Family Planning Program Policy Manual

1100, Contact Information

Revision 23-4; Effective Nov. 17, 2023

Mailing Address 

HHSC Family Planning Program
North Austin Complex, Mail code 0224
4601 W. Guadalupe Street, Suite #4.507
Austin, TX 78751-2920 

Helpline

8 a.m. to 5 p.m. Central Time
Monday through Friday
Austin Phone No. 512-776-7796

Provider questions: 800-925-9126 
(TMHP contact center, pick option 5)

Email

Websites

1200, Purpose of the Manual

Revision 22-2; Effective April 1, 2022

The Family Planning Program Policy Manual is a guide for contractors who deliver HHSC FPP services in Texas. FPP providers must also follow policies and procedures as established by the Texas Medicaid Program in the Texas Medicaid Provider Procedures Manual (TMPPM).

Federal and state laws related to reporting of child abuse, operation of health facilities, professional practice, insurance coverage and related topics also affect family planning services. Contractors must be aware of and follow existing laws.

2100, Program Authorization and Services

Revision 23-4; Effective Nov. 17, 2023

HHSC Family Planning Program Overview 

The Texas Health and Human Services Commission (HHSC) Family Planning Program (FPP) provides comprehensive family planning and related health services throughout the state to reduce unintended pregnancies, positively affect future pregnancies and improve the health status of low-income women and men.

Rules

State rules governing the FPP can be found in Texas Administrative Code (TAC) Title 1, Part 15, Chapter 382, Subchapter B

Federal rules for Medicaid are located under Title XIX, Social Security Act, 42 USC Section 1396-1396v et. seq. Grants to States for Medical Assistance Programs

Funding Sources

All HHSC FPP grantees and subgrantees are required to be enrolled providers of services to Medicaid-eligible women and men.

FPP services are funded by state general revenue and federal Temporary Assistance for Needy Families (TANF) to Title XX funds.

2200, Definitions

Revision 24-1; Effective May 1, 2024

The following words and terms, when used in this manual, have the following meanings:

Barrier to Care—A factor that hinders a person from receiving health care. For example, distance, lack of transportation, documentation requirements and copayment amount.

Birth Control—The means of pregnancy prevention, which includes permanent and temporary methods.

Class D (Clinic) Pharmacy License – A pharmacy license issued to a pharmacy to dispense limited types of drug or devices under a prescription drug order. Information to apply for a Class D Pharmacy License may be found on the Texas State Board of Pharmacy’s website (PDF).

Client – A person who has been screened and determined to be eligible for the program. The term client and patient may be used interchangeably in other sources.

Compass 21 – Texas Medicaid & Healthcare Partnership’s automated claims processing system used to process claims for services delivered to HHSC FPP and Medicaid.

Consultation – A type of service given by a health care provider with expertise in a medical or surgical specialty. When another appropriate health care provider requests assistance, helps with the evaluation or management of a client.

Contraception – Refer to Birth Control above.

Contraceptive Methods – A broad range of birth control options, that are approved by the U.S. Food and Drug Administration.

Copay or Copayment – Money collected directly from clients for services.

Cost Reimbursement – Funding used to develop and maintain grantee infrastructure for the provision of family planning services.

Diagnosis – The recognition of disease status determined by evaluating the history of the client and the disease process, and the signs and symptoms present. Determining the diagnosis may require some or all the following: 

  • microscopic or culture;
  • chemical or blood tests; and
  • radiological examinations or X-rays. 

Eligibility Date – Date the grantee or program administrator determines a person becomes eligible for the program.

Family Planning Services – Educational or comprehensive medical activities that enable clients to freely determine the number and spacing of their children and select how this may be achieved. 

Federal Poverty Level (FPL) – The set minimum amount of income a family needs for food, clothing, transportation, shelter and other necessities. In the United States the Department of Health and Human Services determines this level. FPL varies by family size. The number is adjusted for inflation and reported annually in the Federal Poverty Guidelines. Public assistance programs, such as Medicaid, define eligibility income limits in terms of a percentage of FPL.

Fee-for-Service – Payment mechanism for services that are reimbursed on a set rate per unit of service. This is also known as unit rate. 

Fiscal Year – The state fiscal year is from Sept. 1 through Aug. 31.

Grantee – A non-state entity that receives an award directly from a state awarding agency to carry out an activity under a state program. The term grantee does not include subgrantees.  

Health and Human Services Commission (HHSC) –The Texas administrative agency established under Chapter 531, Texas Government Code, or its designee. HHSC manages programs that help families with food, health care, safety and disaster services.

Health Care Provider – A physician, physician assistant, nurse practitioner, clinical nurse specialist, certified nurse midwife, federally qualified health center, family planning agency, health clinic, ambulatory surgical center, hospital ambulatory surgical center, laboratory or rural health center. Health care provider is used interchangeably with provider throughout this manual.

Healthy Texas Women (HTW) – A Medicaid waiver program administered by HHSC. The program provides uninsured women with women’s health and family planning services such as women’s health exams, health screenings and birth control. HTW providers must provide client services on a fee-for-service basis. They may also contract with HHSC to give support services that enhance the HTW fee-for-service client delivery on a cost reimbursement basis. This is not required. 

Informed Consent – The process a health care provider uses to ensure that the following are explained to a client in an understandable way allowing the person to participate and make sound decisions about her or his own medical care. The benefits and risks of: 

  • a diagnostic or treatment plan;
  • other options; and 
  • taking no action. 

Inreach Activities – Activities done to inform and educate existing clients within an organization about services they are not receiving but may be eligible to receive.

Intimate Partner Violence (IPV) – Physical, sexual or psychological harm by a current or former partner or spouse. IPV may also be referred to as domestic violence or family violence.

Long-Acting Reversible Contraceptives (LARCs) – Methods of birth control that are effective for an extended period without requiring user action. LARCs include intrauterine devices (IUDs) and subdermal contraceptive implants.

Medicaid –The Texas Medical Assistance Program, a joint federal and state program provided in Texas Human Resources Code Chapter 32 is subject to all the rules in Title XIX of the Social Security Act, 42 U.S.C. Section1396. It reimburses for health care services delivered to low-income clients who meet eligibility guidelines.

Minor –Per with the Texas Family Code, a minor is a person under 18 years old who is not and has not been married. They also have not had the disabilities of minority removed for general purposes such as being emancipated. In this policy manual, minor and child may be used interchangeably.

Monthly Voucher Packet – Required forms, B-13X, 4116 and Data Management, to request reimbursement for the categorical contract.

Outreach – Activities that are conducted to inform and educate the community about services and increasing the number of people served.

Program Income – Money that is collected directly by the grantee, subgrantee or provider for services provided under the contract award such as client copay fees and donations.

Referral – The process of directing or redirecting a medical case or a person to an appropriate specialist or agency for information, help or treatment.

Reproductive Life Plan – A plan that outlines a person’s individual goals about if they should have children, the desired number of children, and the best timing and spacing of children. Counseling should include the importance of developing a reproductive life plan and information about reproductive health, family planning methods and services, and how to get preconception health services, as needed.

Subgrantee: A non-state entity that receives a subaward from a pass-through entity to carry out part of a state program. It does not include a person that is a beneficiary of such a program. A subgrantee may also be a grantee of other state awards directly from a state awarding agency or be referred to as a subrecipient.

Texas Medicaid & Healthcare Partnership (TMHP) – The Texas Medicaid Claims and Primary Care Case Management administrator. HHSC contracts with TMHP to process claims for providers.

 

3100, Client Access

Revision 23-4; Effective Nov. 17, 2023

Grantees must ensure services are provided in a timely and nondiscriminatory manner and must:

  • have a policy in place to identify and eliminate possible barriers to client care, including ensuring clinic or reception room waiting times do not present a barrier to care;
  • have a policy in place that delineates the timely provision of services, as follows:
    • people  who are deemed eligible for FPP should be given an appointment as soon as possible and no later than 30 days from the initial request;
    • clients who request a contraceptive method but cannot be given a clinical appointment immediately must be offered a non-prescription method; and 
    • minors under 18 years old should be seen as soon as possible, with every effort made to provide an appointment within two weeks of the request; 
  • have a policy in place that requires qualified staff to assess and prioritize a person’s needs;
  • provide referral sources for people who cannot be served or cannot receive a specific service;
  • manage funds to ensure established clients continue to receive services throughout the budget year (Sept. 1 through Aug. 31); 
  • inform applicants of FPP services and encourage them to bring required documentation to the first visit for eligibility processing; 
  • comply with all laws, regulations, and contract terms and conditions, as outlined in Section 3500, Nondiscrimination and Limited English Proficiency.

Grantees may not deny services to a qualifying person based on the person’s inability to pay. 

3200, Former Military Service Members

Revision 23-4; Effective Nov. 17, 2023

In addition to FPP, people who have served in any branch of the U.S. Armed Forces, including Army, Navy, Marines, Air Force, Space Force, Coast Guard, Reserves or National Guard, may be eligible for benefits and services under other HHSC programs. For more information, visit the Texas Veterans Portal.

3300, Abuse and Neglect Reporting

Revision 23-4; Effective Nov. 17, 2023

Grantees must obey state laws governing the reporting of suspected abuse and neglect of children, adults with disabilities, or people aged 65 years or older. The Texas Human Resources Code, Chapter 48, requires that suspected abuse, neglect or exploitation of an elderly person, a person with a disability or a person  receiving services from certain home and community-based providers be reported. Grantees must have an agency policy regarding abuse and neglect.

Reporting an Abuse Emergency

To report an emergency that involves the abuse or neglect of children, adults with disabilities, people aged 65 years or older, or a person receiving services from certain home and community-based providers, call the Texas Abuse Hotline at 800-252-5400 or online at TXAbuseHotline.org. For cases that pose an imminent threat or danger to the person, call 9-1-1 or any local or state law enforcement agency. 

Call the Texas Abuse Hotline at 1-800-252-5400 for situations including but not limited to:

  • Serious injuries.
  • Any injury to a child 5 years or younger.
  • Immediate need for medical treatment (including suicidal thoughts).
  • Sexual abuse where the abuser has or will have access to the victim within the next 24 hours.
  • Children aged five and under who are alone or are likely to be left alone within the next 24 hours.
  • Anytime you believe your situation requires action in less than 24 hours.

Reporting a Suspicion of Abuse

For situations that do not require immediate investigation and to report suspicions of abuse, neglect and exploitation of children, adults with disabilities, people aged 65 years or older, or a person receiving services from certain home and community-based providers, use the Department of Family and Protective Services Texas Abuse Hotline.

3310 Child Abuse Reporting, Compliance and Monitoring

Revision 23-4; Effective Nov. 17, 2023

Grantees and providers must develop policies and procedures that follow the reporting guidelines and requirements in Texas Family Code, Chapter 261. Grantee must develop an internal policy to determine:

  • how child abuse reporting requirements will be implemented throughout their agency;
  • how staff will be trained; and
  • how internal monitoring will be done to ensure timely reporting.

During quality assurance (QA) monitoring, compliance with the following criteria will be evaluated:

  • The grantee's process must ensure staff is reporting abuse as required by Texas Family Code, Chapter 261. To verify compliance, QA monitors examine the grantee to assess whether the they:
    • have an internal policy which details how the grantee will determine, document, report and track instances of abuse, sexual and non-sexual, for all persons under age 18 in compliance with the Texas Family Code, Chapter 261;
    • follow their own internal policy; and
    • document staff training on child abuse reporting requirements and procedures.
  • The grantee’s internal policy must clearly describe the reporting process for child abuse.
     

Resources for child abuse reporting policy development are found at the Texas Abuse Hotline.

3320 Human Trafficking

Revision 23-4; Effective Nov. 17, 2023

HHSC requires that grantees obey state laws governing the reporting of abuse and neglect. Additionally, as part of the requirement that grantees follow applicable federal laws, family planning grantees must follow anti-trafficking laws, including the Trafficking Victims Protection Act of 2000 (22 USC Section 7101, et seq.).

Grantees must have a written policy on human trafficking which includes the provision of annual staff training.

Resources for Human Trafficking Policy Development  

3330 Domestic and Intimate Partner Violence

Revision 23-4; Effective Nov. 17, 2023

Intimate partner violence (IPV) describes physical, sexual or psychological harm by a current or former partner or spouse. Per Texas Human Resources Code, Chapter 51, family violence may also include emotional harm and a threat of harm. This type of violence can occur among heterosexual or same-sex couples. IPV can exist regardless of the presence of sexual intimacy.

Grantees must have a written policy related to assessment and prevention of domestic and intimate partner violence, including the provision of annual staff training.
 

3400, Confidentiality

Revision 23-4; Effective Nov. 17, 2023

All contracting agencies must comply with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards for protection of privacy.

Grantees must ensure all employees and volunteers receive training about client confidentiality during orientation and understand violation of the law regarding confidentiality may result in civil damages and criminal penalties. A health care provider’s staff (paid and unpaid) must be informed during orientation of the importance of keeping client information confidential (1 Texas Administrative Code Section 382.125(c)). All employees, volunteers, subgrantees and advisory board members must sign a confidentiality statement during orientation.

A grantee must document the client’s  preferred method of follow-up for clinic services (cell phone, email, work phone or text) and preferred language in the client’s record. Each client must receive verbal assurance of confidentiality, an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as abuse reporting. 

Additionally, grantees may not require consent for family planning services from the spouse of a married client (1 TAC Section 382.125).

For information specific to minors and confidentiality, refer to Responsibilities for Treatment of Minors within the Family Planning Program and Healthy Texas Women Program.

