SECTION 354.1251. Benefits and Limitations

Subject to the specifications, conditions, requirements, and limitations established by the Texas Health and Human Services Commission (HHSC) or its designee and according to state and federal laws, rules, and regulations, and in the case of services furnished in an institution, hospital or other facility to the extent permitted by the institution, hospital, or facility, nurse-midwife services are limited as follows.

(1) Nurse-midwife services must be provided by a certified nurse-midwife (CNM) who is enrolled and approved for participation in the Texas Medical Assistance (Medicaid) Program.

(2) Nurse-midwife services are covered if the services:

(A) Are within the scope of practice for certified nurse midwives, as defined by state law;

(B) Are consistent with rules and regulations promulgated by the Board of Nurse Examiners for the State of Texas or other appropriate state licensing authority; and

(C) Would be covered by the Texas Medical Assistance Program if provided by a licensed physician (M.D. or D.O.).

(3) For purposes of coverage and reimbursement by the Medicaid Program, deliveries by a CNM that are performed in a general or acute care hospital or special hospital or facility must be done in a hospital or facility licensed and approved by the appropriate state licensing authority for the operation of maternity and newborn services and approved by the department for participation in the Texas Medical Assistance Program. Home deliveries performed by a CNM are reimbursable when HHSC or its designee has prior authorized the home delivery. The CNM must submit a written request for prior authorization during the recipient's third trimester of pregnancy. The CNM must include a statement signed by a licensed physician who has examined the recipient during the third trimester and determined that at that time she is not at high risk and is suitable for a home delivery.

(4) To be directly reimbursed by the Texas Medical Assistance Program, a CNM who manages the medical aspects of a case under a physician's control and supervision according to the rules of the State Board of Nurse Examiners and the Medical Practice Act must perform the services according to the written protocols required by the State Board of Nurse Examiners and the services must not be duplicative of other charges to the Medicaid Program. For services other than nurse-midwife services, other provisions of the state plan apply.

(5) The Medicaid Program does not reimburse the CNM for conducting childbirth education classes.

(6) HHSC or its designee reimburses only the CNM actually performing or directing the approved service, unless federal requirements related to reassignment of claims have been met.

(7) Reimbursement for services that are other than nurse-midwife services are governed by the applicable provisions of the Medicaid Program, as specified by HHSC.

(8) A nurse-midwife is not reimbursed directly by the Medicaid Program for services provided if employed, salaried, or reimbursed by a hospital, nursing facility, other institution, or facility where the nurse-midwife's remuneration for services is included in the reimbursement formula or vendor payment to the hospital, facility, institution, or other provider.

(9) CNMs who are employed by or remunerated by a physician, health maintenance organization (HMO), hospital, or other facility may not bill the Medicaid Program directly for nurse-midwife services if that billing would result in duplicate payment for the same services. If the services are covered and reimbursable by the Medicaid Program, payment may be made to the physician, hospital, or other provider, if approved for participation in the Medicaid Program who employs or reimburses the nurse-midwife. The basis and amount of Medicaid reimbursement depends on the nurse-midwife services actually provided, who provided the services, and the reimbursement methodology utilized by the Medicaid Program as appropriate for the services and provider(s) involved.

Source Note: The provisions of this §354.1251 adopted to be effective September 3, 1985, 10 TexReg 3178; amended to be effective September 1, 1988, 13 TexReg 3829; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective October 1, 1993, 18 TexReg 8789; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective July 1, 2006, 31 TexReg 5070