I CAN Act
- Sponsor
- Sen. Merkley, Jeff [D-OR]
- Committees
- Finance Committee (primary)
- Last action
- Feb 13, 2025
Bottom line
The I CAN Act seeks to enhance patient access to healthcare services and improve efficiency by removing federal restrictions on the practice and reimbursement of Advanced Practice Registered Nurses within Medicare and Medicaid.
What it actually does
This bill, known as the "Improving Care and Access to Nurses Act" or "I CAN Act," aims to expand the scope of practice and reimbursement eligibility for Advanced Practice Registered Nurses (APRNs), including Nurse Practitioners (NPs), Certified Registered Nurse Anesthetists (CRNAs), Certified Nurse-Midwives (CNMs), and Clinical Nurse Specialists (CNSs), under the Medicare and Medicaid programs. It removes various federal-level barriers that currently limit APRNs from practicing to the full extent of their education and training, thereby increasing patient access to a wider range of healthcare services.
Proponents argue
Supporters argue that this bill is crucial for addressing healthcare provider shortages, particularly in rural and underserved areas, by allowing highly trained APRNs to utilize their full skill sets. They contend that expanding APRN autonomy will improve patient access to timely care, streamline administrative processes, and potentially reduce healthcare costs by leveraging a cost-effective workforce.
Opponents contend
Critics, primarily some physician organizations, often raise concerns that expanding the independent practice authority of APRNs without physician supervision could compromise patient safety and the quality of care, especially in complex medical situations. They advocate for physician-led team-based care models, arguing that physicians' extensive training is essential for comprehensive patient management.
The bill is moderately complex due to its numerous technical amendments to the Social Security Act, requiring careful reading to understand the full scope of changes across different APRN specialties and federal programs.
Sec. 101, amending 42 U.S.C. 1395x(eee) and (fff)
Expanding Access to Cardiac and Pulmonary Rehabilitation Programs
This provision amends the Social Security Act to allow Physician Assistants (PAs), Nurse Practitioners (NPs), and Clinical Nurse Specialists (CNSs) to refer or prescribe for cardiac and pulmonary rehabilitation programs under Medicare. Previously, only physicians could authorize these services, which often created administrative delays and limited patient access, particularly in areas with physician shortages. The change aims to streamline the process and ensure more beneficiaries can access these vital rehabilitation services.
Supporters argue
Supporters argue that this change removes an unnecessary administrative barrier, allowing patients quicker access to critical rehabilitation services. They contend that PAs, NPs, and CNSs are fully qualified to make these referrals, improving efficiency and leveraging the full capacity of the healthcare workforce.
Critics contend
No specific opposition is typically raised against this provision, as it aligns with the recognized competencies of these practitioners and aims to improve patient access without fundamentally altering the nature of the services.
Tradeoffs
The provision navigates the balance between traditional physician oversight and the desire to streamline care delivery by recognizing the capabilities of other advanced practitioners.
Sec. 106, amending 42 U.S.C. 1395f(a)(7)(A) and 1395x(dd)(1)(C)
Increasing Access to Hospice Care Services by Nurse Practitioners
This section amends Medicare law to permit Nurse Practitioners (NPs) to certify and recertify a patient's eligibility for hospice care. Currently, this critical function is largely restricted to physicians, which can cause delays in patients receiving hospice benefits. Additionally, it directs the Secretary of Health and Human Services to revise regulations to allow NPs to bill for services not typically covered under the hospice per diem, similar to how physicians can bill for such services, at the specified physician fee schedule rate.
Sec. 107, amending various sections of 42 U.S.C. 1395f, 1395i-3, 1395u, 1395x, 1396a, 1396r
Streamlining Care in Skilled Nursing Facilities and Authorizing NP Care for Inpatients
This comprehensive section makes numerous amendments to Medicare and Medicaid laws to significantly expand the authority of Nurse Practitioners (NPs) in skilled nursing facilities (SNFs) and nursing facilities (NFs), as well as for inpatient hospital care. Key changes include allowing NPs to certify post-hospital extended care services, serve as the 'attending practitioner' for Medicare and Medicaid inpatient hospital patients, and supervise resident healthcare in SNFs and NFs in accordance with state law. These changes aim to reduce reliance on physicians for routine certifications and oversight, providing greater flexibility in care delivery.
Sec. 204, amending 42 U.S.C. 1395x(bb)(2)
Removing Unnecessary and Costly Supervision of Certified Registered Nurse Anesthetists
This provision amends the Social Security Act to explicitly prohibit Medicare from requiring Certified Registered Nurse Anesthetists (CRNAs) to provide services under the supervision of a physician. It clarifies that while the Secretary can establish requirements for CRNA certification, these cannot include physician supervision. This change aligns federal policy with the growing number of states that have opted out of federal physician supervision requirements for CRNAs, recognizing their independent practice capabilities.
Sec. 205, amending 42 U.S.C. 1396d(a)(5) and 1396d(a)
CRNA Services as a Medicaid-Required Benefit and Payment Floor
This section mandates that services furnished by Certified Registered Nurse Anesthetists (CRNAs) become a required benefit under state Medicaid plans, provided the CRNA is authorized to perform such services under state law. Furthermore, it establishes a payment floor, requiring that states reimburse CRNA services at amounts no lower than those used for payment under Medicare, using the same methodology. This ensures consistent coverage and fair compensation for CRNA services across Medicaid programs.
