New legislation supported by the American Association of Nurse Practitioners (AANP) and American Academy of PAs (AAPA) would increase NPs and PAs roles in providing cardiac and pulmonary rehabilitation care and ordering therapeutic shoes for patients with diabetes as well as allow PAs to receive direct payment under Medicare. Two major legislative wins for PAs and NPs in Connecticut are also presented in this month’s legislative update.

Cardiac and Pulmonary Rehabilitation Care

Heart disease is the leading cause of death in the United States; approximately 655,000 people in the US die from heart disease each year.1 Cardiac rehabilitation reduces deaths linked to cardiovascular complications and hospital readmissions, but only 20% of eligible patients receive these services, according to AANP.

AANP called on members of Congress to cosponsor the bill S. 1986/H.R. 1956, Increasing Access to Quality Cardiac Rehabilitation Care Act of 2021, which would allow “nurse practitioners [NPs] to order and provide supervision of cardiac and pulmonary rehabilitation services beginning in 2022.”1

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In 2018, Congress passed the Bipartisan Budget Act (BBA) to increase Medicare patients’ access to cardiac and pulmonary rehabilitation. The new bill would expedite BBA’s authorization for NPs to supervise cardiac and pulmonary rehabilitation care by moving the implementation date from 2024 to 2022, and authorize NPs to order this care starting in 2022.

“Removal of this outdated barrier will allow Medicare patients to have timely access to these lifesaving programs,” noted AANP. “While an NP may be the primary care provider for a patient and be most familiar with the patient’s health care needs, under current law, the NP must refer the patient to a physician to order these services, and a physician must also supervise these services until the BBA authorization for NPs supervision begins in 2024.”

Therapeutic Shoes for Patients With Diabetes

AANP and AAPA are supporting legislation to improve Medicare patients with diabetes access to therapeutic shoes.2,3  The new bill Promoting Access to Diabetic Shoes Act, S.800, would authorize NPs to certify their patients’ need for therapeutic shoes.

NPs have been authorized Part B Medicare providers, recognized to furnish, order, and refer for services and durable medical equipment (DME) under their Medicare provider numbers since 1998. “Early intervention involving diabetic shoes has been shown to reduce ulcerations and their resulting complications, improve quality of life, and reduce health care spending,” noted AANP.

While therapeutic shoes may be considered a type of durable medical equipment, “they are in fact covered under a separate section of the Social Security Act. Social Security Act §1861(s)(12) provides coverage for therapeutic shoes and inserts for persons with diabetes only if 1) they are certified to be medically necessary by a physician, and 2) the patient’s diabetes is being managed by a physician,” AAPA noted in a press release.3

“It is inconsistent and problematic that NPs are recognized as Part B Medicare providers who can order DME but are still unable to certify their patients with diabetes need for therapeutic shoes,” stated the association.

Passage of this legislation will allow NPs to order diabetic shoes when necessary for their Medicare patients. “It will reduce Medicare spending by eliminating duplicative services while also improving the quality and timeliness of care for beneficiaries with diabetes who need therapeutic shoes,” AANP said.

AAPA continues to advocate for legislation necessary to authorize PAs to order diabetic shoes without unnecessary restrictions.

Direct Payments for PAs From Medicare

Thanks to the Centers for Medicare and Medicaid Services (CMS), PAs will now be eligible to receive direct payment under Medicare as part of the Coronavirus Relief & Omnibus Agreement, according to a statement from the American Academy of PAs (AAPA).4 “The proposed rule implements legislative language championed by AAPA and will authorize PAs to receive Medicare direct payment effective January 1, 2022,” noted AAPA.

Currently, PAs are unable to receive direct payment from Medicare and this hinders PAs’ ability to fully participate in certain practice opportunities. Being able to receive direct payment from Medicare will be important to PAs who choose to:

  • Practice as self-employed contractors
  • Own their own practice
  • Work in certified rural health clinics (RHCs) and want to receive reimbursement for RHC services

Several states, however, currently have laws or regulations prohibiting PA direct payments. According to AAPA, if state law prohibits PAs from receiving direct payments, Medicare will not override those state provisions. The scope of practice and reimbursement rates will not change with this ruling.

Two Major Wins for PAs in Connecticut

There were 2 major legislative wins for PAs and patients in Connecticut, thanks to the determination of the Connecticut Academy of PAs (ConnAPA).5 Public Act No. 21-196, which will go into effect October 1, 2021, adds PAs to almost 80 areas of state law that only mention physicians or NPs.

PAs were added to areas of law including:

  • Certification or approval authority for insurance purposes
  • Certification, documentation, or other authority related to employment
  • Certification, documentation of patient’s disability or health condition in other contexts
  • Other provisions extending authority to PAs

The second win, Public Act No. 21-121, pertains to PAs and NPs being able to order home health and hospice care in Connecticut. AAPA stated that they worked with ConnAPA over the past few years to support their legislature, “including providing legislative drafting and technical assistance, research, and letters of support.”


1. American Association of Nurse Practitioners. Improve access for patients who need cardiac and pulmonary rehabilitation services. Accessed July 29, 2021.

2. American Association of Nurse Practitioners. Improve Medicare patient access to needed therapeutic shoes. Accessed July 29, 2021.

3. American Academy of PAs. Rule change provides more flexibility to PAs ordering diabetic shoes. May 21, 2021. Accessed August 2, 2021.

4. American Academy of PAs. Medicare moves to implement PA direct pay. July 20, 2021. Accessed July 29, 2021.

5. American Academy of PAs. Connecticut 2021 legislative session ends with major wins for PAs and patients. July 20, 2021. Accessed July 29, 2021.