Massachusetts 2023-2024 Regular Session

Massachusetts House Bill H2209 Compare Versions

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1	1	1 of 2
2	2	HOUSE DOCKET, NO. 3100 FILED ON: 1/20/2023
3	3	HOUSE . . . . . . . . . . . . . . . No. 2209
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Kay Khan and Brandy Fluker Oakley
8	8	_________________
9	9	To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
10	10	Court assembled:
11	11	The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
12	12	An Act promoting access to midwifery care and out-of-hospital birth options.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :DATE ADDED:Kay Khan11th Middlesex1/19/2023Brandy Fluker Oakley12th Suffolk1/30/2023Lindsay N. Sabadosa1st Hampshire1/30/2023Tram T. Nguyen18th Essex1/30/2023Russell E. Holmes6th Suffolk1/30/2023Steven Owens29th Middlesex1/31/2023Dylan A. FernandesBarnstable, Dukes and Nantucket1/31/2023David Henry Argosky LeBoeuf17th Worcester1/31/2023Hannah Kane11th Worcester1/31/2023Vanna Howard17th Middlesex1/31/2023David F. DeCoste5th Plymouth1/31/2023Christopher J. Worrell5th Suffolk1/31/2023Joanne M. ComerfordHampshire, Franklin and Worcester1/31/2023Brian W. Murray10th Worcester2/1/2023Patricia A. Duffy5th Hampden2/2/2023Tackey Chan2nd Norfolk2/2/2023Christine P. Barber34th Middlesex2/2/2023David M. Rogers24th Middlesex2/3/2023 2 of 2
16	16	Jack Patrick Lewis7th Middlesex2/5/2023Daniel Cahill10th Essex2/6/2023David Paul Linsky5th Middlesex2/6/2023Samantha Montaño15th Suffolk2/6/2023Adrian C. Madaro1st Suffolk2/6/2023Jon Santiago9th Suffolk2/6/2023Carole A. Fiola6th Bristol2/7/2023Jennifer Balinsky Armini8th Essex2/7/2023Patrick M. O'ConnorFirst Plymouth and Norfolk2/7/2023Andres X. Vargas3rd Essex2/8/2023Carmine Lawrence Gentile13th Middlesex2/8/2023Sally P. Kerans13th Essex2/8/2023Walter F. TimiltyNorfolk, Plymouth and Bristol2/8/2023Jessica Ann Giannino16th Suffolk2/8/2023Rob Consalvo14th Suffolk2/8/2023Carlos González10th Hampden2/9/2023Thomas M. Stanley9th Middlesex2/9/2023James B. EldridgeMiddlesex and Worcester2/10/2023Margaret R. Scarsdale1st Middlesex2/13/2023Mindy Domb3rd Hampshire2/15/2023James C. Arena-DeRosa8th Middlesex2/21/2023Steven Ultrino33rd Middlesex2/21/2023Natalie M. Blais1st Franklin2/21/2023Bud L. Williams11th Hampden2/22/2023Erika Uyterhoeven27th Middlesex2/22/2023Smitty Pignatelli3rd Berkshire2/22/2023Natalie M. Higgins4th Worcester2/22/2023Sean Garballey23rd Middlesex2/22/2023Patrick Joseph Kearney4th Plymouth2/22/2023Christopher Richard Flanagan1st Barnstable2/23/2023Bradley H. Jones, Jr.20th Middlesex2/26/2023James J. O'Day14th Worcester2/28/2023John Barrett, III1st Berkshire3/1/2023Jonathan D. Zlotnik2nd Worcester3/1/2023Adrianne Pusateri Ramos14th Essex3/1/2023 1 of 14
17	17	HOUSE DOCKET, NO. 3100 FILED ON: 1/20/2023
18	18	HOUSE . . . . . . . . . . . . . . . No. 2209
19	19	By Representatives Khan of Newton and Fluker Oakley of Boston, a petition (accompanied by
20	20	bill, House, No. 2209) of Kay Khan, Brandy Fluker Oakley and others for legislation to establish
21	21	a board of registration in midwifery and further regulating out-of-hospital birth access and safety.
22	22	Public Health.
23	23	[SIMILAR MATTER FILED IN PREVIOUS SESSION
24	24	SEE HOUSE, NO. 2341 OF 2021-2022.]
