,,ii #aagth ,,congress #b;d ,session ,s4 #ebab ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,december #h1 #bjbb,mr4 ,merkley introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend titles ,,xviii and ,,xix of the ,social ,security ,act and the ,bipartisan ,budget ,act of #bjah to increase access to services provided by advanced practice registered nurses under the ,medicare and ,medicaid programs1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,in general ,this ,act may be cited as the ,improving ,care and ,access to ,nurses ,act or the ,i ,,can ,act4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,,title ,i--,removal of ,barriers to ,practice on ,nurse ,practitioners ,sec4 #aja4 ,expanding access to cardiac rehabilitation programs and pulmonary rehabilitation programs under ,medicare program4,sec4 #ajb4 ,permitting nurse practitioners to satisfy ,medicare documentation requirement for coverage of certain shoes for individuals with diabetes4,sec4 #ajc4 ,improvements to the assignment of beneficiaries under the ,medicare shared savings program4,sec4 #ajd4 ,expanding the availability of medical nutrition therapy services under the ,medicare program4,sec4 #aje4 ,preserving access to home infusion therapy under the ,medicare program4,sec4 #ajf4 ,increasing access to hospice care services under the ,medicare program4,sec4 #ajg4 ,streamlining care delivery in skilled nursing facilities and nursing facilities2 authorizing medicare and medicaid inpatient hospital patients to be under the care of a nurse practitioner4,sec4 #ajh4 ,improving access to ,medicaid clinic services4,,title ,,ii--,removal of ,barriers to ,practice on ,certified ,registered ,nurse ,anesthetists,sec4 #bja4 ,clarifying that certified registered nurse anesthetists can be reimbursed by ,medicare for evaluation and management services4,sec4 #bjb4 ,revision of conditions of payment relating to services ordered and referred by certified registered nurse anesthetists4,sec4 #bjc4 ,special payment rule for teaching student registered nurse anesthetists4,sec4 #bjd4 ,removing unnecessary and costly supervision of certified registered nurse anesthetists4,sec4 #bje4 ,,crna services as a ,medicaid-required benefit4,,title ,,iii--,removal of ,barriers to ,practice on ,certified ,nurse-,midwives,sec4 #cja4 ,improving access to training in maternity care4,sec4 #cjb4 ,improving ,medicare patient access to home health services provided by certified nurse-midwives4,sec4 #cjc4 ,improving access to ,,dmepos for ,medicare beneficiaries4,sec4 #cjd4 ,technical changes to qualifications and conditions with respect to the services of certified nurse-midwives4,,title ,,iv--,improving ,federal ,health ,programs for ,all ,advanced ,practice ,registered ,nurses,sec4 #dja4 ,revising the local coverage determination process under the ,medicare program4,sec4 #djb4 ,locum tenens4 ,i ,removal of ,barriers to ,practice on ,nurse ,practitioners #aja4 ,expanding access to cardiac rehabilitation programs and pulmonary rehabilitation programs under ,medicare program 7a7 ,cardiac rehabilitation programs ,section #ahfa7;eee7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7eee77 is amended-- 7#a7 in paragraph 7#b7-- 7,a7 in subparagraph 7,a77i71 by striking a physician's office and inserting the office of a physician 7as defined in subsection 7r77#a77 or the office of a nurse practitioner1 clinical nurse specialist1 or physician assistant 7as those terms are defined in subsection 7aa77#e772 and 7,b7 in subparagraph 7,c71 by inserting 7as defined in subsection 7r77#a771 nurse practitioner1 clinical nurse specialist1 or physician assistant 7as those terms are defined in subsection 7aa77#e77 after physician2 7#b7 in paragraph 7#c77;,a71 by striking physician-prescribed exercise and inserting exercise prescribed by a physician 7as defined in subsection 7r77#a771 nurse practitioner1 clinical nurse specialist1 or physician assistant 7as those terms are defined in subsection 7aa77#e772 and 7#c7 in paragraph 7#e71 in the matter preceding subparagraph 7,a71 by inserting 7as defined in subsection 7r77#a771 nurse practitioner1 clinical nurse specialist1 or physician assistant 7as those terms are defined in subsection 7aa77#e771 after physician4 7b7 ,pulmonary rehabilitation programs ,section #ahfa7;fff7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7fff77 is amended-- 7#a7 in paragraph 7#b77;,a71 by striking physician-prescribed exercise and inserting exercise prescribed by a physician 7as defined in subsection 7r77#a771 nurse practitioner1 clinical nurse specialist1 or physician assistant 7as those terms are defined in subsection 7aa77#e772 and 7#b7 in paragraph 7#c71 in the matter preceding subparagraph 7,a71 