(a) Subject to the specifications, conditions, requirements, and limitations established by the Texas Health and Human Services Commission (HHSC) or its designee, services performed by advanced practice registered nurses (APRNs) are covered if the services:
  (1) are within the scope of practice for APRNs, as defined by state law;
  (2) are consistent with rules and regulations promulgated by the Texas Board of Nursing or another state's licensing authority as recognized by the Texas Board of Nursing; and
  (3) would be covered by the Medicaid program if provided by a licensed physician (MD or DO).
(b) To be payable, services must be reasonable and medically necessary as determined by HHSC or its designee.
(c) APRNs who are employed or remunerated by a physician, hospital, facility, or other provider must not bill the Medicaid program directly for their services if that billing would result in duplicate payment for the same services. If the services are coverable and reimbursable by the Medicaid program, payment may be made to the physician, hospital, or other provider (if the provider is approved for participation in the Medicaid program) who employs or reimburses the APRN. The basis and amount of Medicaid reimbursement depend on the services actually provided, who provided the services, and the reimbursement methodology determined by the Medicaid program as appropriate for the services and the providers involved.
(d) The policies and procedures in this division do not apply to certified registered nurse anesthetists (CRNAs) and certified nurse-midwives (CNMs). Coverage of services provided by CRNAs and CNMs are described in Divisions 16 and 21 of this subchapter (relating to Certified Nurse-Midwife Services and Certified Registered Nurse Anesthetists' Services).

Source Note: The provisions of this §354.1331 adopted to be effective January 23, 1991, 16 TexReg 124; amended to be effective May 1, 1993, 18 TexReg 2307; 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; amended to be effective July 1, 2011, 36 TexReg 3705