States have a long history of providing Medicaid reimbursement for certified nurse midwives (CNMs) as a strategy to provide critical services, strengthen the maternal health workforce, and improve perinatal health outcomes. Evidence demonstrates that midwifery care is associated with positive outcomes, including lower rates of cesarean delivery, fewer obstetric interventions, high patient satisfaction, and improved maternal and infant health outcomes.
With increases in areas with no obstetric providers, many states are leveraging Medicaid coverage of CNM services as part of a comprehensive strategy to expand access to high-quality maternity care.
Nurse midwife services are a mandatory benefit under Medicaid and are reimbursed by all 50-states and Washington, DC. While a mandatory benefit, states have varying approaches to operationalizing Medicaid coverage of CNMs, including differences in scope of practice authority, reimbursement rates, coverage of services, and the settings in which CNM services are eligible for reimbursement. This brief summarizes findings from NASHP’s updated analysis of Midwife Medicaid Reimbursement Policies by State.
About Midwifery Care and Certified Nurse Midwives
What is Midwifery Care?
Midwifery care includes a full range of services for pregnant and postpartum women, including gynecologic and family planning services, preconception care, prenatal care, labor and delivery, and postpartum care. A midwife’s scope of practice depends on their certification and licensure credentials (i.e., CNM or licensed professional midwife), which vary by state.
What is a Certified Nurse Midwife?
A Certified Nurse Midwife (CNM) is an advanced practice registered nurse (APRN) who is educated and trained to provide comprehensive reproductive, maternal, and newborn health care. CNMs pass a national certification exam administered by the American Midwifery Certification Board (AMCB) to receive the professional designation of CNM.
Medicaid Reimbursement Structures
Most states set reimbursement rates for CNMs based on a percentage of what physicians are reimbursed for the same service. In recent years, many states have increased the reimbursement rate for CNMs to equal to, or 100 percent, the rate paid to physicians as part of broader efforts to strengthen the perinatal workforce and improve access to maternity care.
In 2025, 29 states and Washington, DC, reimbursed CNMs at 100 percent of the physician’s rate for a vaginal delivery, reflecting an increase from 25 states and DC in 2023. In contrast, the remaining 31 states continue to reimburse CNMs at rates less than that of physicians, generally ranging from 75 to 98 percent of the state’s physician reimbursement rate.
States reimburse CNMs under Medicaid using a variety of approaches. Ten states have developed specific fee schedules, or a standardized list of allowable fees for specific services, for CNMs. Consistent with rate-setting practices for providers, states implementing fee schedules for CNMs do so to standardize payments and provide clarity and predictability regarding CNM reimbursement amounts. Some states (Tennessee, Virginia) also only allow CNMs to bill for services through MCOs, meaning that CNMs must be contracted through an MCO in one of these states to bill Medicaid for services.
Beyond standardized reimbursement rates, some states also adjust CNM reimbursement rates based on additional conditions or requirements such as the type of health care delivery system, fee structure, and geography. In some states, CNM reimbursement rates vary by managed care organization (MCO) entity (Pennsylvania, Tennessee) or differ between fee-for-service claims and those submitted under MCO arrangements (North Dakota). This type of arrangement may indicate that payment for the same service can differ depending on whether it is reimbursed directly by the state under a traditional fee-for-service model or paid through a contracted MCO, and in some cases may also vary across MCO plans within the same state. Several states have established different reimbursement rates for CNMs based on special conditions including geographic location (e.g. rural) (AL), service setting (ID), or type of service provided (KS).
Coverage of Primary Care and Other Services
CNMs are often a main source of health care for women and as such, most states cover services provided by a CNM beyond prenatal, delivery, and postpartum care. In 41 states, CNMs can be reimbursed for services such as well-woman exams, family planning counseling, behavioral health screenings (e.g. maternal depression, substance use disorder), and in some cases, newborn care. Over 30 states allow CNMs to serve as a primary care provider (PCP) under Medicaid. Two states, Illinois and New Mexico, allow CNMs to provide and be reimbursed for all services that physicians are eligible to provide. Oregon allows CNMs to bill for expanded services, but the services must be provided in hospital settings.
Licensing and Practice Requirements
Certified nurse midwives must fulfill state licensure requirements to legally practice and receive Medicaid reimbursement. Licensure requirements for CNMs vary by state but generally include requirements for an active registered nurse license, master’s degree or higher degree in nursing, and certification as a CNM from the American Midwifery Certification Board (AMCB). These requirements are typically determined by a state’s Department of Health or Board of Nursing.
In addition to determining licensing requirements, states determine if CNMs can practice independently or must practice under a physician’s supervision (i.e., collaborative practice). Independent practice allows CNMs to provide the full scope of services they are trained and licensed to deliver without requiring a formal supervisory or collaborative agreement with a physician. Collaborative practice requirements vary by state and typically require a CNM to engage in a legally binding contract, known as a collaborative practice agreement (CPA), with an OB-GYN. A CPA outlines the conditions under which a CNM may practice, including permitted settings (e.g. office, hospital), scope of practice, supervision requirements, and prescriptive authority.
Since NASHP’s 2023 analysis, some states revised policies to allow CNMs to practice independently. As of 2025, 26 states and Washington, DC, allow CNMs to independently practice (24 states in 2023), and 21 states require CNMs to enter into a collaborative practice agreement with a supervising physician (22 states in 2023). Four states have adopted a hybrid approach, where CNMs can practice independently but with specific, state-defined restrictions or requirements (e.g., supervision requirements for complex pregnancies, 1,000 hours under physician supervision).
Place of Service Codes
State Medicaid agencies determine the physical setting, or place of service (POS), where different types of providers can care for patients (e.g., patient’s home, in-office) and bill for services. Place of Service Codes are two-digit codes designated by the Centers for Medicare and Medicaid Services (CMS) attached to health care professional claims to indicate the setting in which a service was provided. Certain POS codes may also be linked to facility fees or enhanced payments that CNMs can only access if they are recognized as eligible providers in that setting.
Among the 50 states and DC, CNMs provide care in sixteen different settings (Table 1), with the most common being inpatient hospitals, birthing centers, and off-campus outpatient hospitals. Two states, California and Illinois, do not have restrictions on the setting in which a CNM can practice, meaning that a CNM can utilize any place of service code for Medicaid claims.
Table 1. Summary of Allowable Place of Service Code for CNMs by State
Conclusion
States continue to support the CNM workforce as a strategy to strengthen access to maternity care by expanding their scope of practice and broadening the types of settings in which CNMs can provide care. Together, these efforts demonstrate a sustained commitment to advancing a more comprehensive perinatal care system with improved maternal health outcomes.
Acknowledgments
The authors of this brief would like to thank Karen VanLandeghem for their guidance, review, and insights on this work. This brief is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC54191; $396,167. This information, content, and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. government.