by inserting after physician the following3 7as defined in subsection 7r77#a771 nurse practitioner1 clinical nurse specialist1 or physician assistant 7as those terms are defined in subsection 7aa77#e7714 7c7 ,effective date 7#a7 ,in general ,the amendments made by subsections 7a7 and 7b7 shall apply to items and services furnished on or after the date that is #c months after the date of enactment of this ,act4 7#b7 ,expediting implementation of supervision authority ,section #eajjh7;c7 of the ,bipartisan ,budget ,act of #bjah 7,public ,law #aae-abc2 #db ,u4,s4,c4 #aciex note7 is amended by striking ,january #a1 #bjbd and inserting ,january #a1 #bjbc4 #ajb4 ,permitting nurse practitioners to satisfy ,medicare documentation requirement for coverage of certain shoes for individuals with diabetes 7a7 ,in general ,section #ahfa7s77#ab7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#ab77 is amended-- 7#a7 in subparagraph 7,a71 by inserting 1 nurse practitioner1 or physician assistant after physician2 and 7#b7 in subparagraph 7,c71 by inserting 1 nurse practitioner1 or physician assistant after physician each place it appears4 7b7 ,effective date ,the amendments made by this section shall apply to items and services furnished on or after ,january #a1 #bjbc4 #ajc4 ,improvements to the assignment of beneficiaries under the ,medicare shared savings program ,section #ahii7;c77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;jjj7c77#a77 is amended-- 7#a7 in subparagraph 7,a71 by striking and at the end2 7#b7 in subparagraph 7,b71 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following new subparagraph3 7,c7 in the case of performance years beginning on or after ,january #a1 #bjbc1 primary care services provided under this title by an ,,aco professional described in subsection 7h77#a77;,b74 4 #ajd4 ,expanding the availability of medical nutrition therapy services under the ,medicare program ,section #ahfa7vv77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7vv77#a77 is amended by inserting 1 a nurse practitioner1 or a clinical nurse specialist 7as such terms are defined in subsection 7aa77#e77 before the period at the end4 #aje4 ,preserving access to home infusion therapy under the ,medicare program 7a7 ,allowing applicable providers ,to establish home infusion therapy plans ,section #ahfa7;iii77#a77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7iii77#a77;,b77 is amended-- 7#a7 by striking a physician 7as defined in subsection 7r77#a77 and inserting an applicable provider 7as defined in paragraph 7#c77;,a772 and 7#b7 by striking a physician 7as so defined7 and inserting an applicable provider 7as so defined74 7b7 ,conforming amendment ,section #ahcd7u77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7u77#f77 is amended by striking physician and inserting applicable provider 7as defined in section #ahfa7;iii77#c77;,a774 #ajf4 ,increasing access to hospice care services under the ,medicare program 7a7 ,in general ,section #ahad7;a77#g77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#g77;,a77 is amended-- 7#a7 in clause 7i77,i71 by striking a nurse practitioner or2 7#b7 in clause 7i77,,ii71 by inserting or nurse practitioner after physician2 and 7#c7 in clause 7ii71 by striking or physician and inserting 1 physician1 or nurse practitioner4 7b7 ,hospice care definition ,section #ahfa7;dd77#a77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#a77;,c77 is amended by inserting or nurse practitioner after physician4 #ajg4 ,streamlining care delivery in skilled nursing facilities and nursing facilities2 authorizing medicare and medicaid inpatient hospital patients to be under the care of a nurse practitioner 7a7 ,medicare 7#a7 ,certification of post-hospital extended care services ,section #ahad7;a77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#b77 is amended1 in the matter preceding subparagraph 7,a71 by striking 1 or a nurse practitioner1 and inserting or a nurse practitioner 7in accordance with ,state law71 or4 7#b7 ,certification authority for nurse practitioners ,section #ahad7;a77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#c77 is amended by inserting or nurse practitioner after physician4 7#c7 ,supervision requirement in skilled nursing facility services ,section #ahai7;b77#f77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;b77#f77;,a77 is amended-- 7,a7 in the heading1 by striking ,physician supervision and inserting ,supervision2 and 7,b7 by inserting or a nurse practitioner1 in accordance with ,state law after physician4 7#d7 ,administration of part ,b ,section #ahdb7;b77#b77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#b77;,c77 is amended1 in the second sentence1 by striking working in collaboration