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ACNM Policy Update - 3/17/14

1. CMS Releases Final 2015 Letter to Issuers and Request for Information Regarding Provider Non-Discrimination

2. Selected State Developments from Hawaii, Kentucky, Nebraska, New Mexico, Ohio, Oregon, South Dakota, Virginia, and West Virginia

Note: Many of the state developments were slated to be included in an earlier policy update, but did not go out because I inadvertently scheduled the email to be sent in the year 2104. We assure you that your national office staff aspires to appropriately inform you of events before you die of old age.


1. CMS Releases Final 2015 Letter to Issuers and Request for Information Regarding Provider Non-Discrimination

This past week, the Centers for Medicare and Medicaid Services (CMS) issued two important documents related to the new Health Insurance Marketplaces. The first is the final “ 2015 Letter to Issuers in the Federally-facilitated Marketplaces.” This document outlines policies and operational practices CMS will adopt with regard to the federally facilitated marketplaces for the 2015 plan year. Among these are provisions specific to determinations of plan network adequacy.

In its proposed Letter to Issuers, CMS indicated the agency would no longer allow plans’ network adequacy to be determined via accreditation or by state agencies and would instead make those determinations itself. ACNM supported this course, as it allows for a more consistent, centralized approach. It also make advocacy on this point simpler, as we will not have to approach each individual state exchange when we note problems with coverage of midwifery services. In the final Letter, CMS indicates it will follow this approach.

In the final Letter, as with the proposal, CMS indicates it is considering appropriate formats for collection of provider network data, which would allow for the creation of a search engine function for consumers to find particular providers and provider types on HealthCare.gov. ACNM supported this approach in its comments on the proposed Letter.

Related to questions of network adequacy, CMS has issued a Request for Information regarding implementation of Section 2706 of the Public Health Services Act (PHSA). Section 2706 was added to the PHSA by the Affordable Care Act (ACA) and requires that a ‘‘group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable state law.’’

On April 29, 2013, the Departments of Labor, Treasury and Health and Human Services issued an FAQ stating that they had no plans for establishing regulations implementing Section 2706 in the near future and that plans would be responsible for implement the requirements of Section 2706 using a good faith, reasonable interpretation. Unfortunately, the FAQ went on to state that Section 2706 “does not require plans or issuers to accept all types of providers into a network.”

A coalition, of which ACNM is a member, had lobbied Congress on this issue and in a Senate Appropriations Committee Report, dated July 11, 2013 (page 126), the Committee stated that ‘‘The goal of this provision is to ensure that patients have the right to access covered health services from the full range of providers licensed and certified in their State. The Committee is therefore concerned that the FAQ document issued by HHS, DOL and the Department of Treasury on April 29, 2013, advises insurers that this nondiscrimination provision allows them to exclude from participation whole categories of providers operating under a State license or certification.” The Committee directed HHS, DOL and Treasury to “correct the FAQ to reflect the law and congressional intent within 30 days of enactment of this act.”

In response, CMS has issued the Request for Information, asking for input on all aspects of implementing Section 2706. As you are aware, ACNM is undertaking a survey of health insurance plans regarding their coverage of midwifery services. The results of this survey will put us in a good position for providing reliable information to the federal government regarding whether plans are appropriately covering the services of midwives. (Hooray for our survey volunteers!)

2. Selected State Developments

Hawaii - S.2649 requires reimbursement for services provided through telehealth to be equivalent to reimbursement for the same services provided via face-to-face contact between a health care provider and a patient. The bill clarifies that a health care provider of telehealth includes primary care providers, mental health providers, and oral health providers such as physicians and osteopathic physicians, advanced practice registered nurses, psychologists, and dentists. It passed the Senate on March 4.

Kentucky - S.7 removes the requirement for a written collaborative agreement to prescribe non-scheduled legend drugs (CAPA-NS). After four years of prescribing in collaboration with a physician, APRNs will no longer be required to maintain the CAPA-NS. An agreement will still be needed for controlled substances. The bill was signed into law on February 13.

