header><subsection id="H65F3185254A84C16B7A324CE19859D91"><enum>(a)</enum><header>Medicare payments for supervision by certified nurse-Midwives</header><text display-inline="yes-display-inline">Paragraph (1) of section 1861(gg) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(gg)</external-xref>) is amended to read as follows:</text><quoted-block style="OLC" display-inline="no-display-inline" id="HCA273F00D35D43FB96BE563AF1616B66"><paragraph id="H3905CD105D54456BA309F9A92EEE4F28"><enum>(1)</enum><text display-inline="yes-display-inline">The term <term>certified nurse-midwife services</term> means—</text><subparagraph id="HBE71426C932845C68D4AE266975D9FE1"><enum>(A)</enum><text>such services furnished by a certified nurse-midwife (as defined in paragraph (2)); and</text></subparagraph><subparagraph id="HD1EB527B26EC4641AFA625C0489CF864"><enum>(B)</enum><text>such services (and such supplies and services furnished as an incident to the nurse-midwife's service) which—</text><clause id="HA389154C0BAC4812865FC1ADD281F14F"><enum>(i)</enum><text>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;</text></clause><clause id="H780F1F59DA3E43B585734AC3EC9BA56E"><enum>(ii)</enum><text>are furnished under the supervision of a certified-nurse midwife by an intern or resident-in-training (as described in subsection (b)(6));</text></clause><clause id="HC456E0D4F3E94F55B62AE2B0ACB5BBE6"><enum>(iii)</enum><text>would otherwise be described in subparagraph (A) if furnished by a certified nurse-midwife; and</text></clause><clause id="HE01D35F39C624D77A15F142785314825"><enum>(iv)</enum><text>would otherwise be covered if furnished under the supervision of a physician.</text></clause></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></subsection><subsection id="H4B1CCB39D1044EFABB4299BFCDF1030C"><enum>(b)</enum><header>Clarifying permissibility of using certain grants for clinical training by certified nurse-Midwives</header><text>Section 811(a)(1) of the Public Health Service Act (<external-xref legal-doc="usc" parsable-cite="usc/42/296j">42 U.S.C. 296j(a)(1)</external-xref>) is amended by inserting <quote>, including clinical training,</quote> after <quote>projects</quote>.</text></subsection></section><section id="HE1B3398AB54E46F3AC3AA01805D77F4C"><enum>302.</enum><header>Improving medicare patient access to home health services provided by certified nurse-midwives</header><subsection id="HF47EB1A96C84447DB5CC3296AB5E9F34"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Section 1835(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395n">42 U.S.C. 1395n(a)</external-xref>) is amended—</text><paragraph id="H07374CEF79D845B98C085A0B7E6CA988"><enum>(1)</enum><text>in paragraph (2)—</text><subparagraph id="HE684B5707E654CF0A9B5662067DB37B5"><enum>(A)</enum><text>by inserting <quote>or a certified nurse-midwife (as defined in section 1861(gg)),</quote> after <quote>or a physician assistant (as defined in section 1861(aa)(5)) who is working in accordance with State law,</quote>; and</text></subparagraph><subparagraph id="H3FE957DD82114E5298A9DB32373FCD40"><enum>(B)</enum><text>in subparagraph (A)—</text><clause id="H7D5A33BA36F14E368997F8F890E151DC"><enum>(i)</enum><text>in each of clauses (ii) and (iii), by striking <quote>or a physician assistant (as the case may be)</quote> and inserting <quote>a physician assistant, or a certified nurse-midwife (as the case may be)</quote>; and</text></clause><clause id="H3DB57C4C20E64C5A89E762BFE47CE878"><enum>(ii)</enum><text>in clause (iv), by—</text><subclause commented="no" id="H3EA37F197E834F70A521D0B451C01AFA"><enum>(I)</enum><text>inserting <quote>or by a certified nurse-midwife (as defined in section 1861(gg))</quote> after <quote>(but in no case later than the date that is 6 months after the date of the enactment of the <short-title>CARES Act</short-title>)</quote>; and</text></subclause><subclause id="H67D23D1B227D499ABB4A42BC8B5E9E2F"><enum>(II)</enum><text>by striking <quote>(as defined in section 1861(gg))</quote>; and</text></subclause></clause></subparagraph></paragraph><paragraph commented="no" id="HB2D08C873D9B4F9886164200C50187DC"><enum>(2)</enum><text>in the matter following paragraph (2), by striking <quote>or physician assistant (as the case may be)</quote> and inserting <quote>physician assistant, or certified nurse-midwife (as the case may be)</quote> each place it appears.</text></paragraph></subsection><subsection id="H70D492D190204CC7B2932B8DE828B6BD"><enum>(b)</enum><header>Conforming amendments</header><text>Section 1895 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395">42 U.S.C. 1395(fff)</external-xref>) is amended—</text><paragraph id="H23D77DAE184F4BDF9411CCB7C888FA46"><enum>(1)</enum><text>in subsection (c)(1), by inserting <quote>a certified nurse-midwife (as defined in section 1861(gg)),</quote> after <quote>clinical nurse specialist (as those terms are defined in section 1861(aa)(5)),</quote>; and</text></paragraph><paragraph id="H98E1B68F1D6E4386885FB55AF6A1DBAE"><enum>(2)</enum><text>in subsection (e)(1)(A), by striking <quote>a physician a nurse practitioner or clinical nurse specialist,</quote> and inserting <quote>a physician, a nurse practitioner, a clinical nurse specialist, a certified nurse-midwife,</quote>.</text></paragraph></subsection></section><section id="H0AB05C8827CF4CC69D1C111A954A20B1"><enum>303.