with that physician4 7#e7 ,provision of medical and other health services ,section #ahfa7s77#b77,k77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b77,k77ii77 is amended by striking or clinical nurse specialist 7as defined in subsection 7aa77#e77 working in collaboration 7as defined in subsection 7aa77#f77 with a physician 7as defined in subsection 7r77#a77 and inserting 7as defined in subsection 7aa77#e77;,a771 or by a clinical nurse specialist 7as defined in subsection 7aa77#e77;,b77 working in collaboration with a physician 7as defined in subsection 7r77#a7714 7#f7 ,privileges for nurse practitioners ,section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 is amended-- 7,a7 in subsection 7e77#d71 by inserting 7or nurse practitioner1 in accordance with ,state law7 after physician2 7,b7 in subsection 7f77#a71 by inserting or nurse practitioner after physician2 and 7,c7 in each of subparagraphs 7,b7 and 7,f7 of subsection 7ee77#b71 by inserting or nurse practitioner after physician4 7b7 ,medicaid 7#a7 ,certification authority for nurse practitioners ,section #aijb7;a77#dd7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#dd77 is amended to read as follows3 7#dd7 in each case for which payment for inpatient hospital services1 skilled nursing facility services1 services in an intermediate care facility described in section #aije7;d71 or inpatient mental hospital services is made under the ,state plan-- 7,a7 a physician or nurse practitioner 7or1 in the case of skilled nursing facility services or intermediate care facility services1 a physician or nurse practitioner1 or a clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician7 certifies at the time of admission1 or1 if later1 the time the individual applies for medical assistance under the ,state plan 7and a physician or nurse practitioner1 or a physician assistant under the supervision of a physician1 or1 in the case of skilled nursing facility services or intermediate care facility services1 a physician or nurse practitioner1 or a clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician1 recertifies1 where such services are furnished over a period of time1 in such cases1 at least as often as required under section #aijc7;g77#f7 7or1 in the case of services that are services provided in an intermediate care facility1 every year71 and accompanied by such supporting material1 appropriate to the case involved1 as may be provided in regulations of the ,secretary71 that such services are or were required to be given on an inpatient basis because the individual needs or needed such services1 and 7,b7 such services were furnished under a plan established and periodically reviewed and evaluated by a physician or nurse practitioner1 or1 in the case of skilled nursing facility services or intermediate care facility services1 by a physician or nurse practitioner1 or a clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician2 4 7#b7 ,nursing facility services supervision and clinical records ,section #aiai7;b77#f77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr7b77#f77;,a77 is amended to read as follows3 7,a7 require that the health care of every resident be provided under the supervision of a physician or nurse practitioner 7or1 at the option of a ,state1 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 physician72 4 #ajh4 ,improving access to ,medicaid clinic services ,section #aije7;a77#i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a77#i77 is amended by adding or nurse practitioner after physician in both places that it appears4 ,,ii ,removal of ,barriers to ,practice on ,certified ,registered ,nurse ,anesthetists #bja4 ,clarifying that certified registered nurse anesthetists can be reimbursed by ,medicare for evaluation and management services ,section #ahfa7;bb77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7bb77#a77 is amended by inserting 1 including pre-anesthesia evaluation and management services1 after and related care4 #bjb4 ,revision of conditions of payment relating to services ordered and referred by certified registered nurse anesthetists ,not later than #c months after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services shall revise section #daj4fi of title #db1 ,code of ,federal ,regulations1 to clarify that1 for purposes of payment under part ,b of title ,,xviii of the ,social ,security ,act-- 7#a7 certified registered nurse anesthetists are authorized to order1 certify1 and refer services to the extent allowed under the law of the ,state in which the services are furnished2 and 7#b7 payment shall be made under such part for such services so ordered1 certified1 or referred by certified registered nurse anesthetists4 #bjc4 ,special