H.R. 1317 — I CAN Act

This section revises Medicare coverage rules for cardiac rehabilitation programs and pulmonary rehabilitation programs by allowing services to be furnished in the office setting, rather than only in a physician’s office, and by expanding the practitioners who may prescribe the exercise component of those programs to include a physician, physician assistant, nurse practitioner, or clinical nurse specialist. As background, cardiac rehabilitation and pulmonary rehabilitation are supervised programs that help Medicare beneficiaries recover from heart and lung conditions through prescribed exercise and related services. Thus, the section broadens access by permitting more nonphysician clinicians to order these services and by making the site-of-service requirement less restrictive.

This section revises the Medicare documentation requirement for coverage of therapeutic shoes for individuals with diabetes by allowing a nurse practitioner or physician assistant, in addition to a physician, to certify the need for the shoes and related services under 42 U.S.C. 1395x(s)(12). (Thus, Medicare beneficiaries with diabetes may satisfy the required documentation through a nurse practitioner or physician assistant rather than only through a physician.)

This section revises the Medicare Shared Savings Program beneficiary assignment rules under 42 U.S.C. 1395jjj(c)(1) by adding, for performance years beginning on or after January 1, 2026, primary care services furnished under Medicare by an accountable care organization (ACO) professional described in subsection (h)(1)(B) as a basis for assignment. (Thus, beginning in 2026, Medicare beneficiaries may be assigned to an ACO based on primary care services provided by the specified ACO professionals, in addition to the existing assignment criteria.)

This section expands the list of Medicare providers authorized to furnish medical nutrition therapy services by adding nurse practitioners, clinical nurse specialists, and physician assistants, as those terms are defined under 42 U.S.C. 1395x(aa)(5), to the existing provider list. (Thus, Medicare beneficiaries may receive covered medical nutrition therapy services from these additional practitioners.)

This section revises Medicare home infusion therapy requirements by allowing an applicable provider, rather than only a physician, to establish a home infusion therapy plan under 42 U.S.C. 1395x(iii)(1)(B), and makes a conforming change in 42 U.S.C. 1395m(u)(6) to replace “physician” with “applicable provider (as defined in section 1861(iii)(3)(A)).” (Thus, the bill expands the set of clinicians who may authorize home infusion therapy services under Medicare.)

This section expands access to hospice care by authorizing nurse practitioners to perform and bill for certain hospice-related services. Specifically, it amends section 1814(a)(7)(A) of the Social Security Act to allow a nurse practitioner, in addition to a physician, to certify and recertify hospice eligibility for terminally ill patients, including by revising the statutory references to the certifying practitioner and the supporting documentation requirements. It also amends the hospice care definition in section 1861(dd)(1)(C) to include a nurse practitioner as a practitioner who may provide the required hospice-related certification. Finally, it directs the Secretary of Health and Human Services, not later than 90 days after enactment, to revise 42 C.F.R. § 418.304 so that nurse practitioners may bill for services not described in that regulation in the same manner as physicians, with payment at the applicable percentage of the physician fee schedule under 42 U.S.C. 1395l(a)(1)(O).

This section revises Medicare and Medicaid rules to allow nurse practitioners to perform additional certification, supervision, and care-planning functions in skilled nursing facilities, nursing facilities, and certain inpatient settings. In Medicare, it amends 42 U.S.C. 1395f(a)(2) to allow a nurse practitioner to certify post-hospital extended care services in accordance with State law, and amends 42 U.S.C. 1395f(a)(3) to authorize nurse practitioners to make the required certifications. It also makes conforming changes to Medicare provider and facility provisions to add nurse practitioners to supervision, attending-physician, and privileges language, including in skilled nursing facility resident rights and Part B administration provisions. In Medicaid, it revises 42 U.S.C. 1396a(a)(44) to allow a physician or nurse practitioner to certify inpatient hospital, skilled nursing facility, intermediate care facility, and inpatient mental hospital services, and to allow a physician or nurse practitioner to establish and periodically review the plan of care; it also revises 42 U.S.C. 1396r(b)(6)(A) to permit resident care in nursing facilities to be supervised by a physician or nurse practitioner.

This section expands Medicaid clinic services by adding nurse practitioners to the list of practitioners whose services may be covered when furnished in a clinic, by inserting “or nurse practitioner” after “physician” in both places that term appears in section 1905(a)(9) of the Social Security Act (42 U.S.C. 1396d(a)(9)). (Thus, states may reimburse clinic services provided by nurse practitioners on the same basis as those provided by physicians under this Medicaid benefit.)

This section revises the Medicare definition of certified registered nurse anesthetist services under section 1861(bb)(1) of the Social Security Act (42 U.S.C. 1395x(bb)(1)) to include pre-anesthesia evaluation and management services within the services for which certified registered nurse anesthetists may be reimbursed. (Thus, Medicare coverage for certified registered nurse anesthetist services explicitly encompasses pre-anesthesia evaluation and management services, in addition to anesthesia and related care.)

