The American Nurses Association has recommended to CMS that plans on state health insurance exchanges must include a certain number of advanced practice registered nurses (APRNs) to qualify.

APRNs are trained in primary care and can help alleviate the upcoming shortage in primary care physicians, the ANA said.

"If you're not scouring the woods for providers of primary care, such as nurse practitioners and clinical nurse specialists, then you're missing the boat," Peter McMenamin, ANA senior policy fellow and proposal designer, told DOTmed News.

The comments proposed that each health insurance plan include 10 percent of the APRNs who independently bill Medicare Part B in that state. In 2011, 100,585 APRNs provided $2.4 billion dollars in services to 10.4 million Medicare Part B recipients, or 30 percent of the fee-for-service population.

"A recent study in Health Affairs suggests that 3 percent of Medicare part B beneficiaries have a primary care provider who is in fact a nurse practitioner," McMenamin said. "It's a growing role in the Medicare program. There's no question that they're qualified."

While the role of APRNs has expanded in Medicare coverage, only half of private insurers credential nurse practitioners. McMenamin said many insurers are either indifferent or even hostile toward APRNs, and are "more interested in pleasing the doctors" by getting them into their networks.

Besides limitations through insurance companies, APRNs are also restricted through "scope-of-practice" laws that vary from state to state. Sixteen states allow APRNs to work autonomously, while others require APRNs to work under supervision from physicians.

Physicians who are against expanding scope-of-practice say that they're simply more qualified than APRNs to provide primary care. APRN advocates argue that their training qualifies them to perform all primary care duties, and that knowing when to refer a patient to a different professional is part of their training.

"I think there's this apprehension that they have that somehow something bad might happen if APRNs are given independence," said McMenamin. "There's also a little bit of economic self interest, whether they admit it or not, of this is my turf, and I don't want someone offering services that I can offer."

McMenamin said he's optimistic that scope-of-practice issues will be resolved as the need for primary care providers intensifies.

As for the CMS recommendations, he said that while he notes that if CMS does not accept the proposal, individual states could still choose to adopt it. The exchanges will be open for enrollment on October 1.

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