3500, Nondiscrimination and Limited English Proficiency

Revision 23-4; Effective Nov. 17, 2023

As outlined in the HHSC Uniform Terms and Conditions – Grant Version 2.16.1, HHSC grantees must comply with state and federal anti-discrimination laws, including but not limited to:

Additionally, grantees must comply with Article IX, Section 9.21 (a-f) Civil Rights, the HHSC Special Conditions Version 1.1, Article V, Section 5.06 Services, and Information for Persons with Limited English Proficiency. These are part of a grant with the state. 

It is highly recommended that grantees comply with Texas Government Code, Section 2054.457, Access to Electronic and Information Resources.

Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights website and the HHSC Civil Right Office, Requirements for Contractors website.

Grant Terms and Conditions

To ensure compliance with nondiscrimination laws, regulations and policies,
grantees must:

  • sign a written assurance to comply with applicable federal and state nondiscrimination laws and regulations;
  • have a written policy   that states the agency does not discriminate on the basis of race, color, national origin, including limited English proficiency (LEP), sex, age, religion or disability;
  • have a policy that addresses individual rights and responsibilities applicable to all persons requesting family planning services;
  • have procedures for notifying the HHSC Civil Rights Office of any program or service-related discrimination allegation or complaint no more than 10 calendar days after the allegation or complaint;
  • ensure all grantee staff is trained in the discrimination policies, including policies for serving people with LEP and people with disabilities, and HHSC complaint procedures;
  • notify all applicants who are applying for family planning services of the grantee’s nondiscrimination policies and complaint procedures; and
  • prominently display civil rights posters in common areas, including lobbies and waiting rooms, front reception desk and locations where people apply for services (posters can be found on the Civil Rights Office website).

More information about nondiscrimination laws and regulations can be found on the HHSC Civil Rights Office page

3600, Client Rights

3610 Resolution of Complaint

Revision 23-4; Effective Nov. 17, 2023

Grantees must ensure clients have a means to express complaints and concerns about care received to HHSC, and ensure those complaints and concerns are handled in a consistent manner. Grantee’s policy manuals must explain the process clients may follow if they are not satisfied with the care received. If an aggrieved client makes a request for a hearing, a grantee shall not terminate the client until a final decision is rendered by HHSC. Any client complaint must be documented in the client’s record.

3620 Termination of Services 

Revision 23-4; Effective Nov. 17, 2023

A qualifying person must never be denied services due to an inability to pay.

Grantees have the right to terminate services to a client if the client is disruptive, unruly, threatening or uncooperative to the extent that the client seriously impairs the grantee to provide services effectively and safely, or if the client’s behavior jeopardizes his or her own safety, clinic staff or others. A client has the right to appeal the denial, suspension or termination of services (1 TAC Section 382.111). 

For more information, see Fair and Fraud Hearings on the HHSC website.

Policies for termination of services must be included in the grantee’s policy manual.
 

3630 Freedom of Choice

Revision 23-4; Effective Nov. 17, 2023

FPP clients are guaranteed the right to voluntarily choose qualified family planning providers and methods without coercion or intimidation. Acceptance of family planning services may not be required for eligibility for, or receipt of, any other service or assistance from the entity or individual that would provide the service or assistance.

3640 Research (Human Subject Clearance)

Revision 23-4; Effective Nov. 17, 2023

To participate in proposed research that would involve the use of FPP clients as subjects, the use of clients’ records or any data collected from FPP clients, grantees must get prior approval from their own internal Institutional Review Board (IRB) and from HHSC. For information about the process, grantees may visit the Institutional Review Board website

The grantee must have a policy that states that approval will be obtained from HHSC before instituting any research activities. The grantee must ensure all staff members are aware of this policy through staff training. The grantee must keep documentation of training on this topic.
 

3700, Client Records Management

Revision 23-4; Effective Nov. 17, 2023

Grantees must have an organized and secure client record system. The grantee must ensure records are organized, readily accessible and available to the client upon request with a signed release of information. Records must be kept confidential and secure, as follows:

  • safeguarded against loss or use by unauthorized persons;
  • secured by lock when not in use and inaccessible to unauthorized persons; and
  • maintained in a secure environment in the facility, as well as during transfer between clinics and between home and office visits.

The written consent of the client is required for the release of personally identifiable information, except as may be necessary to provide services to the client, or as required by law, with appropriate safeguards for confidentiality. If the client is a minor, the minor’s parent, managing conservator or guardian, as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release. Emancipated or married minors authorize the release of their own information. HIV information should be handled according to state and federal Law, Rules, and Authorization.

When information is requested, grantees must release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistical or other form that does not identify clients. Upon request, clients transferring to other providers must be provided with a copy or summary of their record to ensure continuity of care. Electronic records are acceptable as medical records.

Grantees and subgrantees must maintain for the time specified by HHSC all records of client services, contracts and payments. 

Requirements are found in Title 1, Part 15 TAC Section 354.1003, relating to time limits for submitted claims, and in Title 22, Part 9 TAC Section 165, relating to maintenance of medical records. Grantees must follow contract provisions, maintain medical records for at least seven years after the close of the contract and follow the retention standards of the relevant licensing entity. All records relating to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law. 
 

3800, Clinic Operations

3810 Personnel Policy and Procedures

Revision 23-4; Effective Nov. 17, 2023

Grantees must develop and maintain personnel policies and procedures to ensure all staff are hired, trained and evaluated appropriately for their job position. Personnel policies and procedures must include:

  • job descriptions;
  • a written orientation plan for new staff members that includes a statement of skills and competencies appropriate for the position; and
  • a performance evaluation process for all staff members.

Job descriptions, including those for contracted personnel, must specify required qualifications and licensure.

Grantees must show evidence employees meet all required qualifications and receive annual training. Job evaluations should include observation of staff-client interactions during clinical, counseling and educational services.

Grantees must establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest or personal gain. All employees and board members must complete a conflict-of-interest statement during orientation. All medical care must be provided under the supervision, direction and responsibility of a qualified medical director. The designated medical director for a grantee must be a licensed Texas physician.

Grantees must have a documented plan for organized staff development. There must be an assessment of:

  • training needs;
  • quality assurance indicators; and
  • changing regulations and requirements.

Staff development must include orientation and in-service training for all personnel and volunteers. Nonprofit entities must provide orientation for board members and government entities must provide orientation for their advisory committees. Employee orientation and continuing education must be documented in agency personnel files. 

3820 Facilities and Equipment

Revision 23-4; Effective Nov. 17, 2023

Grantees are required to always maintain a safe environment. Grantee must provide clean and well-maintained facilities where services can be delivered with space for exam rooms, client intake, waiting areas and space for clinical and administrative staff. Grantees must have policies and procedures addressing hazardous materials, fire safety and medical equipment.

Hazardous Materials 

Grantees must have written policies and procedures addressing:

  • the handling, storage and disposing of hazardous materials and waste according to applicable laws and regulations;
  • the handling, storage and disposing of chemical and infectious waste, including sharps; and
  • an orientation and education program for personnel who manage or have contact with hazardous materials and waste.
     

Fire Safety 

Grantees must have a written fire safety policy that includes a schedule for testing and maintenance of fire safety equipment. Evacuation plans for the premises must be clearly posted and visible to all staff and clients.

Medical Equipment 

Contractors must have a written policy and keep documentation of the maintenance, testing and inspection of medical equipment, including automated external defibrillators (AEDs). Documentation must include:

  • assessments of the clinical and physical risks of equipment through inspection, testing and maintenance;
  • reports of any equipment management problems, failures and use of errors;
  • an orientation and education program for personnel who use medical equipment; and
  • manufacturer recommendations for care and use of medical equipment.

Radiology Equipment and Standards 

All facilities providing radiology services must:

For information on X-ray machine registration, see the DSHS Radiation Control Program.

Smoking and Vaping Ban

Grantees must have written policies prohibiting smoking and vaping in any portion of their indoor facilities. If a grantee contracts with another entity for the provision of health services, the subgrantee must uphold this policy.

Disaster Response Plan

Grantees must have written plans addressing how staff is to respond to emergency situations (i.e., fires, flooding, power outages, bomb threats, etc.). The disaster plan must identify the procedures and processes to be initiated during a disaster and the staff position responsible for each activity. A disaster response plan must be in writing, formally communicated to staff and kept in the workplace available to employees for review. For an employer with 10 or fewer employees, the plan may be communicated orally to employees.

For resources on facilities and equipment, see the Occupational Safety and Health Administration Compliance Assistance Guide.

Clinical Emergencies

Grantees must be adequately prepared to handle clinical emergency situations, as follows:

  • There must be a written plan for the management of on-site medical emergencies, emergencies requiring ambulance services and hospital admission.
  • Each site must have staff trained in basic cardiopulmonary resuscitation (CPR) and emergency medical action, and staff trained in CPR must be present during all hours of clinic operations.
  • There must be written protocols to address vasovagal reactions, anaphylaxis, syncope, cardiac arrest, shock, hemorrhage and respiratory difficulties.
  • Each site must maintain emergency resuscitative drugs, supplies, and equipment appropriate to the services provided at that site and appropriately trained staff when clients are present.
  • Documentation must be maintained in personnel files that staff have been trained regarding these written plans or protocols. 

3900, Quality Management

Revision 23-4; Effective Nov. 17, 2023

Quality assurance and quality improvement (QA/QI) support the quality of clinical service delivery. Grantees must use internal quality assurance and quality improvement (QA/QI) systems and processes to monitor FPP services. Grantees must have a quality management (QM) program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, quality and continuity of care. Grantees should integrate QM concepts and methods into the structure of the organization and day-to-day operations. 

Grantees are expected to develop quality processes based on four core QM principles that focus on:

  • the client;
  • systems and processes;
  • measurement; and
  • teamwork.

The QM program must be developed and implemented in such a way that provides for ongoing evaluation of services. Grantees should have a written , comprehensive plan for the internal review, measurement and evaluation of services, the analysis of monitoring data, and the development of strategies for improvement and sustainability.

Grantees who subcontract for the provision of services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with the subcontracting entities.

An important part of the QM program is the QM committee, whose membership consists of key leadership of the organization, including the executive director or chief executive officer, medical director and other appropriate staff, where applicable. The committee must annually review and approve a quality work plan for the organization.

The QM committee must meet at least quarterly to:

  • receive reports of monitoring activities;
  • make decisions based on the analysis of data collected;
  • determine QI actions to be implemented; and
  • reassess outcomes and goal achievement.

Meeting dates, minutes of the discussion, actions taken by the committee and a list of the attendees must be maintained and made available during QA/QI reviews.

The comprehensive quality work plan, at a minimum, must:

  • be reviewed annually;
  • include clinical and administrative standards by which services will be monitored;
  • include the process for credentialing and peer review of clinicians;
  • identify persons  responsible for implementing, monitoring, evaluating and reporting;
  • establish timelines for QM activities;
  • identify tools and forms to be used; and
  • outline reporting to the QM committee.

Although each organization’s QM program is unique, the following activities must be undertaken by all agencies providing client services:

  • ongoing eligibility, billing, and clinical record reviews to ensure compliance with program requirements and clinical standards of care;
  • utilization review;
  • tracking and reporting of adverse outcomes;
  • annual review of facilities to maintain a safe environment, including an emergency safety plan;
  • annual review and update of all prescriptive authority agreements (PAAs) for mid-level providers; 
  • annual review of all standing delegation orders and clinical protocols used;  
  • annual review of all policies and forms; and 
  • up-to-date performance evaluations to include primary license verification, Drug Enforcement Administration and immunization status 

The review or revision date must be clearly noted on each policy, form, agreement, order, etc. used. 

Grantees who subcontract for the provision of services must also address how quality will be evaluated and how compliance with policies and basic standards will be assessed with the subgrantee, to include at a minimum:

  • annual license verification (primary source verification);
  • clinical record review;
  • billing and eligibility review;
  • utilization review;
  • facility on-site review;
  • annual client satisfaction evaluation process; and
  • child abuse training and reporting for subgrantee staff.

Data from these activities must be presented to the QM committee. Plans to improve quality should result from the data analysis and reports considered by the committee and should be documented.
 

4000, Eligibility and Assessment of Copay and Fees

Revision 23-4; Effective Nov. 17, 2023

Grantees must perform an eligibility screening assessment on all clients who present for services. The contractor must ensure documentation provides a clear understanding of the eligibility screening process.

4100, Client Eligibility Screening Process

Revision 23-4; Effective Nov. 17, 2023

Grantees must screen all family planning applicants for eligibility in the following programs that provide family planning services in this order:

  • Medicaid;
  • Healthy Texas Women (HTW); and
  • FPP.

Eligibility screening criteria and processes are described below.

4110 Screening for Medicaid

Revision 22-2; Effective April 1, 2022

If the client has a Medicaid card, it can be used to document Medicaid eligibility.

How to know if a person is covered by Medicaid

  • He/she will be issued a “Your Texas Benefits” card.
  • He/she should show his/her “Your Texas Benefits” card at the point-of-service delivery.

Even with this card, providers must verify Medicaid eligibility by calling Texas Medicaid & Healthcare Partnership (TMHP) at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN). 

4120 Screening for HTW

Revision 23-4; Effective Nov. 17, 2023

Healthy Texas Women (HTW) is a Medicaid waiver program administered by HHSC to provide eligible uninsured women with women’s health and family planning services, such as women’s health exams, health screenings and contraception. HTW providers must provide clinical services on a fee-for-service basis. They may also (but are not required to) contract with HHSC to provide support services that enhance clinical service delivery on a cost reimbursement basis.

Potential female clients who are ages 15 through 44, are U.S. citizens or qualified immigrants and live in Texas, must be screened for HTW eligibility.

