Medicaid Bulletin MSA 19-10

Enrollment and Reimbursement for Clinical Nurse Specialists

On May 1, 2019, the Medical Services Administration of the Michigan Department of Health & Human Services (“MDHHS”), which administers the Michigan Medicaid program, issued Bulletin MSA 19-10 (the “Bulletin”), setting out new general information regarding enrollment, billing and reimbursement for a Clinical Nurse Specialist (“CNS”). CNS is a relatively new category of specialty certification available to a registered nurse (“RN”) in Michigan (Click here to access Bulletin MSA 19-10). The CNS Medicaid enrollment and coverage provisions essentially mirror those that apply to a Nurse Practitioner (“NP”), a long-established specialty certification for RNs in Michigan. Both NPs and CNSs, along with specialty certified nurse midwives (“CNM”), fall within the category of Advanced Practice Registered Nurse or APRN, which have an expanded independent scope of practice under recent amendments to the Michigan Public Health Code (“Code”).

New Collaboration Agreement Requirements for CNSs and NPs

Current Requirements. The existing Medicaid collaboration agreement standards are written only for NPs, as the new CNS certification category was not previously addressed by Medicaid. Currently, Medicaid requires a NP to have a “formal document” that describes the terms under which the NP and the physician deliver covered medical services and any criteria for referral and consultation. The document must be renewed annually and updated as needed. All services provided through the collaboration agreement must fall within each practitioner’s legal scope of practice. The Medicaid “Practitioner/Physician Agreement” form (DCH-1575) developed for this purpose will be discontinued under the Bulletin’s new requirements.

New Requirements. Effective June 1, 2019, a CNS and a NP will have to attest to having a valid collaborative practice agreement with a Medicaid-enrolled physician as part of the Medicaid enrollment and recertification process. Oddly, the revised requirements for Medicaid NP/CNS collaboration agreements are identical to those required under the Code for a “practice agreement” between a physician and a physician’s assistant. The rationale and legal basis for this approach is not clear, given that a PA has no independent scope of practice outside the practice agreement (which is not true for a CNS/NP practicing under a collaboration agreement) and a PA is not in a delegation/supervision relationship as to any aspect of the PA’s practice (as is a CNS/NP as to delegated medical tasks such as prescribing controlled substances). It is also unclear why Medicaid is not applying these same collaboration requirements to CNMs, which, like NPs and CNSs, also fall into the APRN category under the Code.

Despite the unclear rationale or legal basis for the change, the Bulletin states that a collaboration agreement between a NP/CNS and a physician must:

  • Be in writing;
  • Be signed by both the NP/CNS and the physician;
  • State the effective date and subsequent review dates;
  • Outline the performance of medical care services and/or prescribing controlled substances to be done by the NP/CNS;
  • Not include an act, task, or function that the NP/CNS or physician is not qualified to perform by education, training, or experience, or that is not within the legal scope of the NP’s/CNS’s or physician’s license;
  • State the process between the NP/CNS and the physician for communication, availability, and decision making, including an emergency plan;
  • Include a protocol for designating an alternative physician for consultation when the primary collaborating physician is not available;
  • Describe the duties and responsibilities of the NP/CNS and physician based on their education, training and experience;
  • Include a termination clause.
  • Be maintained by the NP/CNS at his/her primary practice location; and
  • Be provided to MDHHS upon request.

The NP/CNS must notify MDHHS if the collaboration agreement is terminated by either party, which may lead to the NP’s/CNS’s disenrollment from Medicaid.

These new requirements will be effective June 1, 2019. NPs and CNSs who are enrolled in Medicaid or plan to enroll should act now to bring their collaboration agreements into compliance.