CERTIFIED NURSE MIDWIFERY SERVICES ACT OF 1999 -- HON. EDOLPHUS TOWNS (Extensions of Remarks - August 05, 1999)

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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,
This Act may be cited as the ``Certified Nurse Midwifery Medicare Services Act of 1999''.
(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
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(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).
(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)''.
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.

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