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Medicaid Coverage of Advanced Practice Nursing

Current federal law requires fee-for-service Medicaid to cover health care services provided by some APRNs (pediatric nurse practitioners, family nurse practitioners, and certified nurse midwives). Some states have opted to also cover the services of certified registered nurse anesthetists and clinical nurse specialists - mainly because these practitioners are willing to provide needed services in physician shortage areas.

The Balanced Budget Act of 1997 (BBA, P.L. 105-33) encouraged states to use primary care case managers as gatekeepers to care in the fee for service program. The BBA granted the states the option to recognize pediatric nurse practitioners, family nurse practitioners, and certified nurse midwives as primary care case managers; while also allowing them the option to refuse these providers. It precluded the states from recognizing any other type of APRN as a primary care case manager.

In addition, the BBA urged the states to move their Medicaid population into managed care. This law provided only a very vague reference to the types of providers that must be included in managed care panels. Plans must only show that they provide access to a sufficient number, mix, and geographic distributions of providers. In effect, the BBA permitted APRNs to be excluded as Medicaid providers in primary care case management and managed care

Changes in Federal Medicaid law are still needed that will:

  • Expand fee-for-service Medicaid to include direct payment for services provided by all nurse practitioners (NPs) and clinical nurse specialists (CNSs).
  • Recognize all NPs and CNMs as primary care case managers.
  • Require Medicaid managed care panels to include NPs, CNSs, CRNAs, and CNMs.

Many studies have shown that APRNs provide cost-effective, high-quality care. Many Medicaid plans reimburse APRNs at a fraction of the physician fee schedule. In addition, APRNs are often willing to provide services in rural and inner-city areas where access to physicians is limited. APRNs increase access to health care and decrease preventable acute care admissions and emergency room visits.

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