[Congressional Record Volume 145, Number 114 (Thursday, August 5, 1999)]
[Extensions of Remarks]
[Pages E1787-E1788]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]


             CERTIFIED NURSE MIDWIFERY SERVICES ACT OF 1999

                                 ______
                                 

                          HON. EDOLPHUS TOWNS

                              of new york

                    in the house of representatives

                        Thursday, August 5, 1999

  Mr. TOWNS. Mr. Speaker, I rise today with my colleague, Mr. Upton of 
Michigan, to reintroduce the Certified Nurse Midwifery Services Act.
  There are approximately two million disabled women in Medicare who 
are of child bearing years that are not receiving ``well women'' 
services, due to the fact that Medicare is a poor payer for these 
covered services. Last year, the Agency for Health Policy and Research 
(AHPR) released a study stating that disabled women were not receiving 
their primary care services. A disproportionate number of disabled 
women who are covered by Medicare are currently being seen by Certified 
Nurse-Midwives (CNMs), who are duly equipped to handle the underserved 
population through the unique personal training of CNMs. Although, CNMs 
are sought to deliver these services Medicare currently reimburses a 
CNM in rural areas $14 for a typical well-women visit, which could 
include: a pap smear, mammogram, and other pre-cancer screenings. The 
typical well-woman visit in fee for services cost on average $50 per 
visit. CNMs administer the same tests and incur the same associated 
costs but receive only 65 percent of the physician fee schedule for 
these services. At this incredibly low rate of reimbursement, a CNM 
simply cannot survive.
  Our legislation, which has over 30 bipartisan co-sponsors, increases 
the level of reimbursement to 95 percent of the physician fee schedule, 
which is the economic reality in the marketplace. Moreover, CNMs serve 
as faculty members of medical schools. For over 20 years, they have 
supervised and trained interns and residents. The bill guarantees 
payment for graduate medical education and includes technical 
corrections that will clarify the reassignment of billing rights for 
CNMs who are employed by others. Additionally, the bill ensures 
facility fee payments for freestanding birth centers where a woman can 
receive the full range of care from her preferred CNM.
  This bill will enhance access to ``well woman'' care for thousands of 
women in underserved communities. I urge my colleagues to support this 
legislation as we move forward with initiatives to address shortfalls 
in the Medicare system.

                                H.R. --

       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 ``Certified Nurse Midwifery 
     Medicare Services Act of 1999''.

     SEC. 2. MEDICARE PAYMENT FOR CERTIFIED NURSE-MIDWIFE AND 
                   MIDWIFE SERVICES.

       (a) Certified Midwife, Certified Midwife Services 
     Defined.--(1) Section 1861(gg) of the Social Security Act (42 
     U.S.C. 1395x(gg)) is amended by adding at the end the 
     following new paragraphs:
       ``(3) The term `certified midwife services' means such 
     services furnished by a certified midwife (as defined in 
     paragraph (4)) and such services and supplies furnished as an 
     incident to the certified midwife's service which the 
     certified midwife is legally authorized to perform under 
     State law (or the State regulatory mechanism provided by 
     State law) as would otherwise be payable under this title if 
     furnished by a physician or as an incident to a physician's 
     service.
       ``(4) The term `certified midwife' means an individual who 
     has successfully completed a bachelor's degree from an 
     accredited educational institution and a program of study and 
     clinical experience meeting guidelines prescribed by the 
     Secretary, or has been certified by an organization 
     recognized by the Secretary.''.
       (2) The heading in section 1861(gg) of such Act (42 U.S.C. 
     1395x(gg)) is amended to read as follows:

   ``Certified Nurse-Midwife Services; Certified Midwife Services''.

       (b) Certified Midwife Service Benefit.--

                           *   *   *   *   *

       (B) in paragraph (6), by striking ``; or'' and inserting 
     ``or in the case of services in a hospital or osteopathic 
     hospital by an intern or resident-in-training in the field of 
     obstetrics and gynecology, nothing in this paragraph shall be 
     construed to preclude a certified nurse-midwife or certified 
     midwife (as defined in paragraphs (1) and (3), respectively, 
     of subsection (gg)) from teaching or supervising such intern 
     or resident-in-training, to the extent permitted under State 
     law and as may be authorized by the hospital; or'';
       (C) in paragraph (7), by striking the period at the end and 
     inserting ``; or''; and
       (D) by adding at the end the following new paragraph:
       ``(8) a certified nurse-midwife or a certified midwife 
     where the hospital has a teaching program approved as 
     specified in paragraph (6), if (A) the hospital elects to 
     receive any payment due under this title for reasonable costs 
     of such services, and (B) all certified nurse-midwives or 
     certified midwives in such hospital agree not to bill charges 
     for professional services rendered in such hospital to 
     individuals covered under the insurance program established 
     by this title.''.
       (4) Benefit under part b.--Section 1832(a)(2)(B)(iii) of 
     such Act (42 U.S.C. 1395k(a)(2)(B)(iii)) is amended--
       (A) by inserting ``(I)'' after ``(iii)'';
       (B) by inserting ``certified midwife services,'' after 
     ``certified nurse-midwife services,''; and
       (C) by adding at the end the following new subclause:
       ``(II) in the case of certified nurse-midwife services or 
     certified midwife services furnished in a hospital which has 
     a teaching program described in clause (i)(II), such services 
     may be furnished as provided under section 1842(b)(7)(E) and 
     section 1861(b)(8);''.
       (5) Amount of payment.--Section 1833(a)(1)(k) of such Act 
     (42 U.S.C. 1395l(K)) is amended--
       (A) by inserting ``and certified midwife services'' after 
     ``certified nurse-midwife services''; and
       (B) by striking ``65 percent'' each place it appears and 
     inserting ``95 percent''.
       (6) Assignment of payment.--The first sentence of section 
     1842(b)(6) of such Act (42 U.S.C. 1395u(b)(6)) is amended--
       (A) by striking ``and (F)'' and inserting ``(F)''; and

