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ACNM Policy Update - 7/20/2015

State Issues
1.  Rhode Island Certified Midwife Bill Signed into Law!
2.  Introductions and Progress: DE, IL, MI, NJ, OH
3. New Laws:  HI, ME, RI
4.  Oregon Passes Bill to Provide OTC Access to Contraceptives
5.  Congratulation to Sandy Elliott:  Winner of the ACNM Public Policy Award
Federal Issues
1.  CMS Proposes Significant Change to Incident To Billing Requirements 
2.  Administration Releases Final Rule on Coverage for Contraceptives
3.  ACNM Comments on Network Adequacy Requirements in Medicaid Managed Care Proposed Regulation
4.  Follow-Up on Lobby Day Contacts
5.  Students - Here’s How to Maximize the Chance of Receiving Funding Under the NHSC


State Issues

1.  Rhode Island Certified Midwife Bill Signed into Law!

Rhode Island S.319/H. 5583 grants prescriptive authority for CMs that is equivalent to the authority granted to CNMs. Specifically, the bills state, “The rules regarding the regulation of the practice of midwifery shall authorize a licensed certified nurse-midwife or a licensed certified midwife to prescribe medications that might be reasonably required by his or her patients…” The bills were signed into law on July 9.

2.  Introductions and Progress: DE, IL, MI, NJ, and OH

Delaware S.57 modernizes the abbreviated title of Advanced Practice Nurse (APN) to Advanced Practice Registered Nurse (APRN), updates renewal and reinstatement requirements for advanced practice nursing licensure, and clarifies prescription requirements. The bill passed the House on July 1. 

Delaware S.101 creates a new APRN Committee to assist the Board of Nursing in the regulation of nursing practice consistent with the national Consensus Model for APRN regulation. The bill includes provisions regarding the scope of practice for APRNs and creates a path for a select group of APRNs to obtain autonomous practice. The bill passed the House on July 1.

Illinois H.184 proposes to create a frame for a public education campaign to inform pregnant women and women who may become pregnant about cytomegalovirus under the auspices of the Department of Public Health. The bill was sent to the Governor for consideration on June 29. 

Illinois H. 2790 amends the Newborn Metabolic Screening Act by, among other things, requiring screening tests for the presence of adrenoleukodystrophy within 18 months following the occurrence of various events, including: (1) the development and validation of a reliable methodology; (2) the availability of any necessary reagents; (3) the establishment and verification of relevant and appropriate performance specifications; (4) the availability of quality assurance testing; (5) the acquisition and installment of necessary equipment; (6) the establishment of precise threshold values ensuring defined disorder identification for ALD; (7) the authentication of pilot testing; and (8) the authentication of achieving the potential of high standards. The bill was sent to the Governor for consideration on June 29.

Illinois S.1354 proposes to create the Advisory Committee on Neonatal Abstinence Syndrome within the Department of Public Health. The committee would be responsible for (1) developing a definition of the disease; (2) developing a protocol to identify the disease; (3) identifying and developing methods of training personnel to identify the disease; (4) reporting data to the Department; and (5) making recommendations to the Department to improve outcomes with respect to the disease. The Governor issued an amendatory veto on July 1.
Michigan H.4717 proposes to direct the Department of Health to disseminate information to the public on emergency contraception, which must include an explanation on the use, safety, efficacy, and availability. The bill states that the program will “help remove many of the barriers to emergency contraception and will help bring this important means of pregnancy prevention to American women.” It was introduced on June 16.
New Jersey S.1208 requires the Commissioner of Health to establish a public awareness campaign to advise pregnant women and new parents of the benefits of breastfeeding, and the legal protections and public and community supports for nursing mothers. The bill passed the Senate on June 29.
Ohio S.110 grants APRNs the authority to delegate to unlicensed medical personnel the ability to administer medications. The bill passed the House on June 25.

3.  New Laws: HI, ME, RI

Hawaii H.467 requires birthing facilities to perform a pulse oximetry test or other medically accepted screening on newborns to screen for critical congenital heart defects. The bill also requires birthing facilities to report certain critical congenital heart defect screening data to the Department of Health. The bill became law on July 6.
Hawaii H.782, requires the Department of Health to establish a public education program to inform and educate women about cytomegalovirus. The bill was signed into law on July 14.
Maine LD.1134 requires the Department of Health and Human Services to establish, maintain and operate an information service for Down syndrome. The information will include physical, developmental, educational and psychosocial outcomes, life expectancy, clinical course and intellectual and functional development and treatment options. The bill further requires CNMs who provide prenatal or postnatal care to offer parents this information upon receipt of a positive test result. The bill became law on June 30.