To screen for HTW, contractors may use the Prescreening Tool on YourTexasBenefits.com, or the “Am I Eligible?” tool on the HTW website. Both tools are acceptable methods for screening for HTW eligibility.

If the applicant is determined to be ineligible for HTW, either by screening ineligible or by client presentation of the denial letter or reason for denial, then screening for FPP can take place.

Rescreening for HTW

  • If the applicant seeks services within 45 days from the application submission date, and the person has undetermined HTW eligibility, then contractors are not required to rescreen for HTW.
  • If the applicant has screened eligible, but the application determination was deemed ineligible for HTW, a copy of the denial letter or reason for denial must be maintained in the applicant’s record. If an applicant does not provide a copy of the denial letter or reason for denial, providers should discuss their application or advise them to contact 866-993-9972 to discuss the status of their application.
  • If a person indicates they would not meet eligibility requirements for HTW and refuses to be screened for the program, documentation of the refusal and reason should be noted in the client’s record. This documentation should be reviewed annually, and eligibility screening and application offered if a change in circumstances would indicate a change in eligibility. Applicants who were initially screened ineligible for HTW because of their citizenship or immigration status must be rescreened annually or when the person reports a change in their citizenship or immigration status. 

4130 Screening for and Determining FPP Eligibility

Revision 23-4; Effective Nov. 17, 2023

Grantees must determine and document FPP eligibility before services are rendered. To assess eligibility for services, grantees must use either Form 1065, or an HHSC-approved eligibility screening form substitute (for example, in-house form, electronic form or phone interview) that contains the required information for determining eligibility.

The eligibility assessment may be completed over the phone or in the office. The completed eligibility form must be kept in the applicant’s record and must show the person’s FPL and the copay amount he or she may be charged. A person’s eligibility must be assessed annually. If eligibility is determined over the phone, the contractor is authorized to sign the form on the applicant’s behalf using a digital ID or handwritten signature.

Eligibility Requirements

Eligible applicants must be:

  • age 64 years and younger;
  • Texas residents (residency is self-declared). Grantees may request residency verification, but such verification should not jeopardize delivery of services;
  • at or under 250% of the federal poverty level. Grantees must require income verification. If the methods used for income verification jeopardize the applicant’s right to confidentiality or impose a barrier to receipt of services, the grantee must waive this requirement and approve full eligibility. Reasons for waiving verification of income must be noted in the applicant’s record. See “Calculation of Applicant’s Federal Poverty Level (FPL) Percentage” below in Section 4140.
     

4140 Adjunctive Income Eligibility and Calculation of Applicant Income

Revision 23-4; Effective Nov. 17, 2023

An applicant is considered adjunctively (automatically) income eligible for services at an initial or renewal eligibility screening if she or he is currently enrolled in one of the following programs:

  • Children’s Health Insurance Program (CHIP) Perinatal
  • Medicaid for Pregnant Women
  • Supplemental Nutrition Assistance Program (SNAP)
  • Temporary Assistance for Needy Families (TANF)
  • Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

Applicants determined to be adjunctively income eligible have met the income requirements through their participation in other income-tested programs. Except for calculating the client’s income, grantees must follow all screening procedures outlined in Section 4100, Client Eligibility Screening Process, before enrolling applicants determined to be adjunctively income eligible in FPP. 

The applicant must be able to provide proof of active enrollment in the adjunctively income eligible program. Acceptable eligibility verification documentation may include:

ProgramDocumentation
CHIP PerinatalCHIP Perinatal benefits card
Medicaid for Pregnant WomenYour Texas Benefits Medicaid card*
SNAPSNAP eligibility letter
TANFTANF verification of certification letter
WICWIC verification of certification letter, printed WIC-approved shopping list or recent WIC purchase receipt with remaining balance

*Note: Presentation of the Your Texas Benefits card does not completely verify current eligibility in the Medicaid for Pregnant Women (MPW) program. Grantees must verify current eligibility as outlined below. However, FPP services may not be provided until such time as the applicant is no longer eligible for MPW.

To verify eligibility, providers must call TMHP at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN).

If the applicant or the applicant’s child (must be considered part of the household) is enrolled in CHIP, they may be considered adjunctively income eligible.

If the applicant’s current enrollment status cannot be verified during the eligibility screening process, adjunctive income eligibility would not be granted. The grantee would then determine income eligibility according to usual protocols.

Calculation of Applicant’s Federal Poverty Level (FPL) Percentage – The maximum monthly income amounts by household size are based on the on the U.S Department of Health and Human Services Federal Poverty Guidelines. The guidelines are subject to change around the beginning of each calendar year.

The steps to determine the applicant’s actual household FPL percentage are:

  1. Determine the applicant’s household size.  

    For determining FPP eligibility, the “household” is defined as a person living alone or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and who are legally responsible for the support of the other person. Treat applicants who are 18 years old as adults. No children aged 18 years old or other adults living in the home should be counted as part of the household group. 

    Legal responsibility for support exists between:
    • persons who are legally married (including common-law marriage);
    • a legal parent and a minor child (including unborn children); or
    • a managing conservator and a minor child. A managing conservator is a person designated by a court to have daily legal responsibility for a child. 
       
  2. Determine the applicant’s total monthly income amount. 

    For determining FPP eligibility, income should be determined using the following guidance:
    • For an unmarried applicant living with a partner, only count the partner’s income and children as part of the household if the applicant and his or her partner have mutual children together. Unborn children should also be included. All income received must be included. Income is calculated before taxes (gross). Income is reviewed and determined either countable or exempt (based on the source of the income), as defined in Section 9000, Resources, Definition of Income. Grantees must have a written FPP income verification policy.
    • Proof of income documentation may include:
      • copy(ies) of the most recent paycheck(s) or stub or monthly earning statement(s);
      • employer’s written verification of gross monthly income or Form 1065, Eligibility Application;
      • award letters;
      • domestic relation printouts of child support payments;
      • statement of support;
      • unemployment benefits statement or letter from the Texas Workforce Commission;
      • award letters, court orders or public decrees to verify support payments;
      • notes for cash contributions; and
      • other documents or proof of income determined valid by the grantee.
         
    • For unemancipated, unmarried applicants under 18 years old, if parental consent is required for the receipt of services per Section 32 of the Texas Family Code, the family's income must be considered in determining the charge for the service.
       
    • Income Deductions: Dependent care expenses shall be deducted from total income in determining eligibility. Allowable deductions are actual expenses up to $200 per child per month for children under age 2, $175 per child per month for each dependent age 2 and older, and $175 per adult with disabilities per month. Legally obligated child support payments made by a member of the household group shall also be deducted. Payments made weekly, every two weeks or twice a month must be converted to a monthly amount by using one of the conversion factors listed below.
       
    • Monthly Income Calculation: If income is received in lump sums or at longer intervals than monthly, such as seasonal employment, the income is prorated over the period the income is expected to cover. Income received weekly, every two weeks or twice a month must be converted as follows:
      • weekly income is multiplied by 4.33;
      • income received every two weeks is multiplied by 2.17; and
      • income received twice monthly is multiplied by 2. 
         
  3. Divide the applicant’s total monthly income amount by the maximum monthly income amount at 100% the FPL for the household size.
     
  4. Multiply by 100%.

4200, Client Fees, Copays and Guidelines

Revision 23-4; Effective Nov. 17, 2023

Copays 

If a grantee opts to charge a copay for services, a copay schedule must be developed and implemented with enough proportional increments so that inability to pay is never a barrier to service. The following copay guidelines apply:

  • no FPP client shall be denied services based on an inability to pay;
  • clients with a household federal poverty level (FPL) at or below 100% shall not be charged a copay;
  • clients may not be charged an added copay for services provided by referral;
  • clients assessed a copay shall be presented with the bill at the time of service;
  • grantees must keep records of individual copays paid and any balance owed;
  • grantees must have a system for aging accounts receivable, which must be documented in the grantee’s policy and procedures and must clearly indicate a period for removing balances from a person’s account due to inability to pay;
  • grantees must maintain a copay schedule, approved by HHSC in advance, which must have proportional FPL increments and copay amounts (Note: An example of a copay schedule is provided by HHSC to grantees annually, following release of the Federal Poverty Guidelines. Grantees may opt to use the pre-approved Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL), which can be found in Section 9000, Resources);
  • the maximum copay amount must not exceed $30;
  • the copay schedule must be updated when the revised Federal Poverty Guidelines are released annually;
  • the copay must include all prescriptions;
  • copays collected by the grantee are considered program income and must be used to support the delivery of FPP services;
  • grantees must have policies and procedures regarding copay collection, which must be approved by the grantee’s governing body; and
  • signs indicating this policy must be visibly posted at contractor clinic sites.
     

Other Fees

Clients shall not be charged administrative fees for items such as processing or transfer of medical records, copies of immunization records, etc. Grantees can bill clients for services outside the scope of allowable services if the service is provided at the client’s request and the client is made aware of their responsibility for paying for the charges.

Insurance 

Services may be provided to clients with third-party insurance if the confidentiality of the person is a concern or if the person’s insurance deductible is 5% or more of their monthly income. Most insurance deductibles are given as an annual amount. FPP household incomes are figured as a monthly amount. To compare an annual deductible with a monthly income, multiply the monthly income by 12 and then determine 5% of that amount. See the example below for a monthly household income of $1,000:

  1. Determine the total household’s monthly income.
  2. Determine the total household’s annual income by multiplying the monthly income by 12 (months).
  3. Determine 5% of the total annual income by multiplying it by 0.05 (5%).
Total Monthly Household IncomeTotal Annual Household Income5% of Total Annual Household Income
$1,000 x 12 (months) =$12,000 x 0.05= $600
If the applicant’s annual insurance deductible is any amount over $600, they are eligible under this criterion for FPP.

Another way to make the comparison is to divide the annual insurance deductible into a monthly amount. See the example below for an annual insurance deductible of $6,000 and a monthly household income of $1,000:

  1. Determine the household’s monthly insurance deductible by dividing the annual deductible by 12 (months).
  2. Determine 5% of the total monthly household income by multiplying it by 0.05 (5%).
Household Annual Insurance DeductibleHousehold Monthly Insurance DeductibleTotal Monthly Household Income5% of Total Monthly Household Income
$6,000 ÷ 12= $500$1,000 x 0.05= $50
If the applicant’s monthly insurance deductible is any amount over $50, they are eligible under this criterion for FPP.

Date Eligibility Begins  

A person or household is eligible for services beginning with the date the grantee determines the person or household is eligible for the program and signs the completed application. 

Annual Recertification 

Annual eligibility determination and recertification is required for all clients who receive services. Client eligibility must be redetermined every 12 months. Grantees must have a system in place to track client eligibility and renewal status on an annual basis. 

Client Responsibility for Reporting Changes

A client must report changes in the following areas no later than 30 days after the client is aware of the change: income, household composition, residence, current address, employment, types of medical insurance coverage, and receipt of Medicaid, CHIP or other third-party coverage benefits. The client may report changes by mail, phone, in person or through someone acting on the client's behalf. If changes result in the client no longer meeting eligibility criteria, the client is denied continued services. By signing Form 1065, the client attests to the truth of the information provided.
 

4300, Continuation of Services

Revision 23-4; Effective Nov. 17, 2023

Grantees are required to continue to serve their existing FPP clients for the duration of the budget year (Sept. 1 through Aug. 31), regardless of whether all awarded funds have been expended.

If other funding sources are used to provide services offered through FPP, the funds must be reported as non-HHSC funds on the monthly Form 4116, Authorization for Expenditures, and the quarterly Financial Status Report (FSR) (Form 269A).

5000, Clinical Guidelines

Revision 23-4; Effective Nov. 17, 2023

This section describes the requirements and recommendations pertaining to the delivery of direct HHSC FPP clinical services to clients. In addition to the requirements and recommendations found within this section, grantees must develop protocols consistent with national evidence-based guidelines appropriate to the target population.

All providers must offer the following core family planning services on-site or by referral:

  • Contraceptive services (pregnancy prevention and birth spacing), including but not limited to: 
    • Long-acting reversible contraceptives (LARCs) 
    • Oral contraceptive pills 
    • Three-month (medroxyprogesterone) injections 
    • Sterilizations
  • Pregnancy testing and counseling
  • Health screenings, as follows:
    • Breast cancer screening
    • Cervical cancer screening (Pap smears and other cervical cancer screenings)
    • Screening for hypertension, diabetes, and elevated cholesterol
  • Preconception health (for example, screening for nutrition and obesity, tobacco, and substance use, other high-risk behaviors, social issues and mental health)
  • Sexually transmitted infection (STI) services, as follows:
    • Chlamydia and gonorrhea screening and treatment
    • HIV screening
       

5200, General Consent

Revision 23-4; Effective Nov. 17, 2023

Grantees must obtain the person’s written, informed, and voluntary general consent to receive services before receiving any clinical services. A general consent explains the types of services provided and how a person’s information may be shared with other entities for reimbursement or reporting purposes. If there is a period of three years or more during which a person does not receive services, a new general consent must be signed before reinitiating delivery of services.

Consent information must be communicated to every person in a manner that is easy to understand. This communication must allow the person to participate, make sound decisions about her or his own medical care, and address disabilities that impair communication (in compliance with Limited English Proficiency regulations). Only the person receiving services may give consent. For situations when the person is legally unable to consent, a parent (in case of an unemancipated minor) or legal guardian must consent on their behalf. Consent must never be coerced or obtained in a manner that could be perceived as coercive.

In addition, as described below, the grantee must obtain the informed consent of the person receiving services for procedures as required by the Texas Medical Disclosure Panel.