Nebraska - L.76 establishes the Healthcare Transparency Act. A committee will be appointed to provide objective analysis of health care costs and quality, promote transparency for health care consumers, and facilitate the reporting of health care and health quality data, in the hopes of providing for the facilitation of value-based, cost-effective purchasing of health care services by public and private purchasers and consumers. The bill was signed into law on Feb. 13.

The New Mexico - House passed a legislative memorial which requests that the Secretary of Health convene a task force to identify statutory provisions that create obstacles to the ability of nurse practitioners, nurse-midwives and physician assistants to function at their full scopes of practice.

Ohio - H.95 clarifies in law that CNMs may sign birth certificates. Though CNMs have been signing birth certificates for more than 30 years and the Ohio Department of Health Office of Vital Statistics has accepted nurse midwife-signed documents, CNMs have never had the express authority in the law to do so. Recently two Ohio hospitals have gone so far as to no longer allow their Certified Nurse Midwives to sign birth certificates. The bill became law on March 4.

Ohio - H.139 states that CNMs and other advanced practice nurses may admit patients to the hospital if they have a standard care arrangement with a physician who is a member of the medical staff, the patient will be under the medical supervision of the collaborating physician, and the hospital has granted the CNM admitting privileges and appropriate credentials. The bill was signed into law on February 18.

Oregon - S.1548 amends certain statutes that reference “physician'” to include references to “physician assistant”' and “nurse practitioner.” (In Oregon, CNMs are licensed as NPs.) The bill is not meant to expand scope of practice but to correct language to reflect the work that is already being done lawfully by NPs and PAs. It was signed into law on March 6.

South Dakota - S.30 implements the Advanced Practice Registered Nurse (APRN) credential. It was signed into law on February 10.

Virginia - H.580 clarifies that active-duty military personnel are exempt from state licensure requirements when providing care at public and private health care facilities. The bill became law on February 20.

West Virginia - H.4335 relates to a child's right to nurse. Specifically, the bill states in its entirety that: "The Legislature finds that breast feeding is an important, basic act of nurturing that is protected in the interests of maternal and child health. (b) A mother may breast feed a child in any location, public or private, where the mother and child are otherwise authorized to be." It is eligible for the Governor's consideration as of March 8.

West Virginia - S.12 is an expedited partner therapy bill. The bill proposes to allow a health care professional who makes a clinical diagnosis of a sexually transmitted disease may provide expedited partner therapy for the treatment of the sexually transmitted disease if in the judgment of the health care professional the sexual partner is unlikely or unable to be present for comprehensive health care, including evaluation, testing and treatment for sexually transmitted diseases. Expedited partner therapy is limited to a sexual partner who may have been exposed to a sexually transmitted disease within the previous sixty days and who is able to be contacted by the patient. It is eligible for the Governor's consideration as of March 8.

West Virginia - HCR122 requests the Joint Committee on Government and Finance to study the feasibility of changes to the regulatory requirements of advanced practice registered nurses. Specifically, the Committee is requested to study "the feasibility of the following changes to the regulatory requirements of advanced practice registered nurses (APRN): expanding of scope of practice; expanding prescriptive authority; permitting annual prescriptions supplies; permitting that a signature have the same effect as a physician insofar as patient care documentation in concerned; and removing the collaborative relationship with physicians." The resolution was introduced on March 4.


Should you have questions about federal issues, please contact Jesse Bushman, ACNM’s Director of Advocacy and Government Affairs at jbushman@acnm.org or 240-485-1843.

Should you have questions about state issues, please contact Cara Kinzelman, ACNM’s Manager of State Government Affairs at ckinzelman@acnm.org or 240-485-1841.



Don’t forget to register for ACNM 59th Annual Meeting & Exposition.  Details are available at the conference website.

Want to take action or get involved? Contact ACNM's Government Affairs Committee.

Don't have the time or energy to get involved, but still want to contribute? Support the Midwives-PAC.


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