Sec. 301, amending 42 U.S.C. 1395x(gg)(1) and 42 U.S.C. 296j(a)(1)
Improving Access to Training in Maternity Care by Certified Nurse-Midwives
This section expands the definition of "certified nurse-midwife services" under Medicare to include services furnished under the supervision of a Certified Nurse-Midwife (CNM) by an intern or resident-in-training, making these services eligible for Medicare reimbursement. This change allows CNMs to play a greater role in the education and training of future healthcare providers. Additionally, it clarifies that grants under the Public Health Service Act can be used for clinical training, further supporting maternity care education.
Sec. 302, amending 42 U.S.C. 1395n(a) and 1395fff
Improving Medicare Patient Access to Home Health Services by Certified Nurse-Midwives
This section amends Medicare provisions to allow Certified Nurse-Midwives (CNMs) to certify the need for home health services and establish plans of care for Medicare beneficiaries. Previously, this authority was limited to physicians, nurse practitioners, and physician assistants. By including CNMs, the bill aims to streamline access to home health, particularly for new mothers and infants, and to ensure continuity of care from a trusted provider.
Sec. 401, amending 42 U.S.C. 1395y(l)(5) and 1395ff(f)(2)
Revising the Local Coverage Determination Process Under Medicare
This section significantly revises the process for Local Coverage Determinations (LCDs) under Medicare. It mandates increased transparency by requiring Medicare Administrative Contractors (MACs) to identify medical experts consulted, provide hyperlinks to relied-upon communications, rules, guidelines, and criteria during LCD development. Crucially, it prohibits MACs from imposing coverage limitations based on the qualifications of a physician or other practitioner (like an APRN) who may furnish the service. Non-compliance can result in a civil monetary penalty of up to $10,000 per failure. It also allows aggrieved parties to challenge LCDs earlier in the process.
This amendment subtly rephrases the language regarding Clinical Nurse Specialists (CNSs) working in collaboration with a physician for Medicare services. It changes 'or clinical nurse specialist (as defined in subsection (aa)(5)) working in collaboration (as defined in subsection (aa)(6)) with a physician (as defined in subsection (r)(1))' to 'clinical nurse specialist (as defined in subsection (aa)(5)(B)) working in collaboration with a physician (as defined in subsection (r)(1))'. This separates the CNS definition from the NP definition within the same clause and removes the explicit reference to subsection (aa)(6) for the definition of 'collaboration' for CNSs.
Sec. 107(a)(5), amending 42 U.S.C. 1395x(s)(2)(K)(ii)
Why it matters:This appears to be standard legislative practice for technical corrections or clarifications, aiming to refine statutory language without necessarily introducing a major policy shift.
Case for: Supporters would argue this clarifies the specific definition and collaboration requirements for Clinical Nurse Specialists, potentially streamlining administrative interpretation and ensuring consistency within the Medicare program.
Case against: While seemingly technical, any rephrasing of collaboration requirements could, in theory, be interpreted differently by various stakeholders, potentially leading to subtle shifts in practice or administrative burden, though this specific change appears minor.
Estimated impact: The estimated impact is minor, primarily providing administrative clarity rather than a significant change in policy or fiscal impact.
This provision completely rewrites paragraph (44) of section 1902(a) of the Social Security Act, which governs certification for inpatient services under Medicaid. The revised language explicitly includes nurse practitioners (and, in some cases, clinical nurse specialists working in collaboration with a physician) alongside physicians for certifying and recertifying the medical necessity of inpatient hospital services, skilled nursing facility services, intermediate care facility services, and inpatient mental hospital services. It also allows NPs and CNSs to establish and periodically review patient care plans.
Sec. 107(b)(1), amending 42 U.S.C. 1396a(a)(44)
Why it matters:This is standard legislative practice for comprehensive updates to a specific statutory section, rather than an attempt to obscure the provision. The rewrite ensures all relevant changes are integrated into a single, coherent paragraph.
Case for: Supporters argue this significantly expands the authority of NPs and CNSs within Medicaid, mirroring Medicare changes and improving access to care, particularly in facilities with physician shortages. It streamlines administrative processes and recognizes the advanced capabilities of these practitioners.
Case against: Some physician groups may raise concerns about the breadth of this expansion, particularly for certifying the medical necessity of inpatient services, arguing that it requires the comprehensive diagnostic and management skills of a physician to ensure appropriate utilization and patient safety.
Estimated impact: This provision has a significant impact on Medicaid programs nationwide, expanding the pool of authorized certifiers and care planners for millions of beneficiaries receiving inpatient services. It will likely improve administrative efficiency and patient access.
This section sets the effective date for most provisions of the Act to 90 days after the date of enactment. It also grants the Secretary of Health and Human Services the authority to implement these provisions through interim final rule or subregulatory guidance if deemed necessary to meet the effective date or any other specified effective date in the Act.
Sec. 501, Title V
Why it matters:This is standard legislative practice for specifying implementation timelines and providing administrative flexibility, rather than an attempt to obscure the provision.
Case for: Supporters argue that allowing for interim final rules or subregulatory guidance ensures rapid implementation of the bill's changes, addressing immediate healthcare access needs and minimizing delays in operationalizing the new authorities for APRNs.
Case against: Critics might contend that the use of interim final rules or subregulatory guidance bypasses the full public comment process typically associated with rulemaking, potentially leading to less stakeholder input on crucial implementation details and unforeseen consequences.
Estimated impact: This provision significantly impacts the timeline and method of implementation for all other provisions in the bill, potentially expediting their operationalization across Medicare and Medicaid programs.