25	25	The Commonwealth of Massachusetts
26	26	_______________
27	27	In the One Hundred and Ninety-Third General Court
28	28	(2023-2024)
29	29	_______________
30	30	An Act promoting access to midwifery care and out-of-hospital birth options.
31	31	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
32	32	of the same, as follows:
33	33	1 SECTION 1. Section 9 of chapter 13 of the General Laws, as appearing in the 2020
34	34	2Official Edition, is hereby amended by inserting, in line 7, after the word “counselors” the
35	35	3following words:- , the board of registration in midwifery.
36	36	4 SECTION 2. Said chapter 13, as so appearing, is hereby further amended by adding the
37	37	5following section:-
38	38	6 Section 110. (a) There shall be within the department of public health a board of
39	39	7registration in midwifery. The board shall consist of 8 members to be appointed by the governor,
40	40	85 of whom shall be midwives with not less than 5 years of experience in the practice of
41	41	9midwifery and who shall be licensed under sections 276 to 289, inclusive, of chapter 112, 1 of 2 of 14
42	42	10whom shall be a physician licensed to practice medicine under section 2 of said chapter 112 with
43	43	11experience working with midwives, 1 of whom shall be a certified nurse-midwife licensed to
44	44	12practice midwifery under section 80B of said chapter 112 and 1 of whom shall be a member of
45	45	13the public. Four of the members of the board of registration in midwifery shall have experience
46	46	14working on the issue of racial disparities in maternal health or be a member of a population that
47	47	15is underrepresented in the midwifery profession. When making the appointments, the governor
48	48	16shall consider the recommendations of organizations representing certified professional
49	49	17midwives in the commonwealth. The appointed members shall serve for terms of 3 years. Upon
50	50	18the expiration of a term of office, a member shall continue to serve until a successor has been
51	51	19appointed and qualified. A member shall not serve for more than 2 consecutive terms; provided,
52	52	20however, that a person who is chosen to fill a vacancy in an unexpired term of a prior board
53	53	21member may serve for 2 consecutive terms in addition to the remainder of that unexpired term. A
54	54	22member may be removed by the governor for neglect of duty, misconduct, malfeasance or
55	55	23misfeasance in the office after a written notice of the charges against the member and sufficient
56	56	24opportunity to be heard thereon. Upon the death or removal for cause of a member of the board,
57	57	25the governor shall fill the vacancy for the remainder of that member’s term after considering
58	58	26suggestions from a list of nominees provided by organizations representing certified professional
59	59	27midwives in the commonwealth. For the initial appointment of the board, the 5 members
60	60	28required to be licensed midwives shall be persons with at least 5 years of experience in the
61	61	29practice of midwifery who meet the eligibility requirements set forth in subsection (a) of section
62	62	30281 of chapter 112. Members of the board shall be residents of the commonwealth.
63	63	31 (b) Annually, the board shall elect from its membership a chair and a secretary who shall
64	64	32serve until their successors have been elected and qualified. The board shall meet not less than 4 3 of 14
65	65	33times annually and may hold additional meetings at the call of the chair or upon the request of
66	66	34not less than 4 members. A quorum for the conduct of official business shall be a majority of
67	67	35those appointed. Board members shall serve without compensation but shall be reimbursed for
68	68	36actual and reasonable expenses incurred in the performance of their duties. The members shall be
69	69	37public employees for the purposes of chapter 258 for all acts or omissions within the scope of
70	70	38their duties as board members.
71	71	39 SECTION 3. Section 1E of chapter 46 of the General Laws, as appearing in the 2020
72	72	40Official Edition, is hereby amended by inserting after the definition of “Physician” the following
73	73	41definition:-
74	74	42 “Licensed midwife,” a midwife licensed to practice by the board of registration in
75	75	43midwifery as provided in sections 276 to 289 of chapter 112.
76	76	44 SECTION 4. Section 3B of said chapter 46, as so appearing, is hereby amended by
77	77	45inserting after the word “physician”, in line 1, the following words:- or licensed midwife.