This section directs the Secretary of Health and Human Services to revise Medicare Part B regulations within 3 months of enactment to clarify that certified registered nurse anesthetists may order, certify, and refer services to the extent permitted under the law of the State where the services are furnished, and that Medicare payment shall be made for services so ordered, certified, or referred. (Thus, the provision aligns Medicare billing rules with State scope-of-practice laws for certified registered nurse anesthetists.)

This section revises the Medicare physician fee schedule payment rule to include teaching student registered nurse anesthetists, by inserting “or student registered nurse anesthetists” after “physician residents” in the special payment rule for teaching services under 42 U.S.C. § 1395w–4(a)(6). (Thus, Medicare’s teaching payment methodology would apply not only to physician residents but also to student registered nurse anesthetists.)

This section revises the Medicare definition of certified registered nurse anesthetist services under section 1861(bb)(2) of the Social Security Act (42 U.S.C. 1395x(bb)(2)) by prohibiting the Secretary from requiring certified registered nurse anesthetists to furnish services under the supervision of a physician and by specifying that anesthesiologist assistants must provide services under the supervision of an anesthesiologist. (Thus, Medicare’s conditions of participation and related coverage rules may not impose physician supervision requirements on certified registered nurse anesthetists.)

This section revises Medicaid’s definition of “medical assistance” to require coverage of services furnished by a certified registered nurse anesthetist (CRNA) when the CRNA is authorized to perform the services under State law or the State regulatory mechanism provided by State law. It also requires State Medicaid plans to provide payment for CRNA services at amounts no lower than the amounts, using the same methodology, used under section 1833(a)(1)(H) of the Social Security Act. (Thus, CRNA services become a required Medicaid benefit, and State payment rates for those services must be at least as high as the Medicare-based amounts specified in the bill.)

This section revises the Medicare definition of certified nurse-midwife services under 42 U.S.C. § 1395x(gg)(1) to include services and incident supplies furnished under the supervision of a certified nurse-midwife by an intern or resident-in-training, if the services are within the certified nurse-midwife’s state-law scope of practice, would otherwise be covered if furnished by a physician, and would otherwise be covered if furnished under physician supervision. (Thus, Medicare would recognize certain maternity-care training services performed by medical residents or interns under certified nurse-midwife supervision as covered certified nurse-midwife services.) This section also clarifies that grants under section 811(a)(1) of the Public Health Service Act, 42 U.S.C. § 296j(a)(1), may be used for clinical training by certified nurse-midwives by inserting “including clinical training” after “projects.”

This section revises Medicare home health eligibility rules to allow a certified nurse-midwife, in addition to a physician or physician assistant working in accordance with State law, to certify and recertify a beneficiary’s need for home health services under section 1835(a) of the Social Security Act (42 U.S.C. 1395n(a)). It makes conforming changes to the home health prospective payment system provisions in section 1895 of the Social Security Act (42 U.S.C. 1395fff) to include certified nurse-midwives in the list of practitioners whose documentation and orders may be used for Medicare home health payment purposes. (Thus, Medicare beneficiaries could access home health services based on certification by a certified nurse-midwife, not only by a physician or physician assistant.)

This section revises the Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) face-to-face examination and prescription requirements to allow a certified nurse-midwife (as defined in section 1861(gg)) to satisfy those requirements, in addition to a physician, physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5)). (Thus, Medicare beneficiaries may obtain qualifying DMEPOS items after an examination and prescription by a certified nurse-midwife, which expands the set of practitioners authorized to support payment for covered items under 42 U.S.C. 1395m(a).)

This section revises the qualification standard for certified nurse-midwives under Medicare by striking the alternative pathway that allowed certification by an organization recognized by the Secretary and instead requiring certification by the American Midwifery Certification Board (or a successor organization). (Thus, individuals must meet the specified board certification standard to qualify as certified nurse-midwives for purposes of Medicare coverage and payment.)

This section revises the Medicare local coverage determination review process by allowing an aggrieved party to file a complaint challenging a local coverage determination on or after the date the determination is posted on the Medicare administrative contractor’s website, whether or not the determination has taken effect. (Thus, judicial review may begin earlier than under current law, which ties review to later stages of the coverage process.)

This section revises the Medicare locum tenens payment rule under 42 U.S.C. § 1395u(b)(6) by (1) striking the reference to “and (J)” and inserting “(J),” and (2) adding a new clause to extend the same temporary substitute billing rule to services furnished by a certified registered nurse anesthetist, nurse practitioner, clinical nurse specialist, or certified nurse midwife. As background, locum tenens arrangements allow a physician to bill Medicare for services furnished by a substitute practitioner when the physician is temporarily unavailable. Thus, the amendment applies subparagraph (D) of the existing rule to these nonphysician practitioners in the same manner as it applies to physicians’ services furnished by physicians.

This section delays the effective date of the Act, except for sections 103 and 401, until items and services furnished on or after the date that is 90 days after enactment. It also directs the Secretary of Health and Human Services to implement the Act’s provisions, including the amendments made by the Act, through an interim final rule or subregulatory guidance if the Secretary determines that such action is necessary to meet that 90-day effective date or any other effective date in the Act.