payment rule for teaching student registered nurse anesthetists ,section #ahdh7;a77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;a77#f77 is amended1 in the matter preceding subparagraph 7,a71 by inserting or student registered nurse anesthetists after physician residents4 #bjd4 ,removing unnecessary and costly supervision of certified registered nurse anesthetists ,section #ahfa7;bb77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7bb77#b77 is amended-- 7#a7 in the second sentence1 by inserting 1 but may not require that certified registered nurse anesthetists provide services under the supervision of a physician after certification of nurse anesthetists2 and 7#b7 in the third sentence1 by inserting under the supervision of an anesthesiologist after an anesthesiologist assistant4 #bje4 ,,crna services as a ,medicaid-required benefit 7a7 ,in general ,section #aije7;a77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a77#e77 is amended-- 7#a7 by striking and 7,b7 and inserting 7,b72 and 7#b7 by inserting before the semicolon at the end the following3 1 and 7,c7 services furnished by a certified registered nurse anesthetist 7as defined in section #ahfa7;bb77#b771 which such certified registered nurse anesthetist is authorized to perform under ,state law 7or the ,state regulatory mechanism as provided by ,state law74 7b7 ,payment ,section #aijb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a77 is amended-- 7#a7 in paragraph 7#hf71 by striking and at the end2 7#b7 in paragraph 7#hg71 by striking the period and inserting 2 and2 and 7#c7 by inserting after paragraph 7#hg7 the following new paragraph3 7#hh7 provide for payment for the services of a certified registered nurse anesthetist 7as defined in section #ahfa7;bb77#a77 in amounts no lower than the amounts1 using the same methodology1 used for payment for amounts under section #ahcc7;a77#a77;,h74 4 ,,iii ,removal of ,barriers to ,practice on ,certified ,nurse-,midwives #cja4 ,improving access to training in maternity care 7a7 ,medicare payments for supervision by certified nurse-,midwives ,paragraph 7#a7 of section #ahfa7;gg7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7gg77 is amended to read as follows3 7#a7 ,the term certified nurse-midwife services means-- 7,a7 such services furnished by a certified nurse-midwife 7as defined in paragraph 7#b772 and 7,b7 such services 7and such supplies and services furnished as an incident to the nurse-midwife's service7 which-- 7i7 the certified nurse-midwife is legally authorized to perform under ,state law 7or the ,state regulatory mechanism provided by ,state law7 as would otherwise be covered if furnished by a physician2 7ii7 are furnished under the supervision of a certified-nurse midwife by an intern or resident-in-training 7as described in subsection 7b77#f772 7iii7 would otherwise be described in subparagraph 7,a7 if furnished by a certified nurse-midwife2 and 7iv7 would otherwise be covered if furnished under the supervision of a physician4 4 7b7 ,clarifying permissibility of using certain grants for clinical training by certified nurse-,midwives ,section #haa7;a77#a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bif;j7a77#a77 is amended by inserting 1 including clinical training1 after projects4 #cjb4 ,improving ,medicare patient access to home health services provided by certified nurse-midwives 7a7 ,in general ,section #ahce7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acien7a77 is amended-- 7#a7 in paragraph 7#b7-- 7,a7 by inserting or a certified nurse-midwife 7as defined in section #ahfa7;gg771 after or a physician assistant 7as defined in section #ahfa7;aa77#e77 who is working in accordance with ,state law12 and 7,b7 in subparagraph 7,a7-- 7i7 in each of clauses 7ii7 and 7iii71 by striking or a physician assistant 7as the case may be7 and inserting a physician assistant1 or a certified nurse-midwife 7as the case may be72 and 7ii7 in clause 7iv71 by-- 7,i7 inserting or by a certified nurse-midwife 7as defined in section #ahfa7;gg77 after 7but in no case later than the date that is #f months after the date of the enactment of the ,,cares ,act72 and 7,,ii7 by striking 7as defined in section #ahfa7;gg772 and 7#b7 in the matter following paragraph 7#b71 by striking or physician assistant 7as the case may be7 and inserting physician assistant1 or certified nurse-midwife 7as the case may be7 each place it appears4 7b7 ,conforming amendments ,section #ahie of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;fff7 is amended-- 7#a7 in subsection 7c77#a71 by inserting a certified nurse-midwife 7as defined in section #ahfa7;gg771 after clinical nurse specialist 7as those terms are defined in section #ahfa7;aa77#e7712 and 7#b7 