78	78	46 SECTION 5. Section 1 of chapter 94C of the general laws, as appearing in the 2020
79	79	47Official Edition, is hereby amended by inserting after the definition of “Isomer” the following
80	80	48definition:-
81	81	49 “Licensed midwife,” a midwife licensed to practice by the board of registration in
82	82	50midwifery as provided in sections 276 to 289 of chapter 112.
83	83	51 SECTION 6. Section 7 of said chapter 94C, as so appearing, is hereby amended by
84	84	52adding the following new subsection:- 4 of 14
85	85	53 (j) The commissioner shall promulgate regulations which provide for the automatic
86	86	54registration of licensed midwives, upon the receipt of the fee as herein provided, to issue written
87	87	55prescriptions in accordance with the provisions of sections 279 of chapter 112 and the
88	88	56regulations issued by the board of registration in midwifery under said section 279 of chapter
89	89	57112, unless the registration of such licensed midwife has been suspended or revoked pursuant to
90	90	58the provisions of section 13 or section 14 or unless such registration is denied for cause by the
91	91	59commissioner pursuant to the provisions of chapter 30A. Prior to promulgating such regulations,
92	92	60the commissioner shall consult with the board of registration in midwifery.
93	93	61 SECTION 7. Section 9 of said chapter 94C, as so appearing, is hereby amended by
94	94	62inserting in paragraph (a), after the words “certified nurse midwife as provided in section 80C of
95	95	63said chapter 112” the following words:- , licensed midwife as limited by subsection (j) of said
96	96	64section 7 and section 279 of said chapter 112.
97	97	65 SECTION 8. Section 9 of said chapter 94C, as so appearing, is hereby further amended in
98	98	66paragraph (b), by inserting after the words “midwife” in each place that they appear, the
99	99	67following words:- , licensed midwife.
100	100	68 SECTION 9. Said section 9 of said chapter 94C, as so appearing, is hereby further
101	101	69amended in paragraph (b), by inserting after the words “nurse-midwifery” in each place that they
102	102	70appear, the following words:- , midwifery.
103	103	71 SECTION 10. Section 9 of said chapter 94C is further amended in paragraph (c), by
104	104	72inserting after the words “certified nurse midwife” in each place that they appear, the following
105	105	73words:- , licensed midwife. 5 of 14
106	106	74 SECTION 11. The definition of “medical peer review committee” in section 1 of chapter
107	107	75111 of the General Laws, as appearing in the 2020 official edition, is hereby amended by adding
108	108	76the following sentence:- “Medical peer review committee” shall include a committee or
109	109	77association that is authorized by a midwifery society or association to evaluate the quality of
110	110	78midwifery services or the competence of midwives and suggest improvements in midwifery
111	111	79practices to improve patient care.
112	112	80 SECTION 12. Section 202 of said chapter 111, as so appearing, is hereby amended by
113	113	81inserting, in the second and third paragraphs, after the word “attendance”, in each instance, the
114	114	82following words:- or midwife in attendance.
115	115	83 SECTION 13. Said section 202, as so appearing, is hereby further amended by inserting,
116	116	84in the fourth paragraph, after the word “attendance” the following words:- or without the
117	117	85attendance of a midwife,.
118	118	86 SECTION 14. Section 204 of said chapter 111, as so appearing, is hereby amended by
119	119	87inserting, in lines 7, 12 and 28, after the word “medicine”, in each instance, the following word:-
120	120	88, midwifery.
121	121	89 SECTION 15. Chapter 112 of the General Laws, as appearing in the 2020 Official
122	122	90Edition, is hereby amended by adding the following new sections:-
123	123	91 Section 276. As used in sections 276 to 288, inclusive, of this chapter, the following
124	124	92words shall have the following meanings unless the context clearly requires otherwise:
125	125	93 “Board”, the board of registration in midwifery, established under section 110 of chapter
126	126	9413. 6 of 14
127	127	95 “Certified nurse-midwife”, a nurse with advanced training and who has obtained
128	128	96certification by the American Midwifery Certification Board.
129	129	97 “Certified professional midwife”, a professional independent midwifery practitioner who
130	130	98has obtained certification by the NARM."
131	131	99 “Client”, a person under the care of a licensed midwife, as described by a written
132	132	100statement pursuant to section 284 of this chapter.
133	133	101 “Licensed midwife”, a person registered by the board to practice midwifery in the
134	134	102commonwealth under sections 276 to 288, inclusive, of this chapter.
