CRNAs Fight Back: AANA Appeals Case Against HHS Over ACA Non-Discrimination

Certified Registered Nurse Anesthetists (CRNAs) across the country may soon see a change in how insurance companies reimburse them—if the U.S. Department of Health and Human Services (HHS) is compelled to act. The American Association of Nurse Anesthesiology (AANA) has filed an appeal arguing that HHS has failed in its duty to enforce a key provision of the Affordable Care Act (ACA) that prohibits discrimination against providers based solely on their licensure. 

The AANA says commercial payers continue to punish CRNAs by paying them substantially less than other anesthesia providers for delivering the same services. This discriminatory financing practice puts rural and underserved patients at risk by undermining access to vital anesthesia care often provided solely by CRNAs.

What is the ACA’s Provider Non-Discrimination Provision?

• The ACA contains a nondiscrimination provision, codified at 42 U.S.C. § 300gg-5(a), which forbids insurance plans from discriminating “with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.” 
• Enforcement authority lies with HHS (and individual states); there is no private right of action for individual providers to sue insurers directly under this provision. Only the Secretary of HHS (and possibly states) can enforce it.

What’s the Problem? What the AANA is Claiming

The AANA’s complaint sets out that:

• Numerous insurance companies (notably Cigna and Anthem) have reduced reimbursement rates paid to CRNAs for anesthesia services when those services are provided independently (i.e. without medical direction by physicians). For example, the “QZ modifier” (used when CRNAs provide anesthesia services independently) reimbursement has been cut from 100% to 85% of physician fee schedules. 
• According to AANA, these cuts are based solely on the licensure of the provider (i.e. nurse vs. physician), not on differences in care, safety, patient outcome, or performance. CRNAs argue that when they act within their licensure, they deliver the same anesthesia services in the same settings, using the same equipment, with comparable outcomes.
• Despite being aware of such practices and of its legal mandate, HHS has never enforced the nondiscrimination provision since the ACA was passed—and has never proposed a rule implementing it, even though Congress required proposed rules by January 1, 2022, under the No Surprises Act. 

Legal Action: What AANA Has Done (and What the Courts Have Ruled)

• Complaint Filed: In September 2024, AANA filed a petition (under the writ of mandamus and the Administrative Procedure Act) in the U.S. District Court for the Northern District of Ohio, seeking to force HHS to fulfill its statutory responsibilities. 
• District Court Dismissal: On August 26, 2025, the court granted HHS’s motion to dismiss AANA’s petition. In its public statement, AANA President Jeff Molter expressed disappointment but emphasized that the association “will continue to evaluate and pursue all available legal options on behalf of our membership and remain focused on advocacy efforts against provider discrimination to ensure patients’ access to care.” 
• Notice to Appeal: On September 11, 2025, AANA filed a notice to appeal the dismissal, saying they “respectfully disagree with the prior ruling and will continue to work tirelessly to ensure private payor compliance with the law.” 

What This Means for Nurses, Patients, and Access to Care

• For CRNAs: If the nondiscrimination clause is enforced, CRNAs would be entitled to reimbursement equal to physicians when performing the same procedures in the same settings. This could mean reversing current policies reducing payments for independent anesthesia services.
• For Patients: Access to anesthesia services—especially in rural and underserved areas—may improve. AANA argues that cuts in reimbursement could force CRNAs out of networks or limit where they practice, thereby reducing patient access. 
• Systemic Equity: The case raises larger questions about how provider type and licensure influence reimbursement. If the rulings stand without appeal, insurers may continue to differentiate based on provider titles rather than function or outcome, a concern that nurses and allied health providers have raised in other contexts.

The case is now on appeal, where AANA will push to overturn the dismissal and secure enforcement of the law. A successful outcome could force regulatory change: HHS might have to issue rules, investigate discriminatory reimbursement policies, and hold insurers accountable under federal law.

For CRNAs, this case is about more than reimbursement. It’s about recognition, legitimacy, and maintaining the ability to provide care—especially in places where nurse anesthetists are essential.

Nurse.org will continue to update this article as the lawsuit progresses.

 

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