in subsection 7e77#a77;,a71 by striking a physician a nurse practitioner or clinical nurse specialist1 and inserting a physician1 a nurse practitioner1 a clinical nurse specialist1 a certified nurse-midwife14 #cjc4 ,improving access to ,,dmepos for ,medicare beneficiaries ,section #ahcd7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7a77 is amended-- 7#a7 in paragraph 7#a77;,e77ii7 by striking or a clinical nurse specialist 7as those terms are defined in section #ahfa7;aa77#e77 and inserting 1 a clinical nurse specialist 7as those terms are defined in section #ahfa7;aa77#e771 or a certified nurse-midwife 7as defined in section #ahfa7;gg772 and 7#b7 in paragraph 7#aa77;,b77ii7-- 7,a7 by striking or a clinical nurse specialist 7as those terms are defined in section #ahfa7;aa77#e77 and inserting a clinical nurse specialist 7as those terms are defined in section #ahfa7;aa77#e771 or a certified nurse-midwife 7as defined in section #ahfa7;gg772 and 7,b7 by striking or specialist and inserting specialist1 or nurse-midwife4 #cjd4 ,technical changes to qualifications and conditions with respect to the services of certified nurse-midwives ,section #ahfa7;gg77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7gg77#b77 is amended by striking 1 or has been certified by an organization recognized by the ,secretary and inserting and has been certified by the ,american ,midwifery ,certification ,board 7or a successor organization74 ,,iv ,improving ,federal ,health ,programs for ,all ,advanced ,practice ,registered ,nurses #dja4 ,revising the local coverage determination process under the ,medicare program 7a7 ,in general ,section #ahfb7l77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7l77#e77 is amended-- 7#a7 in subparagraph 7,d71 by adding at the end the following new clauses3 7vi7 ,identification of any medical or scientific experts whose advice was obtained by such contractor during the development of such determination1 whether or not such contractor relied on such advice in developing such determination4 7vii7 ,a hyperlink to any written communication between such contractor and another entity that such contractor relied on when developing such determination4 7viii7 ,a hyperlink to any rule1 guideline1 protocol1 or other criterion that such contractor relied on when developing such determination4 2 and 7#b7 by adding at the end the following new subparagraphs3 7,e7 ,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 7as defined in section #ahfa7r77 or a practitioner described in section #ahdb7;b77#ah77;,c7 who may furnish the item or service that is the subject of such determination4 7,f7 ,civil monetary penalty ,a ,medicare administrative contractor that develops a local coverage determination that fails to make information described in subparagraph 7,d7 available as required by the ,secretary under such subparagraph or comply with the prohibition under subparagraph 7,e7 is subject to a civil monetary penalty of not more than #aj1jjj for each such failure4 ,the provisions of section #aabh;,a 7other than subsections 7a7 and 7b77 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 #aabh;,a7a74 4 7b7 ,timing of review ,section #ahfi7;f77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7f77#b77 is amended by adding at the end the following new subparagraph3 7,d7 ,timing of review ,an aggrieved party may file a complaint described in subparagraph 7,a7 with respect to a local coverage determination on or after the date that such determination is posted1 in accordance with section #ahfb7l77#e77;,d71 on the ,internet website of the ,medicare administrative contractor making such determination1 whether or not such determination has taken effect4 4 7c7 ,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 ,act4 #djb4 ,locum tenens 7a7 ,in general ,section #ahdb7;b77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#f77 is amended-- 7#a7 by striking and 7,j7 and inserting 1 7,j72 and 7#b7 by inserting before the period at the end the following 1 and 7,k7 in the case of services furnished by a certified registered nurse anesthetist 7as defined in section #ahfa7;bb77#b771 nurse practitioner1 or clinical nurse specialist 7as defined in section #ahfa7;aa77#e771 or a certified nurse-midwife 7as defined in section #ahfa7;gg77#b771 subparagraph 7,d7 of this sentence shall apply to such services and such anesthetist1 practitioner1 specialist1 or nurse-midwife in the same manner as such subparagraph applies to physicians' services furnished by physicians4 7b7 ,implementation ,not later than #ij days after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall update all applicable regulations and subregulatory guidance necessary to carry out this section4