135	135	103 “MBC”, the midwifery bridge certificate issued by the NARM or its successor credential.
136	136	104 “MEAC”, the Midwifery Education Accreditation Council or its successor organization.
137	137	105 “Midwifery”, the practice of providing primary care to a client and newborn during the
138	138	106preconception, antepartum, intrapartum and postpartum periods.
139	139	107 “NARM”, the North American Registry of Midwives or its successor organization.
140	140	108 Section 277. Nothing in sections 276 to 288, inclusive, of this chapter shall limit or
141	141	109regulate the practice of a licensed physician, certified nurse-midwife, or licensed basic or
142	142	110advanced emergency medical technician. The practice of midwifery shall not constitute the
143	143	111practice of medicine, certified nurse-midwifery or emergency medical care.
144	144	112 Section 278. (a) The board shall: 7 of 14
145	145	113 (i) adopt rules and promulgate regulations governing licensed midwives and the practice
146	146	114of midwifery to promote public health, welfare and safety, consistent with the essential
147	147	115competencies identified by the NARM;
148	148	116 (ii) administer the licensing process, including, but not limited to:
149	149	117 (A) receiving, reviewing, approving, rejecting and issuing applications for licensure;
150	150	118 (B) renewing, suspending, revoking and reinstating licenses;
151	151	119 (C) investigating complaints against persons licensed under sections 276 to 288,
152	152	120inclusive, of this chapter;
153	153	121 (D) holding hearings and ordering the disciplinary sanction of a person who violates
154	154	122sections 276 to 288, inclusive, of this chapter or a regulation of the board;
155	155	123 (iii) establish administrative procedures for processing applications and renewals;
156	156	124 (iv) have the authority to adopt and provide a uniform, proctored examination for
157	157	125applicants to measure the qualifications necessary for licensure;
158	158	126 (v) develop practice standards for licensed midwives that shall include, but not be limited
159	159	127to:
160	160	128 (A) adoption of ethical standards for licensed midwives and apprentice midwives;
161	161	129 (B) maintenance of records of care, including client charts;
162	162	130 (C) participation in peer review; and 8 of 14
163	163	131 (D) development of standardized informed consent, reporting and written emergency
164	164	132transport plan forms;
165	165	133 (vi) establish and maintain records of its actions and proceedings in accordance with
166	166	134public records laws; and
167	167	135 (vii) adopt professional continuing education requirements for licensed midwives seeking
168	168	136renewal consistent with those maintained by the NARM.
169	169	137 (b) Nothing in this section shall limit the board’s authority to impose sanctions that are
170	170	138considered reasonable and appropriate by the board. A person subject to any disciplinary action
171	171	139taken by the board under this section or taken due to a violation of any other law, rule or
172	172	140regulation may file a petition for judicial review pursuant to section 64 of this chapter.
173	173	141 (c) A licensed midwife shall accept and provide care to clients only in accordance with
174	174	142the scope and standards of practice identified in the rules adopted pursuant to this section.
175	175	143 (d) Notwithstanding any other provision in this section, the board shall not issue any
176	176	144regulations that require a licensed midwife to practice under the supervision of or in
177	177	145collaboration with another healthcare provider or to enter into an agreement, written or
178	178	146otherwise, with another healthcare provider.
179	179	147 Section 279. A licensed midwife duly registered to issue written prescriptions in
180	180	148accordance with the provisions of subsection (j) of section 7 of chapter 94C may order, possess,
181	181	149purchase, and administer pharmaceutical agents consistent with the scope of midwifery practice,
182	182	150including without limitation antihemorrhagic agents including but not limited to oxytocin,
183	183	151misoprostol and methergine; intravenous fluids for stabilization; vitamin K; eye prophylaxes; 9 of 14
184	184	152oxygen; antibiotics for Group B Streptococcal antibiotic prophylaxes; Rho (D) immune globulin;
185	185	153local anesthetic; epinephrine; and other pharmaceutical agents identified by the board, however,
186	186	154that nothing in this section shall be construed to permit a licensed midwife’s use of
187	187	155pharmaceutical agents which are (a) controlled substances as described by Title 21 U.S.C.
