Midwives and Medicare after Health Care Reform


Do we have Medicare equity?

Yes, As of January 1, 2011, Medicare payment for certified nurse-midwives services is increased to 100 percent of the Physician Fee Schedule (PFS). This increase from 65 percent was included in the 2010 Patient Protection and Affordability Care Act (PPACA) (aka Health Care Reform Legislation).

Why does it say that we are reimbursed at 80 percent?

Payment from Medicare for physician and CNM services is 80% of the actual charge but Medicare allows that physicians and CNMs bill the patient for the remaining 20 percent. CNMs and physicians are reimbursed equitably.

Why is Medicare equity so important?

Receiving 100% of the PFS under Medicare allows midwives to more easily expand service to women with disabilities of childbearing age as well as senior women covered by the Medicare program. Medicare also serves as the gold standard of reimbursement rates and sets a precedent for unequal reimbursement rates across specialties which provide similar services. Meaning, Medicare has opened the door to now fight for equitable reimbursement under Medicaid in the 22 states where midwives receive less than 100% as compared to physicians, as well as other third party payers.

Why were Certified Midwives (CMs) not included in the ACA legislation?

ACNM championed Medicare equity on behalf of CNMs and CMs. The legislature was unwilling to include CMs in the final health care reform legislation but ACNM and the Government Affairs Committee is continuing to work to include CMs under Medicare as health care reform legislation is addressed in the 112th Congress.

Can midwives initiate well-woman exams?

Yes, as before, well-woman or annual exams can be initiated by a midwife. A well-woman evaluation and management visit (99384-99387, 99394-99397) includes a history and physical, age-appropriate counseling, anticipatory guidance, risk factor reduction and appropriate lab testing.

Can a midwife initiate a wellness exam?

No. Initial and annual wellness exams are a new phenomenon under Medicare and introduced with the PPACA, only effective January 1, 2011. Unfortunately, midwives are not included in the list of providers able to initiate the wellness visit. Only physicians, nurse practitioners, clinical nurse specialists and physician assistants can initiate the wellness visit in the course of an office visit. However, midwives can participate in components of the wellness visit.

What is a wellness exam?

A wellness exam is not a well-woman annual exam or a physical. In fact, if a physical exam is performed at the annual wellness visit, it receives no additional payment from Medicare. A wellness exam (first visit G0438 or subsequent visit G0439) includes medical and family history, a list of medical providers and medications, height/weight/BMI/blood pressure and other routine measurements, detection of any cognitive impairment, a screening schedule for the next 5-10 years and health advice, and referrals for education and preventive services.

What if additional preventive physical exam services are provided to the Medicare recipient such as a pelvic or breast exam?

If additional preventive services such as a pelvic or breast exam are provided to the Medicare recipient, these are billed in addition to the wellness visit. This would include a pelvic and clinical breast exam (G0101) or a screening pap smear (Q0091). Keep in mind, Medicare will pay for this every two years, and if the patient meets Medicare's criteria for high risk, then the exam is reimbursed every year.

What is ACNM doing about this?

The ACNM national office has been working with the Secretary of the Center for Medicare and Medicaid Services (CMS) since the language was first introduced in 2010 to include midwives to the list of providers eligible to initiate wellness exams under Medicare. ACNM is also working to include CNMs in another section of the AAPCA that would allow midwives to be included in an incentive payment program to receive an additional 10% of the payment amount for primary care services furnished from January 1, 2011 to December 31, 2015.