Location:
MEDICAL PERSONNEL; NURSING;
Scope:
Connecticut laws/regulations;

OLR Research Report


February 27, 2013

 

2013-R-0149

REGULATION OF NURSE MIDWIVES IN CONNECTICUT

By: Nicole Dube, Associate Analyst

Robin Cohen, Principal Analyst

You asked (1) how Connecticut regulates nurse-midwives and (2) what amount the state spends on Medicaid nurse-midwife services.

SUMMARY

The Department of Public Health (DPH) licenses nurse-midwives in the state. Licensure requirements include (1) eligibility for a Connecticut registered nurse (RN) license, (2) current certification from the American College of Nurse-Midwives (ACNM), and (3) completion of 30 hours of pharmacology education. There are currently 217 licensed nurse-midwives in the state. The department also allows individuals licensed under the previous category of “midwife” as of June 1983 to renew their license annually for a $15 fee. (There are currently no licensed midwives.)

DPH regulates nurse-midwives with input from an advisory panel the commissioner appoints. The panel consists of three nurse-midwives in practice for at least five years who are not ACNM officers (CGS 20-86d).

Nurse-midwives manage all of women's health care needs, focusing on family planning, gynecology, pregnancy, childbirth, and post-partum care of mothers and newborns. They must do this within a health care system and have clinical relationships with obstetrician-gynecologists (OB-GYNs). They have prescriptive authority for Schedule II, III, IV, and V controlled substances and are covered by most health insurance plans in the state.

DPH can take a variety of disciplinary actions against a licensed nurse-midwife for failing to conform to accepted professional standards, including license suspension or revocation, probation, censure, or imposition of a civil penalty.

The Department of Social Services (DSS) reimburses midwives for performing a variety of obstetrical and gynecological procedures for Medicaid recipients. In 2011, DSS paid a total of nearly $1.7 million to nurse-midwives for providing prenatal, delivery, and postpartum services alone; in 2012, this figure rose to nearly $2.3 million. (This figure does not include clinics, including federally qualified health centers.)

NURSE-MIDWIVES

Licensure Requirements

DPH may issue a nurse-midwife license to an applicant who pays a $100 fee and (1) is eligible for RN licensure in the state, (2) has and maintains current ACNM certification, and (3) completed 30 hours of pharmacology education for nurse-midwifery. Foreign trained nurse-midwives not currently licensed as an RN in another state must complete the Commission on Graduates of Foreign Nursing Schools examination.

DPH also allows individuals licensed as of June 1983 under the previous category of “midwifery” to renew their licenses annually for a $15 fee (CGS 20-86g). (The department licensed “midwives” until 1983, when it began licensing “nurse-midwives.”) Currently, there are no licensed midwives in the state.

By law, only a person with a DPH license can use the title “licensed nurse-midwife” (LNM), “certified nurse-midwife” (CNM, indicating national certification), or any other words or letters indicating licensure (CGS 20-86e). The department cannot issue a license to a person facing disciplinary action or with an unresolved complaint (CGS 20-86c).

Temporary Licensure Exception

The department allows a graduate of an ACNM-approved nurse-midwife program to practice midwifery without a license in a hospital or other facility for up to 90 days after graduation or until learning that she failed the licensing exam, whichever occurs first. The facility must (1) verify the graduate's successful completion of an approved program and (2) provide supervision the DPH commissioner determines is adequate (CGS 20-86i).

Scope of Practice

Nurse-midwives manage women's health care needs, particularly family planning, gynecology, pregnancy, childbirth, and post-partum care of mothers and newborns. They must do this within a health care system and have clinical relationships with OB-GYNs that provide for consultation, collaborative management, or referral, as indicated by the patient's health status. The law requires each nurse-midwife to provide (1) care consistent with ACNM standards and (2) information about, or referral to, other providers or services, if the patient asks or requires care not within the nurse-midwife's scope of practice (CGS 20-86a & 20-86b).

In addition, a licensed nurse-midwife, in good faith and in the course of her practice, may prescribe, dispense, and administer Schedule II, III, IV, and V controlled substances. These controlled substances may also be administered by RNs or LPNs under the nurse-midwife's direction and supervision (CGS 21a-252(f)).

By law, a nurse-midwife must sign the birth certificate of each child she delivered. In addition, she may certify the date of delivery and sign a fetal or infant death certificate under certain conditions (CGS 20-86b).

Disciplinary Action

DPH can take disciplinary action against a licensed nurse-midwife or licensed midwife who fails to conform to accepted professional standards. Conduct or conditions warranting discipline include, among other things, a felony conviction; fraud or deceit in practice; negligent, incompetent, or wrongful conduct in professional activities; emotional, mental, physical, or substance use disorders; and willful false entries in patient records (CGS 20-86f and 20-86h).

Disciplinary actions available to DPH include license revocation or suspension; censure; a letter of reprimand; probation, including conditions or limitations DPH sets; or a civil penalty up to $25,000. The department can also order the licensee to undergo a reasonable physical or mental examination if there is an investigation about his or her physical or mental capacity to practice safely (CGS 19a-17 and 20-86f).

In addition, an RN practicing as a nurse-midwife without a license may also be subject to penalties under the Nurse Practice Act. Any person violating the act or willfully making false representations to the state's Nursing Board of Examiners is subject to a fine of up to $500, imprisonment for up to five years, or both (CGS 20-102).

MEDICAID EXPENDITURES FOR NURSE-MIDWIVES: PRENATAL, DELIVERY, AND POSTPARTUM ONLY

DSS reimburses nurse-midwives for a number of prenatal, delivery, and postpartum procedures they perform. This includes a global payment (for routine obstetric care, including prenatal care, vaginal delivery with or without an episiotomy or forceps, and postpartum care). It also pays for these procedures on an individual basis and cesarean deliveries.

Table 1 provides a comparison of DSS Medicaid OB-GYN nurse-midwife payments for selected services for calendar years (CY) 2011 and 2012. (In 2012, DSS completed its transition from a managed care model of service delivery to an administrative services organization (ASO) model. Hence, more providers, including nurse-midwives, are billing DSS directly rather than seeking payment from the managed care organizations.) The table does not include nurse-midwife services provided at clinics, including federally qualified health centers, because the nurse-midwives working in those clinics cannot bill DSS directly and instead are paid by the clinics.

Table 1: Medicaid Payments for Select OB-GYN Procedures

Performed by Nurse-Midwives in CYs 2011 and 2012

Procedure

CY 2011

CY 2012

 

Units of Service*

Amount Paid

Units of Service*

Amount Paid

Routine obstetric care including antepartum (prenatal) care, vaginal delivery, and postpartum care

203 (E) and 19 (F)

$648,056.74

30 (E) and 212 (F)

$593,275.45

Vaginal delivery only

166 (E) and 105 (F)

405,387.83

46 (E) and 738 (F)

791,003.00

Cesarean delivery only

109 (E) and 67 (F)

46,275.80

14 (E) and 233 (F)

83,927.42

Total OB-GYN Payments to Nurse-Midwives

1,684,028.95

2,257,876.75

Source: DSS

*Key: E=care provided by nurse midwives contracting with managed care organizations; F=care provided on fee-for-service basis

A complete listing of all services for which Medicaid reimbursed nurse-midwives in CYs 2011 and 2012 is attached.

ND/RC:ts