SECTION 354.1271. Benefits and Limitations

(a) Subject to the specifications, conditions, limitations, and requirements established by the department or its designee, maternity clinic services are those clinic services determined by a licensed physician (MD or DO) to be reasonable and medically necessary for the care of a pregnant female (patient) during the patient's prenatal period and subsequent 60-day postpartum period. The physician prescribing the services must be employed by or have a contractual agreement/formal arrangement with the clinic to assume professional responsibility for the services provided to the clinic's patients.

(b) The physician must see each patient and prescribe or approve each patient's plan of care. The physician must base the plan of care on a risk assessment completed by the physician or by licensed, professional clinic staff. The assessment must be based on findings obtained through a health history, laboratory/screening services, and a physical examination. The department or its designee establishes the criteria for assessing the patient's risk. The level of services provided to the patient must be commensurate with the risk assessment. Services must be provided on site or through referral or other formal arrangement to patients experiencing a normal pregnancy and to patients whose pregnancy places them at risk.

(c) Covered services must be furnished on an outpatient basis by the physician or by licensed, professional clinic staff under the direction of the physician. The physician and professional clinic staff must be licensed by the state in which the services are rendered. Services provided by the professional clinic staff must be within staff's scope of practice or licensure as defined by state law.

(d) Covered clinic services include, but are not necessarily limited to, risk assessment, medical services, laboratory/screening services, case coordination/outreach, nutritional counseling, psychosocial counseling, family planning counseling, and patient education regarding maternal and child health.

(e) Although the physician does not necessarily have to be present at the clinic when covered services are provided, the physician must assume professional responsibility for the services provided at the clinic and must ensure through approval of the plan of care that the services are medically appropriate. The physician must spend as much time in the clinic as is necessary to ensure that patients are receiving services in a safe and efficient manner in accordance with accepted standards of medical practice.

(f) Clinics must have arrangements for referral of non-stress test (NST), sonography, and amniocentesis for high-risk patients.

Source Note: The provisions of this §354.1271 adopted to be effective October 17, 1988, 13 TexReg 4783; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561