Grantees should consult a qualified attorney to determine the appropriateness of the consent forms used by their health care agency. 

5210 Texas Medical Disclosure Panel Consent

Revision 23-4; Effective Nov. 17, 2023

The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to:

  • determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their clients or persons authorized to consent for their clients; and
  • establish the general form and substance of such disclosure. 

TMDP has developed List A (informed consent requiring full and specific disclosure) for certain procedures, which can be found in the Texas Administrative Code (TAC).

Grantees that directly perform tubal sterilization or vasectomy (both List A procedures), must also complete the TMDP Disclosure and Consent Form. This consent is in addition to the Sterilization Consent Form noted in Section 5620, Sterilization Procedures, Consent, Billing and Reporting.

For all other procedures that are not on List A, the physician must disclose, through a procedure-specific consent, all risks that a reasonable person would want to know about. This includes all risks that are inherent to the procedure (risks that exist in and are inseparable from the procedure itself) and that are material (could influence a reasonable person in deciding to consent to the procedure).

Additional details on sterilization procedures, consent and reimbursement can be found in Section 5620.

5220 Consent for HIV Tests

Revision 23-4; Effective Nov. 17, 2023

Grantees must follow the Texas Health and Safety Code as follows:

  • Section 81.105 Informed Consent 
  • Section 81.106 General Consent

5300, Pharmacy

Revision 23-4; Effective Nov. 17, 2023

To facilitate immediate client access to, and compliance with, contraceptive methods and related medications, grantees must be capable of providing limited pharmaceutical services (including contraceptive methods and related medications) to family planning clients at each clinic site funded by HHSC FPP.

Grantees are required to have at least a Class D pharmacy on-site at each HHSC family planning clinic site, have applied for a Class D pharmacy license through the Texas Pharmacy Licensing Board, or have obtained approval for a Class D pharmacy exemption from HHSC.

It is the grantee’s responsibility to ensure that all contraceptive methods and related medications approved for reimbursement by HHSC FPP are made available at no added charge to the client.

Pharmacies must follow federal and state laws relating to security and record keeping for drugs and devices. The inventory, supply and provision of pharmaceuticals must be conducted according to state pharmacy laws and professional practice regulations. It is essential that each facility keep an adequate supply and variety of drugs and devices on-site to effectively manage the contraceptive needs of its clients.

Class D Pharmacy Exemption

If extenuating circumstances prohibit a license from being granted, or if having an exemption would facilitate client access to contraceptive methods and related medications, a grantee may request an exemption to the requirement to have a Class D pharmacy.

A request for an exemption must be made in writing using Form 1061 to HHSC and will be considered on a case-by-case basis. A request for an exemption must:

  • describe the process through which a person obtains medication from the referral pharmacy or pharmacies; and
  • demonstrate that referring clients to an off-site pharmacy benefits the agency or clients.

The following criteria must be met to be considered for an exemption:

  • A signed and fully executed memorandum of understanding (MOU) with referral pharmacy or pharmacies which includes the purpose of cooperation and details coordination between the grantees and the referral pharmacy or pharmacies to provide the following medications:
    • Non-clinician administered hormonal contraceptive methods [oral contraceptives, transdermal hormonal contraceptives (patch) and vaginal hormonal contraceptives (ring)]; and
    • Other medications necessary to treat the health care needs of the family planning patient population. 
  • The agreement made with referral pharmacy or pharmacies must not create barriers to the client receiving the prescribed medication.
  • The referral pharmacy or pharmacies must be within a reasonable distance of participating clients.
  • Clients do not incur additional costs (such as a co-payment) to obtain medications.
  • The grantees has a written policy that ensures clients can obtain prescribed medication refills from the cooperating pharmacy or pharmacies without an additional clinic visit (unless medically indicated or necessary).

An exemption request will be reviewed by HHSC staff and, depending on the justification and circumstances specific to each clinic site, may or may not be granted. The HHSC staff reserves the right to approve or deny  an exemption request based upon the merit of the justification.

The pharmacy exemption process is not complete until the grantee receives either an approval or a denial in writing from HHSC. Grantees are responsible for notifying HHSC of any changes to clinic’s pharmacy status.

Note: The grantee must provide the following contraceptive methods and services on-site, regardless of Class D pharmacy exemption status:

  • injectable hormonal contraceptives;
  • barrier methods and spermicides; and
  • counseling and education on sexual abstinence.

5400, Client Health Records and Documentation of Encounters

Revision 23-4; Effective Nov. 17, 2023

Requirement for Documentation of Reproductive Health Services

All clients should receive services related to reproductive health or contraception at least annually. Clients using long-acting reversible contraception (intrauterine device or implantable hormonal contraceptive agent) and patients who have undergone permanent sterilization may continue to receive services under the program if they meet eligibility requirements. 

The guiding principle of FPP is to improve the reproductive health of clients to ensure every pregnancy and every baby is healthy. At each client encounter, including encounters for treatment of other conditions (for example, an abnormal Pap smear follow-up), the provider must educate the client on how the service being provided relates to reproductive health or contraception, and this must be documented in the client record.

For clients who have undergone sterilization and for women who are post-menopausal or have had a hysterectomy, this counseling and documentation are not required when receiving covered services. This must be documented in the medical record at least annually.

Individual Health Records and Documentation of Encounters

Providers must ensure that a client health record (medical record) is created for every person who obtains clinical services. See Section 3700, Client Records Management.

All client health records must be:

  • a complete, legible and correct documentation of all clinical encounters, including those that take place by phone;
  • written in ink, without erasures or deletions, or documented in the Electronic Health Record (EHR) or Electronic Medical Record (EMR);
  • signed by the provider making the entry, including name of provider, provider title and date for each entry (Note: Electronic signatures are allowable to document provider review of care, but stamped signatures are not allowable);
  • readily accessible to ensure continuity of care and availability to clients; and
  • systematically organized to allow easy documentation and prompt retrieval of information.

The client health record must include: 

  • the client’s identification and personal data, including financial eligibility;
  • the client’s preferred language and method of communication;
  • the client’s contact information, including the best way and alternate ways to reach the person to ensure continuity of care, confidentiality and compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations;
  • the client’s problem list, updated as needed at each encounter, indicating significant illnesses and medical conditions;
  • a complete medication list, including prescription and nonprescription medications as well as dietary supplements, updated at each encounter;
  • a complete listing of all medication allergies and adverse reactions, and other allergic reactions, displayed in a prominent place and confirmed or updated at each encounter; 
    • if the person has no known allergies, this should be properly noted;
  • documentation of the person’s past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood products and mental health history;
  • a record or history of immunizations, including immunity to rubella based on a history of vaccine or documented serology testing;
  • the client’s health risk survey and assessment, including past and current tobacco, alcohol and substance use or misuse, domestic or intimate partner violence or abuse (for any positive result, the person must be offered referral to a family violence shelter in compliance with Texas Family Code, Chapter 91), occupational and environmental hazard exposure, environmental safety (for example, seat belt use, car seat use and bicycle helmets), nutritional and physical activity assessment, and living arrangements, updated as appropriate at each encounter;
  • an encounter-relevant history and physical examination pertinent to the person’s reason for presentation, with appropriate laboratory and other studies as indicated, updated at each encounter;
  • a plan of care, updated as appropriate, consistent with diagnoses and assessments, which in turn are consistent with clinical findings;
  • documentation of recommended follow-up care, scheduled return visit dates and follow-up for missed appointments;
  • documentation of informed consent or refusal of services, to include at a minimum:
    • a general consent for treatment;
    • a person’s refusal of testing;
    • sterilization consent forms (noted in Section 5620), if applicable;
    • a completed Texas Medical Disclosure Panel Consent form for surgical services provided, if applicable; and
    • for required or recommended services refused or declined by the person, documentation of the service offered, counseling provided and the person’s decision to decline; 
  • any special documentation or considerations required for minors (under 18 years old) per the Responsibilities for Treatment of Minors within the Family Planning Program and Healthy Texas Women Program; and
  • an update for every clinic visit, with the reason for the visit and documentation of assessments and the services provided. 

5500, Covered Services

Revision 24-1; Effective May 1, 2024

FPP seeks to promote the general and reproductive health of Texas residents. FPP provides safe and effective family planning services to people through 64 years old who live in Texas and meet program eligibility requirements.

The following services are covered under FPP:

  • annual family planning and preventive health care visit;
  • pregnancy testing and counseling;
  • all methods of contraceptive services, including necessary follow-up and surveillance;
  • certain health screening and diagnostic services, including:
    • screening, diagnosis and treatment of cervical intraepithelial neoplasia;
    • cervical cancer screening and diagnosis;
    • breast cancer screening and diagnosis;
    • screening and outpatient treatment for sexually transmitted diseases and infections (STDs and STIs);
    • HIV screening;
    • limited prenatal care services;
    • recommended immunizations;
    • screening and treatment for postpartum depression;
    • diabetes screening and treatment;
    • hypertension screening and treatment;
    • screening and treatment for elevated cholesterol; and
    • preconception health (for example, screening for nutrition and obesity, tobacco and substance use, other high-risk behaviors, social issues and mental health).

Find a complete listing of reimbursable codes for the Family Planning Program can be found in 9000, Resources

Initial Clinical Visit

At the first clinical visit or an early follow-up visit, take a comprehensive health history adapted as appropriate to the gender of the person. It must be taken to include, in addition to the elements required for the individual health record in Section 5400, Client Health Records and Documentation of Encounters, and the following:

  • the reason for the visit and current health status;
  • a review of systems with documentation of pertinent positives and negatives;
  • a reproductive health history for women including:
    • menstrual history; 
    • complete obstetrical history; 
    • sexual activity history including contraceptive practices, number and gender of partners; 
    • sexually transmitted infection or sexually transmitted disease (STI or STD) and HIV history and risk factors, whether currently sexually active; and a reproductive life plan;
    • for men, this includes sexual activity history including contraceptive practices, number and gender of partners, STI or STD and HIV history and risk factors;
    • if currently sexually active; and 
    • a reproductive life plan;
  • a reproductive health history for men including:
    • sexual activity history including contraceptive practices, number and gender of partners, STI or STD and HIV history and risk factors;
    • if currently sexually active; and 
    • a reproductive life plan;
  • additional health history for women:
    • cervical and breast cancer screening history, noting any abnormal results and treatment, and dates of the most recent testing;
    • other history of gynecological conditions;
    • other history of genital or urological conditions; and
    • family health and genetic history.

At every later visit, including the annual primary health care and problem visits, the record must be updated, as appropriate, and the reason for the visit and current health status documented.

Annual Comprehensive Family Planning Visit, Physical Examination and Testing

The annual family planning visit offers an excellent opportunity for providers to address issues of wellness and health risk reduction, as well as findings or client concerns. The annual visit must include an update of the person’s health record, as described in the individual health record in Section 5400, as well as documentation of appropriate screening, assessment, counseling and immunizations. These are based on the person’s age, risk factors, preferences and concerns.

All clients must undergo a physical examination annually as part of the family planning visit. The physical examination may be postponed if the person’s history and current health status do not suggest issues needing an urgent examination. Unless the clinician finds a compelling reason for postponement, do not postpone the annual physical examination should not be postponed more than six months. Document the reason for the postponement in the client’s record. 

A breast or pelvic examination may be performed only with the consent of the client. Clients must be offered a suitable method of contraception, such as oral contraceptives without delay, even if the physical examination is postponed or an otherwise asymptomatic person declines any or all components of the examination.

Pelvic examinations must be administered in compliance with Chapter 167A of the Health and Safety Code.

It is recommended that the family planning visit include all the following components at least annually, in addition to other components as suggested by history and presenting signs and symptoms. Note: All findings, including tests, results, the person’s notification of results, or the person’s refusal or other reason for not testing or performing a specified part of the examination, should be documented in the medical record:

  • Measurement of height, weight and blood pressure (BP) screening for hypertension.
  • Calculation of body mass index (BMI) with assessment for underweight, overweight or obesity, with counseling (if indicated), on achieving and maintaining a healthful body weight (a BMI calculator for adults and a BMI calculator for children and teens are available from the Centers for Disease Control and Prevention).

Recommended components for examinations for females:

  • Clinical breast examination, breast cancer risk assessment and breast cancer screening, as appropriate, based on person’s age, risk and preferences:
    • counseling on breast awareness and advice to report any symptom or sign that is of concern to the person; 
    • screening for cervical cancer beginning at 21 years old regardless of sexual history, and continuing as indicated based on the client’s age, previous test results and treatment history; and
    • pelvic examination, in compliance with Chapter 167A of the Health and Safety Code.
      • for all consenting clients 21 years and older; or
      • consenting clients younger than 21 years old, only if indicated by the medical history:
    • Pelvic examinations include the following:
      • visual examination of the external genitalia, vaginal introitus, urethral meatus and perianal area;
      • speculum examination of the cervix and vagina; and
      • bimanual examination of the cervix, uterus and adnexa, and when indicated, rectovaginal examination;
    • pregnancy testing, available on-site and if the pregnancy test is positive, the person must be given information on safe health practices during pregnancy and referred for appropriate physical evaluation and initiation of prenatal care, within 15 days); and
    • rubella immunity testing in women of reproductive age if the status cannot be determined by history or previous testing.

Recommended components for examinations for males:

  • visual and manual examination of the external genitalia including scrotum, penis and testicles and visual inspection of the perianal area;
  • assessment for hernia;
  • palpation of the prostate as indicated by history, risk factors and person’s age; and
  • advice on testicular awareness and recommendation to report any symptom or sign that is of concern to the person.