Rhode Island H.5046 prohibits a group health plan and health insurance issuer from discriminating regarding participation under the plan or coverage against any health provider acting within the scope of provider's license or certification. The bill became law on July 10.
Rhode Island H.5674 prohibits employers from discriminating against, and failing to provide reasonable accommodations for, employees due to pregnancy or medical conditions related to pregnancy or childbirth. The bill was signed by the Governor on July 2.

4.  Oregon Passes Bill to Provide OTC Access to Contraceptives

Oregon HB 2879, signed into law on July 13, 2015, will allow qualified pharmacists in Oregon to prescribe oral prescribe and dispense hormonal contraceptive patches and self-administered oral hormonal contraceptives to a person who is at least 18 years of age, or to those under age 18 if they have evidence of a previous prescription from a primary care practitioner or women’s health practitioner for such a contraceptive.  Notably, the law also requires that state and federal laws governing insurance coverage would apply to such over the counter contraceptives.  California passed a similar law in 2013 and is in the process of implementation. 

5.  Congratulation to Sandy Elliott:  Winner of the ACNM Public Policy Award

We would like to congratulate Sandy Elliott, CNM, MSN, president of the Delaware Affiliate for being selected as the recipient of ACNM’s Public Policy Award, given at the recent annual meeting.  

Sandy was a major stakeholder in negotiations for the CM/CPM licensure bill in Delaware. She has also made significant efforts over a period of several years, to foster a relationship with the home birth community and the local ACOG group. As national office staff, it’s great to work with Sandy and so many other midwives who are so dedicated to improving things for women, babies and the midwifery profession!

Federal Issues

1.  CMS Proposes Significant Change to Incident To Billing Requirements

On July 15, 2015, CMS published the CY 2016 Proposed Medicare Physician Fee Schedule, containing important changes proposed for coverage and reimbursement policies applicable to services rendered on or after January 1, 2016.   ACNM has prepared an issue brief on the proposed regulation, including specifics related to payment updates.  Below are the pertinent details related to the proposed changes to incident to billing requirements.

Under existing Medicare policy, services and supplies commonly provided in a physician or practitioner’s office that are actually rendered by auxiliary personnel “incident to” the services of the physician or other practitioner may be billed under the physician or practitioner’s number if certain requirements are met, including, among others, that the services or supplies are “Furnished under direct supervision (as specified under § 410.26(a)(2)) of a physician or other practitioner eligible to bill and directly receive Medicare payment.”  The regulatory definition of “direct supervision” is thus:  

Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

CNMs may provide services that are billed incident to under a physician’s number, or they may bill services under their own number when those services are provided by some auxiliary personnel incident to the CNM’s own service.

The major reason that services are billed incident to is to obtain payment at the physician level.  If there is a differential between what the physician or practitioner receives and what the auxiliary personnel would receive, there is a strong economic incentive to bill services incident to.  For example, Medicare pays NPs at 85% of physician rates, so it is advantageous for NPs to bill their services incident to, under a physician’s number because when they do, they are paid at 100%.

Under Medicare, the economic incentive for CNMs to bill incident to does not exist since CNMs are paid at 100% of physician rates.  However, many other payers reimburse CNMs/CMs at less than 100% of physician rates, and insofar as those payers follow Medicare’s lead, the economic incentive for CNMs to bill under the physician’s number is substantial.

Current regulation permits the supervision to be provided by a physician or provider other than the one billing for the incident to services.  So, for example, if Dr. Jones establishes a plan of treatment and a CNM then implements that plan by providing a prenatal visit, that prenatal visit can be billed under Dr. Jones’ number and this can occur even if Dr. Jones was not present in the office suite when the prenatal visit occurred, so long as there was another physician available in the office suite to provide the required direct supervision.  

CMS is proposing to modify this requirement to state that the physician or other practitioner who bills for incident to services must also be the physician or other practitioner who directly supervises the auxiliary personnel who provide the incident to services. 

This is a serious problem for physician/CNM groups.  To go to our example, if Dr. Jones initiates a plan of care that involved prenatal visits, but then goes off to a hospital to attend births, a CNM who renders one of those prenatal visits cannot bill the service incident to, under Dr. Jones’ number.  Rather, she/he would have to bill it under her/his own number.  Under Medicare, as noted above, this doesn’t matter economically since CNMs are reimbursed at physician rates, however, where other payers allow incident to billing, follow Medicare’s policies, and reimburse CNMs at a lower rate, it would mean that the CNM would have to bill under her/his own number and accept lower reimbursement, or wait to render the prenatal care until Dr. Jones had come back to the office to provide the required direct supervision.  This would be the case even if Dr. Smith was present in the office to provide direct supervision during the times when Dr. Jones was at the hospital.  