188	188	156Section 812 or in chapter 94C, except for those listed in schedule VI; or (b) not identified by
189	189	157rules and regulations promulgated by the board of registration in midwifery as consistent with
190	190	158the scope of midwifery practice.
191	191	159 Section 280. A person who desires to be licensed and registered as a licensed midwife
192	192	160shall apply to the board in writing on an application form prescribed and furnished by the board.
193	193	161The applicant shall include in the application statements under oath satisfactory to the board
194	194	162showing that the applicant possesses the qualifications described under section 281 prior to any
195	195	163examination which may be required under section 278. The secretary of administration and
196	196	164finance, pursuant to section 3B of chapter 7, shall establish a license application fee, a license
197	197	165renewal fee and any other fee applicable under sections 276 to 288, inclusive, of this chapter;
198	198	166provided, however, that such license applicant and license renewal fees shall not exceed $200
199	199	167biennially. The board, in consultation with the secretary of administration and finance, shall
200	200	168institute a process for applicants to apply for a financial hardship waiver, which may reduce or
201	201	169fully exempt an applicant from paying the fee pursuant to this section. Fees collected by the
202	202	170board shall be deposited into the Quality in Health Professions Trust Fund pursuant to section
203	203	17135X of chapter 10 to support board operations and administration and to reimburse board
204	204	172members for actual and necessary expenses incurred in the performance of their official duties. 10 of 14
205	205	173 Section 281. (a) To be eligible for registration and licensure by the board as a licensed
206	206	174midwife, an applicant shall: (i) be of good moral character; (ii) be a graduate of a high school or
207	207	175its equivalent; and (iii) possess a valid certified professional midwife credential from the NARM.
208	208	176 (b) An applicant for a license to practice midwifery as a certified professional midwife
209	209	177shall submit to the board proof of successful completion of a formal midwifery education and
210	210	178training program as follows:
211	211	179 (i) a certificate of completion or equivalent from an educational program or institution
212	212	180accredited by the MEAC; or
213	213	181 (ii) an MBC, provided that an applicant: (1) is certified as a certified professional
214	214	182midwife within 5 years after the effective date of this section and completed a midwifery
215	215	183education and training program from an educational program or institution that is not accredited
216	216	184by the MEAC; or (2) is licensed as a professional midwife in a state that does not require
217	217	185completion of a midwifery education and training program from an educational program or
218	218	186institution that is accredited by the MEAC.
219	219	187 Section 282. The board may license in a like manner, without examination, any
220	220	188midwife who has been licensed in another state under laws which, in the opinion of the board,
221	221	189require qualifications and maintain standards substantially the same as those of this
222	222	190commonwealth for licensed midwives, provided, however, that such midwife applies and remits
223	223	191fees as provided for in section 279.
224	224	192 Section 283. (a) The board may, after a hearing pursuant to chapter 30A, revoke, suspend
225	225	193or cancel the license of a licensed midwife, or reprimand or censure a licensed midwife, for any
226	226	194of the reasons set forth in section 61. 11 of 14
227	227	195 (b) No person filing a complaint or reporting information pursuant to this section or
228	228	196assisting the board at its request in any manner in discharging its duties and functions shall be
229	229	197liable in any cause of action arising out of providing such information or assistance; provided,
230	230	198however, that the person making the complaint or reporting or providing such information or
231	231	199assistance does so in good faith and without malice.
232	232	200 Section 284. When accepting a client for care, a licensed midwife shall obtain the client’s
233	233	201informed consent, which shall be evidenced by a written statement in a form prescribed by the
234	234	202board and signed by both the licensed midwife and the client.
235	235	203 Section 285. A licensed midwife shall prepare, in a form prescribed by the board, a
236	236	204written plan for the appropriate delivery of emergency care. The plan shall include, but not be
237	237	205limited to: (i) consultation with other health care providers; (ii) emergency transfer; and (iii)
238	238	206access to neonatal intensive care units and obstetrical units or other patient care areas.
239	239	207 Section 286. A health care provider that consults with or accepts a transport, transfer or
240	240	208referral from a licensed midwife, or that provides care to a client of a licensed midwife or such
241	241	209client’s newborn, shall not be liable in a civil action for personal injury or death resulting from
242	242	210an act or omission by the licensed midwife, unless the professional negligence or malpractice of
243	243	211the health care provider was a proximate cause of the injury or death.