Recommended components for examinations for all clients regardless of sex:

  • other examinations as indicated by history, signs and symptoms, and the client’s concerns, for example, thyroid, heart, lungs, abdomen and similar concerns as follows:
    • diabetes screening as appropriate for age and risk factors;
    • sexually transmitted infections;
    • cholesterol and serum lipid testing;
    • thyroid stimulating hormone;
    • immunizations as indicated (health care providers can voluntarily participate in the Texas Department of State Health Services (DSHS) Adult Safety Net (ASN) vaccine program, which provides vaccines at no cost); and
    • other testing, if indicated;
  • appropriate family planning counseling and treatment; and
  • healthful lifestyle interventions and counseling, as indicated based on age, risk factors, and client interest and receptiveness.

Counseling and Education

All clients must receive up-to-date person-centered education and counseling in their preferred language. It must be presented in a way that they can understand and to demonstrate their understanding. The education must be documented in the medical record. Individual education enables the person to understand the range of available services and how to access them, to make informed decisions about family planning, to reduce personal health risk and to understand the importance of recommended tests, health promotion and disease prevention strategies.

Specific clinical policies must be in place for counseling and other services provided to minors under 18 years old, to include at least the following:

  • Counseling of minors, including:
    • all medically approved methods of birth control, including abstinence;
    • prevention of STDs, STIs, and HIV;
    • recognition and avoidance of sexual coercion; and
    • domestic, partner, dating and family violence, offering help as needed.
  • Counseling and clinical services to minors must be expedited so that appointments are made available as soon as possible.
  • Minors must be assured that their privacy and confidentiality will be protected within the parameters of applicable law, including the Health Insurance Portability and Accountability Act (HIPAA), Texas Family Code, Chapter 32, and 5100, Minors, Consent and Confidentiality.

5510 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 23-4; Effective Nov. 17, 2023

Providers must develop and maintain policies and procedures to ensure timely follow-up and continuity of care, to include at a minimum:

  • tracking pending tests until results are reviewed by the provider and the client is notified of their results with recommended follow-up (as applicable);
  • documentation of all tests and results in the client’s health record;
  • a mechanism to inform clients promptly of test results that protects the person’s privacy and confidentiality while supporting timely and appropriate follow-up;
  • a mechanism to track client compliance with recommended follow-up care, schedule return visits and follow-up on missed appointments; and
  • a process to ensure compliance with all applicable state and local laws for disease reporting.

Before a person is considered lost to follow-up, the grantee must make at least three documented attempts to contact the person, using a protocol in which subsequent attempts involve a more intensive effort to contact the person. Example: A phone call on the first attempt, a letter by regular mail on the second attempt and a certified letter on the third attempt. 

Providers should develop processes that are suitable for the population they serve and adapt their usual processes to the known circumstances and preferences of the person whom they are trying to contact.

5520 Visits Regarding a Particular Medical Concern (Problem Visits)

Revision 22-2; Effective April 1, 2022

For all problem visits, the following elements must be documented in the medical record:

  • Reason for the visit;
  • Appropriate interval medical history and focused history relevant to the problem reported; and
  • Relevant physical examination and testing, as indicated, as well as an assessment and prescribed treatment.

5530 Referrals

Revision 23-4; Effective Nov. 17, 2023

When a person is referred to another provider of services for consultation or continuation of care, the chart must reflect a record of the purpose for the referral, the name of the provider consulted or referred to, the counseling that the person received about the purpose of the referral and about questions the person had about the referral. Pertinent information about the person and relevant parts of the medical record must be provided to the referral clinician, and this provision of information must also be documented in the medical record. The results of the consultation or referral must be documented in the medical record.

When services covered under FPP are to be provided only by referral, the grantee must establish a written agreement with a referral resource for the provision of services and for the reimbursement of costs and ensure that the client is not charged by the referral resource for these services.

Grantees must maintain a written policy reflecting these requirements for referral activities.

Prescriptive Authority Agreements 

When services are provided by an advanced practice registered nurse (APRN) or physician assistant (PA), it is the responsibility of the grantee to ensure a properly executed prescriptive authority agreement (PAA) is in place for each mid-level provider. The PAA must meet all the requirements delineated in Texas Occupations Code, Chapter 157, including, but not limited to, the following criteria: 

  • be in writing and signed and dated by the parties to the agreement; 
  • be reviewed at least annually (including amendments);  
  • kept on-site where the APRN or PA provides care;  
  • include the name, address and all professional license numbers of all parties to the agreement; 
  • state the nature of the practice, practice locations or practice settings; 
  • identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed; 
  • provide a general plan for addressing consultation and referral; 
  • provide a plan for addressing client emergencies; 
  • describe the general process for communication and sharing of information between the physician and the APRN or PA to whom the physician has delegated prescriptive authority related to the care and treatment of clients; 
  • if alternate physician supervision will be used, appoint one or more alternate physicians who may: 
    • provide appropriate temporary supervision following the requirements established by the PAA and the requirements of this section; and 
    • participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; 
  • describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes: 
    • chart review, with the number of charts to be reviewed determined by the physician and APRN or PA; and 
    • periodic meetings between the APRN or PA and the physician at a location determined by the physician, APRN or physician assistant. 

References 

  • Texas Occupations Code Title 3, Subtitle B, Chapter 157 Regarding Authority of Physicians to Delegate Certain Medical Acts 
  • Texas Administrative Code Title 22, Part 11, Chapter 222 APRN’s with Prescriptive Authority 
  • Texas Administrative Code Title 22, Part 9, Chapter 185 Physician Assistants  
  • Texas Nurse Practice Act Subchapter I, Section 301.4011, 301.402, 301.4025, 301.407 Regarding Duty of Nurse to Report and Duty of State Agency to Report 

Standing Delegation Orders 

Per TAC Title 22, Part 9, Chapter 193, when services are provided by unlicensed and licensed personnel other than an APRN or PA whose duties include actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms, the clinic must have written standing delegation orders (SDOs) in place. SDOs are distinct from specific orders written for an individual. SDOs are instructions, orders, rules, regulations, or procedures that specify under what set of conditions and circumstances certain actions may be taken. 

The grantee must have SDOs in place for unlicensed and licensed personnel (not APRNs or PAs) that include the following: 

  • actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms;  
  • delineation of the circumstances under which an RN, LVN or non-licensed health care provider (NLHP) may initiate actions or tasks in the clinical setting; and  
  • providing authority for use with a client:  
    • when a physician or advance practice provider is not on the premises; and
    • before a client is examined or evaluated by a physician or advanced practice provider.  

Example: An SDO for assessment of blood pressure and blood-sugar level would name the RN, LVN or NLHP that will perform the task, the steps to complete the task, the ranges for normal and abnormal and the process of reporting abnormal values. 

Other applicable SDOs when a physician is not present on-site may include, but are not limited to: 

  • obtaining a personal and medical history; 
  • performing an appropriate physical exam and the recording of physical findings; 
  • initiating and performing laboratory procedures; 
  • administering or providing drugs ordered by voice communication with the authorizing physician; 
  • providing pre-signed prescriptions for: 
    • oral contraceptives; 
    • diaphragms; 
    • contraceptive creams and jellies; 
    • topical anti-infective for vaginal use; or 
    • antibiotic drugs for treatment of STIs and STDs; 
  • handling medical emergencies to include on-site management, as well as possible transfer of the client; 
  • giving immunizations; or 
  • performing pregnancy testing. 

The grantee must have a process in place to ensure that SDOs are reviewed, signed and dated at least annually by the supervising physician responsible for the delivery of the medical care covered by the orders and by other appropriate staff.  SDOs must be kept on-site. 

References 

  • Texas Administrative Code Title 22, Part 9, Chapter 193 Standing Delegation Orders 

5600, Family Planning and Contraceptive Services

Revision 24-1; Effective May 1, 2024

Reproductive Life Plan

Providers should encourage all clients to develop a reproductive life plan, which includes an outline of each person’s plan for having children. The following questions can be useful to help clients to develop the plan:

  • Do you have children?
  • Do you want to have children?
  • If yes, how many children would you like to have?
  • When would you like to start having children?
  • If you want more than one child, at what intervals would you like to have them? 
  • If you have children, do you want to have more children?

Plans for having a family can change with time. Providers must take the person’s plan into account when counseling on contraceptive and family planning services. The provider can help the person by providing the following:

  • Contraceptive services if the person is sexually active and does not want pregnancy.
  • Pregnancy testing and counseling to any female who may be pregnant or who requests such testing. Initiate or provide referral for prenatal services if the test is positive.
  • Services to help the female and her partner achieve a healthy pregnancy if pregnancy is desired and the female is not pregnant.

Contraceptive Counseling and Education

At each encounter for services, clients must receive client-centered counseling and education to make informed decisions about family planning, including information on preventing STDs, STIs and HIV, the results of the physical examination and other testing, method-specific counseling as described below, and other counseling as suggested by the history and clinical evaluation.

Providers must offer clients a wide array of contraceptive options right for the person’s health status and reproductive plan. Review the Texas LARC Toolkit for more information on implementing a program to provide long-acting reversible contraception (LARC). 

Specific Method Access Requirements for Grantees

Grantees must ensure the following requirements are met for client access to contraceptive methods:

  • LARC methods must be available on-site or by referral. Providers typically purchase LARC devices directly from the manufacturer or a third-party distributor.  Providers may get LARC products through the existing buy and bill process. This requires providers to purchase LARCs from wholesalers or other sources before being reimbursed upon insertion of the device and opting to receive reimbursement for LARC products as a clinician-administered drug. Buy and bill is the preferred option as it allows for same day insertion. Grantees can also order a device from a specialty pharmacy for the client to pick up and bring in for insertion. Grantees are expected to maximize any discount available for purchasing multiple devices at a time.
  • Male and female sterilization must be made available on-site or by referral.
  • All grantees must make injectable hormonal contraceptive agents, male and female condoms, spermicides, diaphragms, contraceptive sponges, cervical caps, and counseling and education on sexual abstinence available on-site.
  • Grantees with a Class D pharmacy must also make oral and transdermal hormonal contraceptive agents or vaginal hormonal contraceptive rings available on-site. Grantees that have received an approved exemption to the Class D pharmacy requirement must ensure these methods are readily accessible to clients through a referral pharmacy. 

The table below outlines the requirements for on-site availability of contraceptive methods and anti-infective agents for grantees:  

Contraceptive Method or Anti-infective AgentOn-site Availability Required
 Class D PharmacyClass D Pharmacy Exempt
Anti-infective agents for treatment of STDs or STIsX 
Barrier methods and spermicidesXX
Injectable hormonal contraceptivesXX
Oral contraceptivesX 
Transdermal hormonal contraceptive (patch) or vaginal hormonal contraceptive (ring)X 
Sexual abstinence education and counselingXX

Contraceptive Methods that May Be Provided by Referral

If a clinician associated with a grantee does not offer covered contraceptive services requiring a special level of training or expertise (for example, sterilization, intrauterine device, hormonal implant and diaphragm fitting), these services may be offered by referral to another provider at no added cost to the client. Grantees offering such services by referral must have a written agreement with the referral provider to offer the method or service under this condition.

Non-Covered Services

Per Texas Administrative Code (TAC) Title 1, Part 15, Chapter 382, Subchapter B, Section 382.113(b), Non-Covered Services, services not provided through FPP include:

  • counseling on and provision of abortion services; and
  • other services that cannot be appropriately billed with a permissible procedure code. 

No state funds appropriated to Texas Health and Human Services may be used to pay the direct or indirect abortion procedures costs including overhead, rent, phones and utilities.

Grantees are responsible for implementing adequate controls to ensure claims submitted for FPP services do not seek reimbursement for any benefit not covered by the program. 

References and Resources

American College of Obstetricians and Gynecologists. ACOG Clinical | ACOG

5610 Preconception Services

Revision 23-4; Effective Nov. 17, 2023

The goal of preconception care is to establish a foundation for the best possible outcome of every pregnancy. Quality preconception care incorporates all components of general health care included in this manual. Attention should be paid to the following components:

  • Awareness and treatment of chronic medical conditions, such as diabetes, hypertension, thyroid disease, epilepsy and asthma:
    • Well-controlled blood sugar, as indicated by normal hemoglobin A1C before and early in pregnancy can substantially reduce the risk of birth defects in the babies of mothers with Type 1 and Type 2 diabetes.
    • Women with hyperthyroidism or hypothyroidism should be treated, as necessary, to ensure they are euthyroid before and during pregnancy to reduce the risk of miscarriage and preterm birth.
    • Women with a history of phenylketonuria should be counseled on the need to follow a low-phenylalanine diet before and during pregnancy to reduce the risk of birth defects and serious developmental delay.
  • Screening, as indicated, for conditions that may be undiagnosed.
  • Confirming immunizations are current.
  • Medications (prescription and non-prescription) and potential radiation exposure in early pregnancy.  In general, the lowest effective dose of necessary medications is preferred, but clients should be cautioned against stopping or changing medications without first consulting their doctor. An untreated or incompletely treated medical condition might pose greater risk to the fetus and mother than the medication prescribed.
  • Prevention of STDs, STIs, and HIV.
  • Nutrition and food insecurity.
  • Occupational and environmental exposures to health risks and teratogens.
  • Tobacco and substance use and other high-risk behaviors.
  • Family medical history and genetic risk.
  • Domestic, intimate and partner violence.
  • Social issues, such as homelessness.
  • Mental health.

