H.R.1317—the Improving Care and Access to Nurses (I CAN) Act—amends Titles XVIII and XIX of the Social Security Act to broaden which advanced practice registered nurses (APRNs) and related clinicians may order, certify, refer, supervise, and bill for care under Medicare and Medicaid. The bill updates dozens of program rules so nurse practitioners (NPs), certified registered nurse anesthetists (CRNAs), certified nurse‑midwives (CNMs), clinical nurse specialists (CNSs), and physician assistants (PAs) can perform tasks currently limited to physicians in many Medicare and Medicaid contexts.
For compliance officers and health system leaders this is a package of operational and payment changes: it creates new billing permissions (including hospice and E/M), removes certain federal supervision requirements for CRNAs, tightens local coverage determination (LCD) transparency, and makes CRNA services a Medicaid required benefit with a payment floor. The result: more clinicians eligible to furnish and document care to beneficiaries, earlier regulatory deadlines for CMS, and direct implications for credentialing, billing systems, and state‑level scope‑of‑practice interactions.
At a Glance
What It Does
The bill amends multiple Social Security Act provisions to recognize APRNs and certain PAs as authorized providers for specific Medicare and Medicaid services (cardiac/pulmonary rehab, medical nutrition therapy, hospice, home infusion, DMEPOS, home health, SNF certifications, etc.), removes a federal supervision mandate for CRNAs, clarifies CRNA E/M and ordering authority, and imposes LCD transparency and enforcement requirements on Medicare contractors.
Who It Affects
Medicare and Medicaid beneficiaries (especially in rural and underserved areas), APRNs (NPs, CRNAs, CNMs, CNSs), physician assistants, hospitals and post‑acute providers, Medicare Administrative Contractors (MACs), and state Medicaid programs required to cover CRNA services.
Why It Matters
The bill shifts operational authority from physicians toward APRNs across a wide set of programs, creating immediate billing and credentialing implications and forcing CMS and MACs to revise rules quickly. It also narrows an administrative lever (LCD practitioner‑qualification limits) that payers have used to control access, with a new transparency and penalty regime that changes how local coverage decisions are made and contested.
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What This Bill Actually Does
H.R.1317 is a comprehensive, statutory-level reallocation of specific Medicare and Medicaid permissions from physicians to APRNs and certain physician assistants. It does this by changing multiple defined terms and coverage conditions in the Social Security Act so that when a statute or regulation today requires a ‘‘physician,’’ the comparable functions—prescription, certification, order, supervision, or documentation—can in many instances be performed by an APRN or PA as defined in the bill’s cross‑references.
That approach avoids a single new program but instead stitches amendments into existing authorities across hospitals, hospice, skilled nursing/long‑term care, home health, rehabilitation programs, DMEPOS, and provider payment rules.
Operational deadlines are baked into the bill. For example, HHS must revise the hospice billing regulation within 90 days to permit nurse practitioner billing for specified hospice services; the Secretary has three months to clarify CRNA ordering and referral authority.
For most other amendments the bill makes the statutory changes effective for items and services furnished 90 days after enactment, allowing CMS to implement by interim final rule or guidance where needed.The bill also addresses how Medicare coverage policy is made at the contractor level. It requires MACs to post supporting materials for local coverage determinations (LCDs), including expert names, communications and relied‑upon guidelines, and forbids MACs from imposing practitioner‑qualification conditions that would bar authorized clinicians from furnishing a covered item or service.
MACs that fail to publish required information or that run afoul of the new prohibition face civil money penalties tied to each failure.Title‑specific changes vary. For NPs the package expands who can prescribe or document cardiac and pulmonary rehabilitation and certain DME/clinic services, authorizes NPs to certify SNF/post‑hospital extended care and hospice orders (with billing parity language), and allows applicable providers beyond physicians to set home infusion plans.
For CRNAs it clarifies that pre‑anesthesia E/M services are payable, removes a federal supervision requirement, permits ordering/certifying/referring to the extent state law allows, and makes CRNA services a required Medicaid benefit with a payment floor tied to existing Medicare methodologies. For CNMs it clarifies training payment rules, home health eligibility, DMEPOS access, and defects the certifying body language to a named organization.