If CMS were to continue existing policy, the CNM could render the service when Dr. Jones was in the hospital, so long as another physician (Dr. Smith) was present in the office to provide the requisite direct supervision.  

ACNM will be developing comments on this proposal.  If this proposal would negatively affect you and your practice please reach out to me directly with your perspective on the proposal’s impact so that I can convey those details to CMS in our comments.

2.  Administration Releases Final Rule on Coverage for Contraceptives

On July 14, 2015, the Centers for Medicare and Medicaid Services (CMS), the Internal Revenue Service (IRS) and Employee Benefits Security Administration (EBSA) jointly published a final regulation regarding coverage of certain preventive and screening services, including contraceptive items and services, by non-grandfathered group health plans and health insurance coverage for individuals.  The regulation responds to more than 75,000 public comments on prior proposals and interim final rules, as well as the decision of the Supreme Court in the Hobby Lobby case.

ACNM has prepared an issue brief on the final regulation, describing its content and anticipated impact.  The Kaiser Family Foundation has also created a simple infographic showing how where women work affects their contraceptive coverage.  

3.  ACNM Comments on Network Adequacy Requirements in Medicaid Managed Care Proposed Regulation

On June 24, 2015, ACNM submitted comments on a proposed regulation modifying requirements for Medicaid managed care programs.  ACNM’s comments focused specifically on proposals made regarding provider network adequacy, arguing that Medicaid managed care plans must be held to the statutory standard that requires coverage of CNM and birth center services (note that CM services are not a required Medicaid benefit at this time).  

ACNM has prepared an issue brief describing specific proposals of interest to midwives in this proposed regulation.

4.  Follow-Up on Lobby Day Contacts

During our ACNM’s annual meeting, we had a fantastic lobby day, with approximately 500 midwives visiting the Hill to advocate for legislation affecting women, infants and the midwifery profession.

We have already seen an impact from that event, with 16 legislators signing on to bills that ACNM supports, after they were visited by our members.

To amplify our impact, we encourage all of you who visited with your legislators to reach out to the staff you talked with and follow up.  Ask them if they have had a chance to talk to their boss about H.R. 1209/S. 628 or S. 466 and whether they have made a decision to cosponsor these important bills.

If you don’t have contact information for the staffer you met with, you can find contact information for your legislators’ offices in the House here, and in the Senate here.  

5.  Students - Here’s How to Maximize the Chance of Receiving Funding Under the NHSC

During ACNM’s annual meeting, Captain Jeanean Willis Marsh, the Director of the Division of National Health Service Corps (NHSC) within the Health Resources and Services Administration (HRSA) gave an excellent presentation on the possibilities for financial support through the NHSC and several other programs operated by HRSA.    

During verbal Q&A after the presentation, a key piece of information came out.  HRSA takes applications for loan repayment under the NHSC from eligible applicants, and orders them by the HPSA score of the location where these applicants have contracted to work.  They then begin funding these applicants starting with the highest HPSA scores and working down.  When they run out of the money appropriated for that year, they cease funding any more applicants.  So, they do not allocate a set number based on license type, for example.  They are looking purely at that HPSA score among qualified applicants.  The highest possible HPSA score is 26.  The cut off point in the 2015 cycle was, we were told, approximately 16. Any qualified applicants who had a contract to work in an organization with a HPSA score at or above that cut off point will very likely be funded.

This cut off point will vary each year based on the amount of money Congress appropriates and the HPSA scores associated with the applications received by HRSA. However, the point is that the higher the HPSA score associated with the application, the more likely the chance of funding.  

Bottom line students, if you’re shooting for NHSC funding, you should aim to get work with an organization with a high HPSA score.  HRSA maintains a listing of jobs for sites located in HPSAs and those organizations can be sorted by HPSA score.  

Please share this Policy Update with any CNMs/CMs you know who are not ACNM members.  We want them to know what the association is doing to help them out and encourage them to become a part of the association.

Should you have questions about state issues, please contact Cara Kinzelman, ACNM's Manager of State Government Affairs at [email protected] or 240-485-1841.  

If you have questions regarding federal issues, please contact Jesse Bushman, ACNM’s Director of Advocacy and Government Affairs at [email protected] or 240-485-1843. 

Not an ACNM member?  You can access all of the member benefits, including receipt of every ACNM Policy Update, by joining today.  

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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American College of Nurse-Midwives.
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Phone: 240-485-1800 | Fax: 240-485-1818
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