References and Resources

American College of Obstetricians and Gynecologists. ACOG Clinical | ACOG

5620 Sterilization Procedures, Consent, Billing and Reporting

Revision 23-4; Effective Nov. 17, 2023

Conditions for Sterilization Procedures

Clients who want to have a vasectomy or tubal ligation or occlusion sterilization procedure must:

  • be age 21 or older;
  • be mentally competent (clients are presumed mentally competent unless adjudicated incompetent for sterilization);
  • not be institutionalized in a correctional facility, mental hospital or other rehabilitative facility;
  • not give consent during labor or childbirth; and
  • not give consent if under the influence of alcohol or drugs.

Date of Sterilization

There is a required waiting period of at least 30 days, but no more than 180 days, between a person’s documented consent for sterilization and the date of service for the sterilization procedure. 

Exceptions to the required waiting period are allowed in the following situations:

  • Sterilization following premature delivery – There must be at least 72 hours between the date of consent and the date of surgery. The informed consent must have been given at least 30 days before the expected date of delivery (EDD). The client’s EDD must be documented when there are less than 30 days between the date of the client’s consent and date of surgery.
  • Sterilization following emergency abdominal surgery – Circumstances must be described on the Sterilization Consent form. Operative report(s) detailing the need for emergency abdominal surgery are required. There must be at least 72 hours between the date of consent and the date of surgery.

Consent for Sterilization Required Forms

For  client who choose sterilization, two consent forms must be signed by the person after the provision of counseling on method-specific risks and benefits and all the person’s questions have been answered:

  • The Sterilization Consent Form (English/Spanish): The grantee must ensure the form is complete and correct before submitting it to TMHP. The Sterilization Consent Form is necessary for both abdominal and trans-cervical sterilization.
  • A Texas Medical Disclosure Panel Consent for the surgical procedure by which sterilization will be performed must be signed by the person after full disclosure of the possible risks and benefits and all the client’s questions are answered.

The client may choose a witness to be present when consent is obtained. The consent for sterilization is valid for 180 days from the date of the client’s signature.  

The consent form must be signed and dated by the:

  • person to be sterilized;
  • interpreter, if one is provided;
  • person who obtains the consent; and
  • physician who will perform the sterilization procedure.

Consent is not considered to be informed consent if the person to be sterilized is:

  • in labor or delivering an infant or infants; or
  • under the influence of alcohol or other substances affecting the person’s state of awareness.

Sterilization Billing and Reporting

Grantees can receive reimbursement for vasectomy or tubal ligation or occlusion sterilization procedures through FPP Fee-for-Service. The client may not be billed for any cost above the reimbursement rates. Client copays for sterilizations must follow the grantee’s established, HHSC-approved copay policy and may not exceed the allowable amount.

Allowable sterilization codes and descriptions are presented in Section 9000, Resources, Reimbursable Codes for the Texas Health and Human Services Commission Family Planning Program. 

Complications and Reimbursement

Grantees may request reimbursement through TMHP for costs associated with client complications related to sterilizations, contraceptive implants or intrauterine devices (IUDs). Grantees may be reimbursed for approved charges up to $1,000 per occurrence. To request reimbursement, grantees should provide TMHP with the following information:

  • a copy of the Remittance and Status (R&S) Report showing that a sterilization, contraceptive implant or IUD procedure was performed on the client in question;
  • a narrative summary detailing the procedure performed and related complications, if any;
  • all surgical and progress notes for the client related to the complications of the sterilization procedure; 
  • the initial operative report for the sterilization surgery; and 
  • a completed paper 2017 Claim Form or CMS-1500 professional claim form detailing the procedures for which the grantee is seeking reimbursement and date of occurrence. List all procedures related to the complication even if they are not typically reimbursable under FPP.

References

American College of Obstetricians and Gynecologists.  ACOG Clinical | ACOG
Texas Administrative Code Title 25, Part 7, Chapter 601, Rule Section 601.4

5700, Screenings

5710 Cervical Cancer Screening

Revision 23-4; Effective Nov. 17, 2023

General Considerations for Cervical Cancer Screening

Cervical cancer screening is primarily performed using the Pap test and the HPV DNA test. FPP uses United States Preventive Services Task Force (USPSTF) cervical cancer screening recommendations.

Clinical guidelines for cervical screening are as follows: 

  • 21 – 29: Cervical cytology (Pap smear) alone every three years, with reflex HPV testing when cytology reveals atypical squamous cells of undetermined significance (ASCUS). 
  • 30 – 64: Cervical cytology (Pap smear) alone every three years, with reflex HPV testing for ASCUS or cervical cytology and HPV co-testing every five years (preferred). 
  • Under 21: Not eligible for cervical cancer screening.

Special circumstances may warrant alterations in screening intervals, as determined by a clinician. Special circumstances must always be documented in the client’s medical record. These may include: 

  • Clients considered high-risk (for example, HIV positive, immunosuppressed, exposed to diethylstilbestrol (DES) in utero or history of cervical cancer). 
  • Clients who had a hysterectomy for cervical intraepithelial neoplasia (CIN) disease. These clients may continue screening for 20 years. 
  • Clients who have had cervical cancer. These clients may be screened indefinitely if they are in good health. 
  • Applicants who have had a hysterectomy for benign disease and the cervix is still present. These people may be eligible for cervical cancer screening services. Funds can be used to pay for an initial examination to determine whether the cervix is still present.

Components of Cervical Cancer Screening

The clinical components of cervical cancer screening are pelvic examination, Pap test, HPV test (if indicated), clinical breast examination (CBE) (if indicated), client education, tobacco assessment and Quitline referral (if indicated). The contractor must document the CBE and cervical cancer screening components in the client’s medical record.

A cervical health history must be included as part of the cervical cancer screening. The health history includes the: 

  • Date and results of the last pelvic examination and Pap test 
  • Date and results of any past diagnostic procedures and treatments for cervical disease 
  • Date of last menstrual period and pregnancy history 
  • Medication history, including current or previous use of hormones (for example, hormone replacement therapy and oral contraceptives) 
  • Risk factors for cervical cancer 
  • Description of present pelvic symptoms

Clinical components of cervical cancer screening must be performed by a physician, physician’s assistant, nurse practitioner, certified nurse midwife or a qualified registered nurse with specialized training as required under standing delegation orders (SDOs). The RN’s specialized training for cervical cancer screening must be documented in the personnel record (for example, an educational certificate, a degree or continuing education credits).

Contractors must have policies and procedures to ensure health care providers follow evidence-based clinical guidelines and provide clinical services consistent with current nationally recognized standards of care.

HPV DNA testing is a reimbursable procedure when used for screening with Pap testing (that is, co-testing) and for follow-up of abnormal Pap results, as per the  American Society for Colposcopy and Cervical Pathology (ASCCP) algorithms. The following guidelines apply: 

  • For women ages 30 through 64, the following screenings are recommended:
    • co-testing (combined cervical cytology and HPV testing) every five years;
    • cervical cytology testing alone, with reflex HPV testing when cytology reveals ASCUS, every three years; and
    • screening with the FDA-approved primary HPV screening test every five years. If the primary HPV test is used for screening, it should be done according to interim guidance provided by the ASCCP.
  • It is reasonable to perform annual cervical cytology testing in women with in utero exposure to diethylstilbestrol.
  • For any client with an abnormal result, further testing and follow-up should be dictated by findings, diagnosis and current evidence-based guidelines, such as that of the ASCCP.

Follow-Up for Abnormal Cervical Screening

When the results of the pelvic exam, cervical cancer screening test (Pap test), or both are abnormal, further diagnostic follow-up is required. A normal Pap test does not rule out cancer if a woman has a cervical lesion on pelvic examination. A colposcopy or cervical biopsy, or both, are allowed if determined appropriate by the clinician after an abnormal pelvic exam.

FPP grantees must follow the algorithms for the management of the specific type of abnormal result and in consideration of special populations (for example, pregnant women and clients 20 years and younger or at high risk). 

5720 Breast Cancer Screening

Revision 23-4; Effective Nov. 17, 2023

The summary of guideline recommendations in this section pertains to people aged 64 and younger and does not include recommendations for people outside this range.

Risk Screening and Individual Counseling

All women should undergo a risk assessment to determine if they are at high risk for breast cancer. Women considered high risk include those who have: 

  • a known genetic mutation such as BRCA 1 or 2;  
  • first-degree relatives with premenopausal breast cancer or known genetic mutation; 
  • a history of radiation treatment to the chest area before the age of 30 (typically for Hodgkin’s lymphoma); 
  • a lifetime risk of 20% or more for development of breast cancer based on risk assessment models that are largely dependent on family history; or 
  • Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.

Providers can choose whichever risk assessment method they prefer to determine if a woman is at high risk for breast cancer. Women at high risk for breast cancer should be screened with both an annual mammogram and an annual breast MRI.

All people should be counseled on breast awareness and advised to be familiar with their breasts and to report any changes such as a mass, lump, thickening or nipple discharge promptly.

All people should be counseled on the benefits and risks of mammography. If a person has the option of having a 3-D mammogram, she should be counseled on the benefits and risks of 3-D mammograms versus 2-D mammograms to make an informed decision.

Breast Cancer Screening Frequency

Women 40 and older may receive breast screening services every 1 to 2 years based on the women’s history and clinical presentation.

FPP recommends that grantees and providers counsel all eligible women, including transgender men and women, about the benefits, potential harms, and limitations of screening, and discuss individual risk factors to determine if screening is medically indicated.

Components of Breast Cancer Screening

The contractor must provide a complete breast cancer screening, which includes a mammogram, individualized client education, tobacco use assessment and Quit Line referral, if indicated, and may include a clinical breast examination (CBE). The contractor must document the breast cancer screening components in the client’s medical record

A breast health history must be included as part of the breast cancer screening. The health history includes: 

  • date and time intervals of previous mammograms;
  • results of previous mammograms;
  • date and results of the last CBE;
  • date and results of any previous breast surgery; 
  • date of last menstrual period; 
  • medication history, including current or previous use of hormones (for example, hormone replacement therapy and oral contraceptives); 
  • other risk factors for breast cancer (personal history of breast cancer or family history of first-degree relatives with breast cancer); and
  • description of breast symptoms, if any.

Breast Cancer Screening Follow-up and Referral for Treatment

Clients with an abnormality found on screening or a specific breast complaint (including, but not limited to a mass, lump, thickening or nipple discharge) should be promptly evaluated, as indicated. Providers should have procedures in place to ensure appropriate client education and counseling, referral for further evaluation (including other testing and biopsy) when indicated, communication and coordination with the person and other providers, and proper follow-up through the conclusion of the case.

For persons who require referral for services beyond those available through the grantee, grantees are encouraged to refer these clients to an HHSC Breast and Cervical Cancer Services (BCCS) grantee. Information is available at Texas Health and Human Services Breast and Cervical Cancer Services and Texas Works Handbook, X-900, Medicaid Eligibility.

Eligible clients in need of treatment for biopsy-proven breast cancer may apply for coverage under the Medicaid for Breast and Cervical Cancer Program. Additional information is available in Section 3354 of the Breast and Cervical Cancer Services Policy Manual and in the Texas Works Handbook, X-900.

5730 Sexually Transmitted Disease and Infection (STD and STI) Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for FPP (age 64 and younger) and do not include guideline recommendations for people outside this range.

Screening and treatment of STDs and STIs must follow the current guidelines for screening and treatment from the Centers for Disease Control and Prevention (CDC). A risk assessment should be completed for all clients to determine what testing is indicated and documented in the medical record. Following is a brief overview of STD and STI screening recommendations (for more detailed information, go to the CDC screening links above).

HIV Screening

  • Grantees must provide HIV testing either on-site or by referral.
  • If HIV testing is done, verbal or written consent must be documented in the medical record. If the patient refuses testing, the refusal must be documented. All clients aged 13 to 64 should be screened at least once for HIV according to a policy that provides HIV education and allows clients to opt out of screening. With an opt-out screening, clients are informed, before testing, that HIV testing will be done as part of the general consent for care and that they are free to decline testing. If they do not decline, the test is performed.
  • Clients who engage in high-risk sexual practices or share injection drug paraphernalia should be tested annually.
  • Clients who seek testing or treatment of STDs and STIs should be tested for HIV at the same time.
  • Grantees may provide negative HIV test results to clients in person, by phone, or by the same method or manner as the results of other diagnostic or screening tests. The provision of negative test results by phone must follow procedures that address a person’s confidentiality, identification of the person and prevention counseling.
  • Grantees must always provide positive HIV test results to clients in a face-to-face encounter with an immediate opportunity for counseling and referral to community support services. Test results must be provided by staff who are knowledgeable about HIV prevention and HIV testing.
  • Clients whose risk assessment reveals high-risk behaviors should be provided directly, or referred for, more extensive risk reduction counseling by a Department of State Health Services (DSHS) HIV-STD program trained risk reduction specialist.  

Clients with a diagnosis of HIV should be referred to a DSHS HIV-STD program grantee for treatment and monitoring. To find a DSHS HIV-STD program grantee, visit DSHS HIV-STD Program.

Chlamydia and Gonorrhea Screening

  • Grantees must provide chlamydia and gonorrhea screening.
  • Annual chlamydia and gonorrhea screening should be provided for all sexually active women under age 25. If a pelvic examination is not performed, as in asymptomatic women under age 21 and other women who decline a pelvic examination, screening can be performed using a nucleic acid amplification technique on a urine sample or a vaginal swab obtained by the client.
  • Testing should be provided for all symptomatic women and asymptomatic women with increased risk 25 years and older. Indications include, but are not limited to:
    • new or multiple sex partners;
    • a partner who has another partner;
    • exposure to an STD or STI;
    • symptoms or signs of cervicitis or an STD or STI;
    • history of pelvic inflammatory disease;
    • a positive test for an STD or STI in the previous 12 months; and
    • sex work or drug use.
  • Treated clients should be retested three to four months after treatment to assess evidence of reinfection.
  • All women who are pregnant or attempting pregnancy should be tested.
  • Routine screening of males for chlamydia and gonorrhea should follow current CDC guidelines.