[[Page E1788]]

       (B) by inserting before the period the following: ``, (G) 
     in the case of certified nurse-midwife services or certified 
     midwife services under section 1961(s)(2)(L), payment may be 
     made in accordance with subparagraph (A), except that payment 
     may also be made to such person or entity (or to the agent of 
     such person or entity) as the certified nurse-midwife or 
     certified midwife may designate under an agreement between 
     the certified nurse-midwife or certified midwife and such 
     person or entity (or the agent of such person or entity);
       (7) Clarification regarding payments under part b for such 
     services furnished in teaching hospitals.--(A) Section 
     1842(b)(7) of such Act (42 U.S.C. 1395u(b)(7)) is amended--
       (i) in subparagraphs (A) and (C), by inserting ``or, for 
     purposes of subparagraph (E), the conditions described in 
     section 1861(b)(8),'' after ``section 1861(b)(7),''; and
       (ii) by adding at the end the following new subparagraph:
       ``(E) In the case of certified nurse-midwife services or 
     certified midwife services furnished to a patient in a 
     hospital with a teaching program approved as specified in 
     section 1861(b)(6) but which does not meet the conditions 
     described in section 1861(b)(8), the provisions of 
     subparagraphs (A) through (C) shall apply with respect to a 
     certified nurse-midwife or a certified midwife respectively 
     under this subparagraph as they apply to a physician under 
     subparagraphs (A) through (C).''.
       (B) Not later than 180 days after the date of the enactment 
     of this Act, the Secretary shall prescribe regulations to 
     carry out the amendments made by subparagraph (A).

     SEC. 3. MEDICARE PAYMENT FOR FREESTANDNG BIRTH CENTER 
                   SERVICES.

       (a) Freestanding Birth Center Services, Freestanding Birth 
     Center Defined.--
       (1) In general.--(A) Section 1861(gg) of the Social 
     Security Act (42 U.S.C. 1395x(gg)), as amended in section 
     2(a)(1), is amended by adding at the end the following new 
     paragraphs:
       ``(5) The term `freestanding birth center services' means 
     items and services furnished by a freestanding birth center 
     (as defined in paragraph (6)) and such items and services 
     furnished as an incident to the freestanding birth center's 
     service as would otherwise be covered if furnished by a 
     physician or as an incident to a physician's service.
       ``(6) the term `freestanding birth center' means a 
     facility, institution, or site (other than a rural health 
     clinic, critical access hospital, or a sole community 
     hospital) (A) in which births are planned to occur (outside 
     the mothers's place of residence), (B) in which comprehensive 
     health care services are furnished, and (C) which has been 
     approved by the Secretary or accredited by an organization 
     recognized by the Secretary for purposes of accrediting 
     freestanding birth centers. Such term does not include a 
     facility, institution, or site that is a hospital or an 
     ambulatory surgical center, unless with respect to ambulatory 
     surgical centers, the State law or regulation that regulates 
     such centers also regulates freestanding birth centers in the 
     State.''.
       (B) The heading in section 1861(gg) of such Act (42 U.S.C. 
     1359x(gg)), as amended in section 2(b)(2), is further amended 
     by adding at the end the following:
       ``; Freestanding Birth Center Services''.
       (2) Medical and other services.--Section 1861(s)(2)(L) of 
     such Act (42 U.S.C. 1395x(s)(2)(L)), as amended in section 
     2(b)(1), is further amended--
       (A) by inserting ``(i)'' after ``(L)'';
       (B) by adding ``and'' after the semicolon; and
       (C) by adding at the end the following new clause:
       ``(ii) freestanding birth center services;''.
       (b) Part B Benefit.--
       (1) In general.--Section 1832(a)(2)(B)(iii) of such Act (42 
     U.S.C. 1395k(a)(2)(B)(iii)), as amended in section 2(b)(4), 
     is further amended by inserting ``freestanding birth center 
     services,'' after ``certified midwife services,''.
       (2) Amount of payment.--Section 1833(a)(1) of such Act (42 
     U.S.C. 1395l(a)(1)) is amended--
       (A) by striking ``and (S)'' and inserting in lieu thereof 
     ``(S)''; and
       (B) by inserting before the semicolon the following new 
     subparagraph: ``, and (T) with respect to freestanding birth 
     center services under section 1861(s)(2)(L)(ii), the amount 
     paid shall be made on an assignment-related basis and shall 
     be 80 percent of the lesser of (i) the actual charge for the 
     services or (ii) an amount established by the Secretary for 
     purposes of this subparagraph, such amount being 95 percent 
     of the Secretary's estimate of the average total payment made 
     to hospitals and physicians during 1997 for charges for 
     delivery and pre-delivery visits, such amounts adjusted to 
     allow for regional variations in labor costs; except that (I) 
     such estimate shall not include payments for diagnostic 
     tests, drugs, or the cost associated with the transfer of a 
     patient to the hospital or the physician whether or not 
     separate payments were made under this title for such tests, 
     drugs, or transfers, and (II) such amount shall be updated by 
     applying the single conversion factor for 1998 under section 
     1848(d)(1)(C)''.

     SEC. 4. INTERIM, FINAL REGULATIONS.

       Except as provided in section 2(b)(7)(B), in order to carry 
     out the amendments made by this Act in a timely manner, the 
     Secretary of Health and Human Services may first promulgate 
     regulations, that take effect on an interim basis, after 
     notice and pending opportunity for public comment, by not 
     later than 6 months after the date of the enactment of this 
     Act.

     

                          ____________________