</enum><header>Improving access to DMEPOS for Medicare beneficiaries</header><text display-inline="no-display-inline">Section 1834(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395m">42 U.S.C. 1395m(a)</external-xref>) is amended—</text><paragraph id="HBF472E95BDD943189390DB27C1A17D43"><enum>(1)</enum><text>in paragraph (1)(E)(ii) by striking <quote>or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5))</quote> and inserting <quote>, 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))</quote>; and</text></paragraph><paragraph id="HB0CE2A1F344F486E8120F3DDC66EF6BE"><enum>(2)</enum><text>in paragraph (11)(B)(ii)—</text><subparagraph id="HC7D0806E025E419592663AAD5790AC50"><enum>(A)</enum><text>by striking <quote>or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5))</quote> and inserting <quote>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))</quote>; and</text></subparagraph><subparagraph id="H075221A4D69645F38EE35762E4D3BD67"><enum>(B)</enum><text>by striking <quote>or specialist</quote> and inserting <quote>specialist, or nurse-midwife</quote>. </text></subparagraph></paragraph></section><section id="HD21E8ADF18734380BCC81087633670A8"><enum>304.</enum><header>Technical changes to qualifications and conditions with respect to the services of certified nurse-midwives</header><text display-inline="no-display-inline">Section 1861(gg)(2) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395x">42 U.S.C. 1395x(gg)(2)</external-xref>) is amended by striking <quote>, or has been certified by an organization recognized by the Secretary</quote> and inserting <quote>and has been certified by the American Midwifery Certification Board (or a successor organization)</quote>.</text></section></title><title id="HDA098BA8BA7A419FB9111628F5CC4A76"><enum>IV</enum><header>Improving Federal Health Programs for All Advanced Practice Registered Nurses</header><section id="H83BFEFAD126E4C78B2B63A4A7D6A5E95"><enum>401.</enum><header>Revising the local coverage determination process under the Medicare program</header><subsection id="HB7A23FE6829F442EB3E8502BD938A42D"><enum>(a)</enum><header>In general</header><text>Section 1862(l)(5) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395y">42 U.S.C. 1395y(l)(5)</external-xref>) is amended—</text><paragraph id="HD8B193167F134573B267694A29B5429B"><enum>(1)</enum><text>in subparagraph (D), by adding at the end the following new clauses:</text><quoted-block style="OLC" id="H534F6951638B41F8B0AE85AF6D9D90D5"><clause id="H1ABEBE28ACD943D88DC0173C49D28965"><enum>(vi)</enum><text>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.</text></clause><clause id="H5288D135CBF64A7981952CFB50F60A6F"><enum>(vii)</enum><text>A hyperlink to any written communication between such contractor and another entity that such contractor relied on when developing such determination.</text></clause><clause id="HF4CA36E69EF64ABFB2BBE4B6F563AABB"><enum>(viii)</enum><text>A hyperlink to any rule, guideline, protocol, or other criterion that such contractor relied on when developing such determination.</text></clause><after-quoted-block>; and</after-quoted-block></quoted-block></paragraph><paragraph id="H4C67B7D82507491B8FC3B32FFB73DC60"><enum>(2)</enum><text>by adding at the end the following new subparagraphs:</text><quoted-block style="OLC" id="HFBD7474E995C4C39B928A9BBD7240017"><subparagraph id="H8F56380914A54C9ABB373A35633B1D8C"><enum>(E)</enum><header>Prohibition on imposition of practitioner qualifications</header><text>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.</text></subparagraph><subparagraph id="HABB46C41EAEE459BBC1BAC6BB9605831"><enum>(F)</enum><header>Civil monetary penalty</header><text>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).</text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="HE8DCB0E963524E03A90FB203EBB50C25"><enum>(b)</enum><header>Timing of review</header><text>Section 1869(f)(2) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395ff">42 U.S.C. 1395ff(f)(2)</external-xref>) is amended by adding at the end the following new subparagraph:</text><quoted-block style="OLC" id="HCE53BACB7A9A46A08F216837235FE8F2"><subparagraph id="HFB968D0AA0DC4999B2BE7825CE7C7831"><enum>(D)</enum><header>Timing of review</header><text>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.</text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></subsection><subsection id="H2760B7E879E44497A2EFCF8724E0803A"><enum>(c)</enum><header>Effective date</header><text>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.</text></subsection></section><section id="H649D3E1AC75844BBB84E0CBA96559014"><enum>402.</enum><header>Locum tenens</header><text display-inline="no-display-inline">Section 1842(b)(6) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395u">42 U.S.C. 1395u(b)(6)</external-xref>) is amended, in the first sentence—</text><paragraph commented="no" id="H8022F43C5BE64BD4A54ED7DDA1FB9CD8"><enum>(1)</enum><text>by striking <quote>and (J)</quote> and inserting <quote>(J)</quote>; and</text></paragraph><paragraph commented="no" id="H96E646C010E44F5DBB7A53424E664243"><enum>(2)</enum><text>by inserting before the period at the end the following: <quote>, 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)), subparagraph (D) of this sentence shall apply to such services and such anesthetist, practitioner, specialist, or nurse-midwife in the same manner as such subparagraph applies to physicians’ services furnished by physicians</quote>. </text></paragraph></section></title><title id="HFDCC1778E98C49DEB87292797E3FB1B4"><enum>V</enum><header>Miscellaneous</header><section id="H2CA558530F08404DB6238E2572B53C8A"><enum>501.</enum><header>Effective date</header><text display-inline="no-display-inline">The provisions of, including the 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 implement 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. </text></section></title></legis-body></bill> 

