ments is less than that for comparable physician providers, some have estimated that an expenditure of $1 billion (of either new funds or those shifted from GME) could lead to a cumulative 25 percent increase in the number of fully qualified APNs over a 10-year period.30

The role of Medicaid and Medicare Medicaid regulations should be clarified to ensure that Nurse-Managed Health Centers and Clinics are eligible for Medicaid reimbursement.

Medicare reimbursement for hospitals should include payment for expanded APN training programs; similarly, reimbursement for APNs’ supervision and training of medical students and residents as well as APN students in hospitals should be made on the same basis as that for physician supervisors.

Promote Parity in Recognition and Payment for Services
  • Medicaid should require states to recognize nurse practitioners and certified nurse midwives as Medicaid Primary Care Case Managers, as opposed to the current provision for “optional” recognition.

  • If an APN’s services are allowed by state law to be provided autonomously without supervision by any other provider, CMS should not condition any designation (such as those required for “Centers of Excellence”) or Medicare or Medicaid coverage and payment for those services upon any required supervision. Among other provisions affecting APNs, this would require a revision of the current CMS “Opt-Out” regulation31 for conditions of participation for anesthesia services in hospitals, critical access hospitals, and ambulatory surgical centers. Under the current regulation, even in states whose licensure laws do not require physician supervision of certified registered nurse anesthetists, CMS will not pay for an “unsupervised” CRNA’s fully competent and authorized services unless the Governor of that state, after conferring with the Boards of Nursing and Medicine, certifies to the CMS that s/he has found that “it is in the best interests of the state’s citizens to opt-out of the current federal physician supervision requirements, and that the opt-out is consistent with state law.”

  • CMS should encourage state Medicaid programs to cover health care services provided by retail or convenient care clinics.

  • Consistent with the comprehensive primary care services they provide to uninsured and vulnerable populations, Nurse-Managed Health Centers


Lewin Group, 2009 study.


66 FR 56762, 11/13/2001, Currently, 15 states have “opted out” of these supervision requirements.

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