Cross‑cutting provisions treat APRNs the same as physicians for locum tenens rules and strengthen timelines and transparency for LCD challenges.
The Five Things You Need to Know
Most provisions take effect for items and services furnished 90 days after enactment; sections 103 (ACO assignment change) and 401 (LCD revisions) are excepted from that timing.
The Secretary must revise the hospice billing regulation within 90 days to allow nurse practitioners to bill for certain hospice services at the percentage specified under section 1833(a)(1)(O).
CMS must revise rules clarifying CRNA ordering/certification/referral and payment for such services within 3 months of enactment; the bill also removes any federal requirement that CRNAs work under physician supervision.
Medicaid must treat certified registered nurse anesthetist services as a required State plan benefit and pay CRNAs at amounts no lower than the methodology used under Medicare section 1833(a)(1)(H).
Medicare Administrative Contractors must publish experts, relied‑upon documents and communications for LCDs; failure to provide required transparency or to avoid imposing practitioner‑qualification limits can trigger civil monetary penalties up to $10,000 per failure.
Section-by-Section Breakdown
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Allowing APRNs/PAs to prescribe and document rehab services
This section amends the cardiac and pulmonary rehabilitation definitions to permit exercise plans and supervisory/documentation duties to be prescribed or certified by a physician assistant, nurse practitioner, or clinical nurse specialist (as defined elsewhere in the Act) in addition to physicians. Practically, providers of rehab can accept documentation from those clinicians and bill Medicare without a physician signature where the statutory definitions require it. That reduces a common administrative barrier in outpatient rehab programs and can broaden referral sources.
NP/PA authorization for diabetes shoe documentation
Amends the Medicare coverage rule for therapeutic shoes so a nurse practitioner or physician assistant may satisfy the practitioner documentation requirement. Compliance teams will need to update intake and claims workflows to accept NP/PA certifications and ensure supporting medical records meet existing coverage criteria.
Home infusion plans and applicable provider definition
The bill replaces multiple references to ‘‘physician’’ with ‘‘applicable provider’’ for establishing home infusion therapy plans and for related payment rules, broadening which qualified clinicians may create and attest to home infusion plans. Durable medical equipment and infusion suppliers must adjust contracting, ordering, and billing pathways to accept plans created by non‑physician providers provided state law permits it.
Hospice, SNF, hospital inpatient care under APRNs
Hospice provisions permit nurse practitioners to serve the same certifying and recertifying roles as physicians and require CMS to update hospice billing regs within 90 days so NPs can bill certain hospice services at a specified physician‑fee‑schedule percentage. SNF and inpatient rules are changed so nurse practitioners can certify post‑hospital extended care, be named as attending/supervising clinicians in SNFs and nursing facilities (subject to State law in some places), and be acknowledged in relevant hospital and Part B administration provisions. Expect immediate credentialing and privileging implications at hospitals and post‑acute facilities.
CRNA E/M, ordering authority, supervision removal, and Medicaid benefit
This title clarifies CRNAs may be reimbursed for evaluation and management services including pre‑anesthesia E/M, requires CMS to update the regulation on services ordered or referred by CRNAs within 3 months, removes any federal requirement that CRNAs work under physician supervision, and makes CRNA services a Medicaid required benefit with a payment floor keyed to an existing Medicare payment methodology. State scope laws still constrain ordering authority, but federally CRNAs gain clearer payment and benefit protections.
Certified nurse‑midwife training, home health, and DME access
These sections expand Medicare recognition of certified nurse‑midwife services for training and for furnishing home health and DMEPOS where state law permits, explicitly allow certain grant funds to be used for clinical training, and names the American Midwifery Certification Board as the certifying body. The changes remove administrative ambiguity that has limited CNM participation in home health and DME programs.
LCD transparency, prohibition on practitioner qualification limits, and penalties
This section adds detailed public‑disclosure requirements for local coverage determinations: MACs must post experts consulted, communications and documents relied upon, and hyperlinks to applicable guidelines. It also prohibits MACs from imposing LCD coverage limits based on practitioner qualifications that would exclude practitioners otherwise authorized under statute to furnish the item or service. MACs that fail to comply can face civil monetary penalties up to $10,000 per violation, with CMS enforcement mechanisms modeled on section 1128A processes.