Herpes Simplex Virus (HSV) Screening

  • Routine screening of asymptomatic clients for genital HSV infection is not recommended in the general or pregnant population.
  • Testing, counseling, and treatment of symptomatic clients (clients who have genital lesions), as well as management of affected pregnant clients, should follow current CDC guidelines.
  • The preferred tests for confirmation of the diagnosis in clients with active genital ulcers or mucocutaneous lesions are cell culture and polymerase chain reaction (PCR) assay.
  • Type-specific serologic testing is appropriate in some circumstances:
    • for people presenting for evaluation of an STD and or STI (especially those who report multiple sexual partners) and persons with HIV infection;
    • for men who have sex with men and whose HSV infection status is unknown, type-specific serologic testing may be appropriate to evaluate an undiagnosed genital tract infection;
    • when infection is suspected, but no lesions are present (a culture or PCR assay is not indicated if no lesions are present);
    • when the diagnosis is uncertain and virologic tests (culture and PCR) are negative in a symptomatic client; or
    • for counseling clients about the risk of infection by a partner with known infection, especially during pregnancy.

Syphilis Screening (Men and Non-pregnant Women)

  • Men and non-pregnant women who are at an increased risk of syphilis infection should undergo screening for syphilis.
  • Men who have sex with men, and men and women who are living with HIV, have a higher risk for syphilis infection.
  • Other factors associated with increased prevalence of syphilis infection include a history of incarceration or commercial sex work.
  • Routine screening for syphilis in a non-pregnant population that is not at increased risk of syphilis infection is not recommended as it may yield a high false-positive rate, leading to overtreatment.

Other Screening and Pregnant Women

Screening for other infections and more frequent screening should be considered as appropriate based on the person’s condition, risk factors and concerns.

Pregnant Women

  • All pregnant women should undergo screening for syphilis, HIV (by an opt-out policy), and hepatitis B surface antigen as early as possible in the pregnancy.
  • Clients under age 25 and women at increased risk should also have chlamydia and gonorrhea testing.

Expedited Partner Therapy

Expedited Partner Therapy (EPT) is the clinical practice of treating the sex partners of clients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the client to take to his or her partner without the health care provider first examining the partner.

Texas Administrative Code, Title 22, Section 190.8(1)(L)(ii), allows the use of EPT for STI treatment. Clinic sites implementing EPT should develop necessary policies, procedures and standing delegation orders (SDOs) to reflect the CDC guidelines. See the DSHS HIV and STD website for more information on implementing EPT.

5740 Diabetes Mellitus Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

Grantees must evaluate all clients for risk factors for diabetes annually and provide screening lab work as appropriate. Grantees must have a process and policy in place for the diagnosis and treatment of clients with uncomplicated diabetes. 

While treatment protocols for diabetes are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as the American Diabetes Association Standards of Care in Diabetes, American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention’s Information for Diabetes Professionals. Providers are responsible for having a policy and process in place for the referral of clients with complex needs that are not covered services under FPP.

5750 Hypertension Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

Grantees must screen all clients for hypertension annually. Grantees must have a process and policy in place for the diagnosis and treatment for clients diagnosed with uncomplicated hypertension.

While treatment protocols for hypertension are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as The American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. Providers are responsible for having a policy and process in place for the referral of clients with complex needs that are not covered services under FPP.

5760 High Cholesterol Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

Grantees must screen all clients for high cholesterol annually. Grantees must have a process and policy in place for the diagnosis and treatment for clients diagnosed with high cholesterol.

While treatment protocols for high cholesterol are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as The American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. Providers are responsible for having a policy and process in place for the referral of clients with complex needs that are not covered services under FPP.

5770 Postpartum Depression Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

Postpartum depression screening must be performed if a client was pregnant in the past year.

Providers are encouraged to review The Texas Clinician’s Postpartum Depression Toolkit for a more detailed review of screening for postpartum depression.

As postpartum depression can be a serious and sometimes life-threatening condition, all new mothers should have screening for postpartum depression at their initial postpartum visit. For those who screen negative, repeat screening should be conducted at a later visit.

A standardized self-administered screening tool with review and follow-up questions in a face-to-face interview with the provider will ensure consistency and efficiency in the screening process. The following postpartum depression screening tools are available online and have been validated for use in postpartum clients:

•    Edinburgh Postnatal Depression Scale (EPDS); Cox, Holden and Sagovsky, 1987
•    Patient Health Questionnaire-9 (PHQ-9); Spitzer, Kroenke and Williams, 1999
•    Postpartum Depression Screening Scale (PDSS); Tatano Beck and Gable, 2002

Postpartum Depression Treatment

FPP covers screening and initial treatment for diagnosis of postpartum depression.

While treatment protocols for postpartum depression are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as the Texas Health and Human Services, the Texas Clinician’s Postpartum Depression Toolkit, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. Providers are responsible for having a policy and process in place for the referral of clients with complex needs that are not covered services under FPP.

The Perinatal Psychiatry Access Network, PeriPAN, can enhance provider capacity to provide the perinatal mental health standard of care FPP clients need. There is no cost to FPP providers or clients for this evidence-based, clinician-to-clinician program. Texas PeriPAN offers real-time access to a multidisciplinary network of mental health experts—including reproductive psychiatrists for peer-to-peer consults by phone and vetted and personalized referrals and resources. Contact information and other details on how to access this resource are available on the PeriPAN website.

For severe and persistent behavioral health issues, please consult with Local Mental Health Authorities or Local Behavioral Health Authorities, or call 211. 
 

5800, Healthful Lifestyle Intervention

Revision 23-4; Effective Nov. 17, 2023

All clients should receive a risk assessment at least annually to determine areas where lifestyle modifications might reduce the risk of future disease and improve health outcomes and quality of life.

Counseling on healthful lifestyle choices should cover the following areas: smoking and tobacco use, healthy eating patterns, and physical activity and fitness. Counseling should be catered towards the client’s current health needs and family planning goals and include relevant information and guidance accessible to the client.

Smoking and Tobacco Use

As necessary, based on the needs of the individual, clients should be advised on the impact of smoking and the use of tobacco products, and to avoid exposure to second-hand smoke. 

Healthy Eating Patterns 

Individuals should be counseled on healthy eating patterns and offered access to information and guidance that is relevant to their needs. This may include limiting salt intake or advising a specific diet plan, if needed. 

Physical Activity and Fitness

Individuals should be advised to engage in moderate-intensity aerobic activity, vigorous aerobic activity, or a combination of both each week. Moderate-intensity activities include walking, social dancing or gardening, while vigorous-intensity activities include running, jumping rope or swimming laps. Physical activity should always be tailored to their individual health condition, risks and abilities. 

5900, Perinatal Clinical Policy

Revision 23-4; Effective Nov. 17, 2023

Prenatal and postpartum services must be based on American College of Obstetricians and Gynecologists (ACOG) guidelines.

Grantees may bill FPP for allowable services provided in clinical prenatal care visits for women during the Medicaid for Pregnant Women and the CHIP Perinatal Program enrollment processes. See Section 9000, Resources, Reimbursable Codes for the Texas Health and Human Services Commission Family Planning Program.
Medically necessary postpartum visits are reimbursable and include interval history, physical examination, assessment, family planning, counseling, education and referral, as indicated.

Tobacco Assessment and Quitline Referral  – All women receiving prenatal services should be assessed for tobacco use. Women who use tobacco should be referred to tobacco quit lines. The Texas Tobacco Quitline provides confidential, free and convenient cessation services to Texas residents ages 13 and older, including quit coaching and nicotine replacement therapy. Services can be accessed by phone at 1-877-YES-QUIT (1-877-937-7848) or online at YesQuit.org. The assessment and referral should be performed by agency staff and documented in the clinical record.

Information for Parents of Newborns Requirement

Chapter 161, Health and Safety Code, Subchapter T requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care to pregnant women during gestation or at delivery to give the woman and the father of the infant or other adult caregiver for the infant with a resource pamphlet that includes information on:

  • postpartum depression;
  • shaken baby syndrome;
  • immunizations;
  • newborn screening;
  • pertussis; and
  • sudden infant death syndrome.  

In addition, document in the client's chart that she received this information. The documentation must be retained for a minimum of five years. It is recommended that the information be given twice, once at the first prenatal visit and again after delivery.

Information for Parents of Newborn:

Information for Parents of Children

Chapter 161, Health and Safety Code, Subchapter T also requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care during gestation or at delivery to pregnant women on Medicaid to provide the woman and the father of the infant or other adult caregiver for the infant with a resource guide that includes information relating to the development, health and safety of a child from birth until 5 years old. The resource guide must provide information about medical home, dental care, effective parenting, child safety, importance of reading to a child, expected developmental milestones, health care and other resources available in the state, and selecting appropriate childcare.

A Parent’s Guide to Raising Healthy, Happy Children” is available through Texans Care for Children.

Provision of Information about Umbilical Cord Blood Donation Requirement

Chapter 162, Health and Safety Code, Subtitle H requires that a physician or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant will give the woman an informational brochure before the third trimester of the woman’s pregnancy, or as soon as reasonably feasible. It should include information about the uses, risks and benefits of cord blood stem cells for a potential recipient, options for future use or storage of cord blood, the medical process used to collect cord blood, any costs that may be incurred by a pregnant woman who chooses to donate or store cord blood after delivery, and average cost of public and private storage.

Referral and Follow-up

Grantees must have written policies and procedures for follow-up on referrals made because of abnormal physical examination or laboratory test findings. These policies must be sensitive to clients’ concerns for confidentiality and privacy and must follow state or federal requirements for transfer of health information.
For necessary services beyond the scope of the grantee, clients must be referred to other providers for care.

Whenever possible, clients should be given a choice of providers from which to select. When a client is referred to another provider or for emergency clinical care, the grantee must:

  • provide pertinent client information to the referral provider and obtain required patient consent with proper safeguards to ensure confidentiality (that is, adhering to HIPAA regulations);
  • advise the client about his or her responsibility to comply with the referral; and
  • counsel the client about the importance of the referral and follow-up plan. 

6000, Program Promotion, Outreach and Inreach

Revision 23-4; Effective Nov. 17, 2023

Within 45 days from the start of each fiscal year, grantees must develop and implement an annual plan for promotion and outreach. Grantees are expected to follow the plan and make the plan available for monitoring purposes. This plan must outline the grantee’s goals to: 

  • inform the public of the purpose of the program and available services; 
  • enhance community understanding of its objectives; 
  • disseminate basic family planning and women’s health care knowledge; 
  • enlist community support; and 
  • recruit potential clients for FPP. 

The plan must be based on an assessment of the needs of the community and contain an evaluation strategy. Grantees must consider a variety of program promotion and client in reach and outreach strategies in accordance with organizational capacity, availability of existing resources and materials, and the needs and culture of the local community. 

To gauge the efficacy of program promotion and client in reach and outreach activities, grantees must complete the biannual survey of promotion and outreach activities. This survey is delivered twice a year and is due within 30 days of receipt. 

Survey SentReporting PeriodSurvey Due Date
Mid-month FebruarySept. 1 – Feb. 28 (Q1 & Q2)Mid-month March
Mid-month AugustMarch 1 – Aug. 30 (Q3 & Q4)Mid-month September

Questions regarding plans and surveys should be submitted to famplan@hhs.texas.gov.

Guidance for Promotion and Outreach Plans

The plan should include the determination of the priority population, a recruitment work plan and in-reach and outreach methods.

Grantees should have an array of materials and resources to aid in community awareness. Grantees must develop and maintain relationships with local partners and collaborators that can assist in the recruitment of the priority populations. Grantees must provide HHSC with current clinic location information. The information provided will be entered into the Healthy Texas Women Find a Doctor function and may be shared with other FPP grantees.

Grantees must include in their outreach plan how they plan to implement strategies to enroll clients in FPP and raise community awareness of FPP services, including the following activities: 

  • identify priority populations in the community; 
  • identify the populations at highest risk for unintended pregnancies and STIs; 
  • provide culturally competent health education and social support; 
  • help reduce participants’ barriers to accessing clinical services;  
  • establish relationships with internal and external partners to reach eligible clients in the priority populations; 
  • establish relationships with clinic sites offering other HHSC programs (e.g. the Breast and Cervical Cancer Services Program, the Primary Health Care  Program, and Healthy Texas Women) to increase cross-program referrals, coordination and service provision;
  • link and connect participants to partner clinics for Family Planning Program services; 
  • educate partners, including subgrantees, other health care providers, community organizations, coalitions and local advocacy groups about Medicaid for Breast and Cervical Cancer program and how to refer a non-BCCS diagnosed client for MBCC screening appropriately; 
  • educate clients diagnosed with breast or cervical cancer about FPP eligibility requirements and how to apply for services; 
  • provide information to each eligible client in their primary language; and
  • provide access to information that is culturally sensitive, linguistically appropriate and available to the visually and hearing impaired.

     

7000, Medicaid Provider Enrollment

Revision 23-4; Effective Nov. 17, 2023

All grantees must enroll as Medicaid (Title XIX) providers with Texas Medicaid & Healthcare Partnership (TMHP). Grantees must complete the required Medicaid provider enrollment application forms and enter into a written provider agreement with HHSC, the single state Medicaid agency. TMHP Provider Enrollment supplies these forms.