244	244	212 Section 287. (a) The board may petition any court of competent jurisdiction for an
245	245	213injunction against any person practicing midwifery or any branch thereof without a license
246	246	214granted pursuant to sections 276 to 288, inclusive, of this chapter. Proof of damage or harm
247	247	215sustained by any person shall not be required for issuance of such injunction. Nothing in this
248	248	216section shall relieve a person from criminal prosecution for practicing without a license. 12 of 14
249	249	217 (b) Nothing in this section shall prevent or restrict the practice, service or activities of:
250	250	218 (i) a person licensed in the commonwealth from engaging in activities within the scope of
251	251	219practice of the profession or occupation for which such person is licensed; provided, however,
252	252	220that such person does not represent to the public, directly or indirectly, that such person is
253	253	221licensed under sections 276 to 289, inclusive, and that such person does not use any name, title
254	254	222or designation indicating that such person is licensed under said sections 276 to 289, inclusive; or
255	255	223 (ii) a person employed as a midwife by the federal government or an agency thereof if
256	256	224that person provides midwifery services solely under the direction and control of the
257	257	225organization by which such person is employed;
258	258	226 (iii) a traditional birth attendant who provides midwifery services if no fee is
259	259	227contemplated, charged or received, and such person has cultural or religious traditions that have
260	260	228historically included the attendance of traditional birth attendants at birth, and the birth attendant
261	261	229serves only individuals and families in that distinct cultural or religious group;
262	262	230 (iv) persons who are members of Native American communities and provide traditional
263	263	231midwife services to their communities; or
264	264	232 (v) any person rendering aid in an emergency.
265	265	233 Section 288. A licensed midwife, registered by the board of registration in midwifery
266	266	234pursuant to sections 276 to 288, inclusive, of this chapter, who provides services to any person or
267	267	235beneficiary covered by Title XIX of the Social Security Act or MassHealth pursuant to section
268	268	2369A of chapter 118E, may accept the Medicaid or MassHealth approved rate as payment in full 13 of 14
269	269	237for such services; provided, that a licensed midwife who accepts the Medicaid or MassHealth
270	270	238approved rate pursuant to this section shall be reimbursed at said rate for such services
271	271	239 SECTION 16. Chapter 118E of the General Laws, as appearing in the 2020 Official
272	272	240Edition, is hereby amended in section 10A by adding the words “licensed midwife,” after the
273	273	241word “physician,” in line 15 and after the word “pediatrician,” in line 20, and by inserting at the
274	274	242end of the section the following sentence:- The division shall provide coverage for midwifery
275	275	243services including prenatal care, childbirth and postpartum care provided by a licensed midwife
276	276	244regardless of the site of services.
277	277	245 SECTION 17. The board established pursuant to section 110 of chapter 13 of the General
278	278	246Laws shall adopt rules and promulgate regulations pursuant to this act within 1 year from the
279	279	247effective date of this act.
280	280	248 SECTION 18. The board established pursuant to section 110 of chapter 13 of the General
281	281	249Laws shall promulgate regulations for the licensure of individuals practicing midwifery prior to
282	282	250the date on which the board commences issuing licenses; provided, however, that individuals
283	283	251practicing midwifery in the commonwealth as of the date on which the board commences issuing
284	284	252licenses shall have 2 years from that date to complete the requirements necessary for licensure.
285	285	253 SECTION 19. Nothing in this act shall preclude a person who was practicing midwifery
286	286	254before the effective date of this act from practicing midwifery in the commonwealth until the
287	287	255board establishes procedures for the licensure of midwives pursuant to this act.
288	288	256 SECTION 20. The department of public health shall promulgate regulations within 1 year
289	289	257from the effective date of this act, governing birth centers, consistent with standards set forth by
290	290	258the American Association of Birth Centers, including without limitation authorizing licensed 14 of 14
291	291	259professional midwives to practice in birth centers as primary birth attendants, director of birth
292	292	260centers, and director of clinical affairs. Licensed professional midwives practicing in licensed
293	293	261birth centers shall not be required to enter into any agreement for supervision or collaboration
294	294	262with any other healthcare provider or hospital.