Locum tenens extension and effective dates
The bill extends existing locum tenens rules to cover CRNAs, NPs, CNSs, and CNMs the same as physicians. The majority of the statutory amendments apply to items and services furnished 90 days after enactment; sections 103 (ACO beneficiary assignment change) and 401 (LCD changes) are carved out of that 90‑day effective regime and handled separately. The Secretary may implement many provisions by interim final rule or guidance to meet the effective‑date schedule.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Medicare and Medicaid beneficiaries in underserved areas—by enlarging the pool of clinicians who can order, certify, and provide services, beneficiaries gain more local access to rehab, hospice, home infusion, and home health without needing a physician encounter.
- Advanced Practice Registered Nurses (NPs, CRNAs, CNMs, CNSs)—the bill expands scope for ordering, certifying, billing, and teaching roles and removes some federal supervision requirements, increasing professional autonomy and billing opportunities.
- Safety‑net clinics and community health centers—allowing APRNs to furnish more covered services and accepting APRN documentation for DME and clinic visits reduces administrative bottlenecks and referral friction for clinic populations.
- Hospice and home‑infusion providers—clear NP billing language and broader applicable‑provider definitions reduce claim denials and administrative rejections tied to practitioner type.
- Patients participating in cardiac/pulmonary rehabilitation and those needing therapeutic shoes or medical nutrition therapy—more clinicians (NPs/PAs/CNSs) can authorize these services, likely reducing wait times and missed care.
Who Bears the Cost
- Medicare Administrative Contractors (MACs) and CMS—new disclosure, posting, and penalty regimes plus rapid regulatory updates (90 days/3 months) create administrative, staffing, and compliance costs for contractors and agency program offices.
- State Medicaid programs—CRNA becomes a required Medicaid benefit with a payment floor, which may increase State plan costs or require budget adjustments to comply with the new payment requirement.
- Hospitals, SNFs and home‑health agencies—credentialing, privileging, medical staff bylaws, and electronic health record workflows must be revised to accept APRN certifications and attending roles, producing short‑term operational costs.
- Physicians and physician groups—some revenue and control over admissions/certifications may shift to APRNs, potentially altering practice patterns and requiring renegotiation of supervisory or collaborative arrangements.
Key Issues
The Core Tension
The central dilemma is access versus localized control: the bill expands federal recognition of APRNs to increase beneficiary access and reduce administrative friction, but it stops short of preempting state scope‑of‑practice rules and leaves quality, credentialing, and oversight largely to states and facilities. That saves political capital but creates operational complexity—federal expansions without uniform state alignment can increase access in some places while producing confusion and compliance costs for multi‑state providers and payers.
The bill aggressively federalizes particular permissions while expressly deferring to State law for the substantive scope of practice: it allows APRNs to perform or certify services ‘‘to the extent allowed under State law.’’ That preserves state primacy but creates a fragmented rollout—providers operating multi‑state systems will need fine‑grained, state‑by‑state operational rules. CMS will face simultaneous demands for regulatory revisions (some with short 90‑day statutory triggers) and new oversight obligations for MAC disclosures and penalties, without corresponding appropriation language for added administrative burden.
Payment tensions are real. The bill requires Medicaid to cover and pay CRNA services with a floor tied to a Medicare methodology, and it sets a payment percentage for certain NP hospice services; yet it does not create a uniform federal reimbursement increase for all APRNs.
States and payers may therefore implement the mandates unevenly. Removing federal supervision requirements for CRNAs reduces a national administrative constraint, but clinical supervision and practice standards will still be governed by state boards and facility credentialing—creating potential conflict where facility bylaws or state law remain more restrictive.
Finally, the bill limits one lever MACs used to manage utilization—practitioner‑qualification LCDs—while increasing MAC transparency and exposure to penalties; expect appeals and litigation over what qualifies as an unlawful practitioner qualification and over the sufficiency of MAC disclosures.
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