When enrolling as a Title XIX provider, Clinical Laboratory Improvement Amendments (CLIA) information must be provided. For public health agencies that provide limited numbers of tests, one CLIA certificate is all that is required for all clinics. For more information, requirements and responsibilities, refer to:

 

7100, Reimbursement for HHSC Family Planning Services

Revision 23-4; Effective Nov. 17, 2023

Grantees may seek reimbursement for costs using one of the following two methods:

  • grantees may submit monthly vouchers for expenses outlined in a categorical budget approved by HHSC, as required for categorical cost reimbursement; or
  • grantees may be reimbursed for direct clinical care services using the fee-for-service reimbursement method by submitting claims to TMHP, which are then paid by HHSC.   

Grantees may designate up to 25%  of their total award on a categorical cost reimbursement basis. The remainder of their award will be paid on a fee-for-service basis. Grantees may designate up to 100% of their total award on a fee-for-services basis. Annual award determination and reallocation of funds will be based in part on those grantees that leveraged a higher percentage for direct services. 

Categorical Cost Reimbursement

The categorical portion of FPP funding is used to develop and support grantee infrastructure for the provision of family planning services. These funds may be used for support services that enhance fee-for-service client service delivery. Cost reimbursement awards may be used to fund personnel, fringe benefits, staff travel, contractual   services, equipment, supplies, other direct costs and indirect costs per state and federal requirements, and must be reasonable, allowable and already allocated. 

Costs may be assessed against any of the following categories the grantee identifies during its budget development process:

  • Personnel;
  • Fringe Benefits;
  • Travel;
  • Equipment and Supplies;
  • Contractual;
  • Other; and
  • Indirect Costs.

Note: Indirect costs are costs incurred for a common or joint purpose benefiting more than one project or cost objective of a grantee’s organization, and not readily identified with a project or cost objective. More information on indirect cost rates is available online here.

Up to 25% of funds may be disbursed to grantees through a voucher system as expenses are incurred during the grant period. Grantees must still submit vouchers monthly, even if program income equals or exceeds program expenses, or if the grant reimbursement award has been met. When program expenses exceed program income, the monthly voucher will result in a payment. Program income includes all client copays and donations. 

To request reimbursement for the categorical grant, the following forms must be submitted by the last business day of the following month in which expenses were incurred or services provided:

  • B-13X Form Budget Category monthly expenditures, program income and non-HHSC funding;
  • Form 4116, Authorization for Expenditures;
  • data management form Required Data Collection; and
  • supporting documentation, such as a General Ledger must be submitted monthly with each Voucher Packet .

Categorical Budget Revisions

HHSC, at its sole discretion, may approve fund transfers between categories within the approved budget workbook upon a grantee’s written request. The request must include a detailed explanation that supports the need for the fund transfer. The grantee must seek HHSC  written approval before making any fund transfers. For more information, visit the Texas Grant Management Guide. Grantees must submit a revised budget to HHSC for review any time a budget revision is made.

Fee-for-Service Reimbursement

The fee-for-service (FFS) component of FPP funding reimburses for direct medical services and supplies provided to eligible individuals. Up to 100% of funds may be reimbursed on a fee-for-service basis. Each grantee is responsible for determining a person’s eligibility for clinical services. Grantees must continue to provide services to established clients and to submit and appeal claims for client services even after the grant funding award has been met.

All grantees are required to submit claims for all direct services to TMHP, using the appropriate claim form found on the TMHP website. The Texas Medicaid Provider Procedures Manual (TMPPM) provides detailed instructions of how to complete the form, including required and optional fields. Grantees may also submit claims electronically using a modified CMS-1500 electronic claim form.

All claims or appeals must be filed within certain time frames:

  • Initial Claims Submission – Submitted within 95 days of the date of service on the claim or date of any third-party insurance explanation of benefit (EOB). If the 95th day falls on a weekend or holiday, the filing deadline is extended until the next business day.
  • Appeals – Submitted within 120 days of the date on the Remittance and Status (R&S) Report on which the claim reaches a finalized status. If the 120th day falls on a weekend or holiday, the filing deadline is extended until the next business day. If the claim is denied for late filing due to the initial submission deadline, documentation of timely filing must be submitted along with the claim appeal. Refer to the TMPPM for further information.
  • All claims and appeals must be submitted and processed within 60 days of the end of the grant period.
  • All claims and appeals must continue to be submitted even after the grant funding award has been met.

For answers to questions about claims and payment status, grantees may contact the TMHP Contact Center from 7 a.m. to 7 p.m. (CT), Monday through Friday, at 800-925-9126.

HTW Claims Pending Eligibility Determination

Grantees may provide services to people deemed eligible for FPP who have pending HTW applications. In such instances, grantees may file a claim for reimbursement any time after the person has a current FPP eligibility form on file.

Codes for Reimbursement

Reimbursement is limited to a prescribed set of procedure codes approved by HHSC. For a complete list of valid procedure codes, see Section 9000, Resources, Reimbursable Codes for the Texas Health and Human Services Commission Family Planning Program. 

Grantees may submit claims for office visits that reflect various levels of service for new and established clients. A new client is defined as one who has not received clinical services at the grantee’s clinic or clinics during the previous three years. The level of services, which determines the procedure code to be billed for that individual visit, is indicated by a combination of factors such as the complexity of the problem addressed and the time spent with the client by clinic providers.  

The American Medical Association (AMA) publishes materials related to Current Procedural Terminology (CPT) coding that includes guidance on office visit codes [Evaluation and Management Services (E/M)].
Medroxyprogesterone Acetate Injection

Providers may not bill a lower complexity office visit code (99211/99212) when the primary purpose is for the client to receive an injection of Medroxyprogesterone acetate (Depo-Provera/DMPA/depo). Rather, grantees should bill the injection fee (96372) with the Depo-Provera contraceptive method (J1050).  

Retroactive Eligibility

Medicaid Retroactive Eligibility – Copays collected from a person who is found to be eligible retroactively for Medicaid must be refunded to the person. If a claim has been paid and later the person receives retroactive Title XIX (Medicaid) eligibility, TMHP recoups or adjusts the funds paid from FPP and processes the claim as Title XIX. An accounts receivable (A/R) is then established for the adjusted claim. Note: Grantees are responsible for refunding HHSC the amount of any FPP A/R balance that may remain at the end of a state fiscal year.

The grantee’s FPP R&S Reports reflect the retroactive Title XIX adjustment with EOB message “Recoupment is due to Title XIX retro eligibility.” Grantees can get help with reconciling R&S reports through the TMHP Contact Center from 7 a.m. to 7 p.m. CT, Monday through Friday, at 800-925-9126. A TMHP Provider Relations representative is also available for questions about reconciling reports. A representative can be found by region on the TMHP website.   

Claims Submitted with Laboratory Services

If a Title XIX retroactive eligibility claim includes laboratory services and the grantee is not CLIA certified for the date of service on the claim, TMHP will deny the laboratory services. The Title XIX R&S report will reflect EOB 00488 message: “Our records indicate that there is not a CLIA number on file for this provider number or the CLIA is not valid for the dates of services on the claim.” 

When this occurs, the laboratory that performed the procedures is responsible for refiling laboratory charges with TMHP to receive Title XIX reimbursement. For claims past the 95-day filing deadline, the laboratory must follow their Medicaid appeals process. Grantees must arrange with their contracted laboratory to recoup any funds paid to the laboratory for lab services for FPP clients before Title XIX retro eligibility determination.  

Donations

Voluntary donations from individuals are permissible. However, individuals must not be pressured to make donations, and donations must not be a prerequisite to the provision of services or supplies. Donations are considered program income per specification of grant general provisions. All donations must be documented by source, amount and date they were received by the grantee. Grantees must have a written policy on the collection of donations. Individual donations collected by the grantee must be used to support the delivery of family planning services.
 

8000, Required Forms and Reports

Revision 23-4; Effective Nov. 17, 2023

Required Form or Report (1): Monthly Voucher Packet

  • Description: Includes Form B-13X, Form 4116, and Form Data Management
  • Submission Date: By the last business day of the month following the month in which expenses were incurred or services provided. Final voucher due within 45 days after end of the grant term.
  • Accepted Method of Submission: Email
  • Submit Copy to: PSPS_Finance@hhs.texas.gov
  • Original Signature Required: No
  • Number of Copies: One
  • Instructions: Enter Cost Reimbursement monthly expenses per budget category, program income collection and data collection. 
  • Note: The Monthly Voucher Packet templates are sent to grantees by their contract manager. Vouchers must be submitted each month even if there are no expenditures. Vouchers must still be submitted each month for actual expenditures of the program even if the grant limit has been reached. 

Required Form or Report (2): Financial Status Report (FSR) Form 269A

  • Description: Quarterly report encompassing all expenditures and program income for the defining three months with amounts received from HHSC.
  • Submission Date: Reports are due as follows: Quarter 1: September through November; Quarter 2: December through February; Quarter 3: March through May; Quarter 4: June through August. Submit 30 days after the end of each quarter. The final quarterly FSR is due 45 days after the end of the grant term. The final quarterly report includes all final charges and expenses associated with the program grant. Mark it as "Final."
  • Accepted Method of Submission: Email
  • Submit Copy to:  PSPS_Finance@hhs.texas.gov
  • Original Signature Required: Yes
  • Number of Copies: One
  • Instructions: Form 269A must have an original signature (scanned email or fax accepted).  

Required Form or Report (3): Fee-for-Service Report       

  • Description: Fee-for-Service (File furnished voucher through Texas Medicaid & Healthcare Partnership (TMHP) TexMedConnect/Compass 21)
  • Submission Date: Claims Filing Deadline: Within 95 days from date of service or date of third-party insurance EOB form. Within 45 days after the end of the grant term.
  • Accepted Method of Submission: TMHP/Compass 21
  • Submit Copy to: Not applicable
  • Original Signature Required: No
  • Number of Copies: Not applicable
  • Instructions: Claims must continue to be submitted to TMHP TexMedConnect/Compass 21 even if the grant award amount has been reached.
  • Note: Appeals must be submitted within 120 days of denial during the grant term. All appeals must be submitted and finalized within 45 days after the end of the grant term.

Required Form or Report (4): Financial Reconciliation Report (FRR) 

  • Submission Date: No later than 60 days after the end of the grant term.
  • Accepted Method of Submission: Email, scan or fax
  • Submit Copy to:  PSPS_Finance@hhs.texas.gov
  • Original Signature Required: Yes
  • Number of Copies: Not applicable
  • Instructions: The FRR form requires a signature (scan or fax accepted). The FRR is necessary only if the grantee has only a fee-for-service component without a cost reimbursement component. 

Required Form or Report (5):  Promotion and Outreach Annual Plan

  • Description: This plan should outline the grantee’s goals to inform the public of the purpose of the program and available services, enhance community understanding of its objectives, disseminate basic family planning and women’s health care knowledge, enlist community support and recruit potential clients for FPP. Grantees may use the Promotion and Outreach Plan Template (Form 1060) in the Forms section as an optional framework for this internal plan.
  • Submission Date: The report will be completed by the contractor within 45 days of the start of the grant period and kept on file for monitoring purposes.
  • Accepted Method of Submission: Not applicable, plans should be kept on file and do not need to be submitted to HHSC. 
  • Submit Copy to: Grantees will keep the Promotion and Outreach Annual Plan on file for monitoring purposes. The plan will not be submitted to HHSC.
  • Original Signature Required: No
  • Number of copies: Not applicable
  • Instructions: Submit completed plan annually by due date outlined.

Required Form or Report (6): Promotion and Outreach Bi-Annual Survey

  • Description: This survey will be sent via email to designated FPP signature authorities bi-annually. Grantees are required to complete the survey within 30 days. 
  • Submission Date: The report is due within 30 days of receipt.
  • Accepted Method of Submission: Email
  • Original Signature Required: No
  • Number of Copies: Not Applicable
  • Instructions: Submit completed surveys bi-annually by the due date outlined. 

Forms

ES = Spanish version available.

FormTitle 
1065Eligibility Application 
4116Authorization for Expenditures 

24-1, Miscellaneous Revisions

Revision 24-1; Effective May 1, 2024

The following changes(s) were made:

RevisedTitleChange
2200DefinitionUpdates language.
5500Covered ServicesUpdates language.
5600Family Planning and Contraceptive ServicesUpdate language.
9000ResourcesUpdates Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL). 

23-4, Miscellaneous Revisions

Revision 23-4; Effective Nov. 17, 2023

The following changes(s) were made:

RevisedTitleChange
1100Contact InformationUpdates language. Removes physical address for courier service.
2100Program Authorization and ServicesUpdates language.
2200DefinitionsUpdates definitions throughout.
3100Client AccessUpdates language.
3200Former Military Service Members Updates language.
3300Abuse and Neglect ReportingUpdates language. Adds situations to call the Texas Abuse Hotline.
3310Child Abuse Reporting, Compliance, and MonitoringUpdates language.
3320Human TraffickingUpdates language.
3330Domestic and Intimate Partner ViolenceUpdates language.
3400ConfidentialityUpdates language.
3500Nondiscrimination and Limited English ProficiencyUpdates language. Revises hyperlinks. Adds regulations for compliance. 
3610Resolution of ComplaintsUpdates language.
3620Termination of ServicesUpdates language.
3630Freedom of ChoiceUpdates language.
3640Research (Human Subject Clearance)Updates language.
3700Client Records ManagementUpdates language.
3810Personnel Policy and ProceduresUpdates language.
3820Facilities and EquipmentUpdates and revises language. Adds language to Disaster Response Plan.
3900Quality ManagementUpdates language. Revises Quality Management program requirements. 
4000Eligibility and Assessment of Copay and FeesUpdates language.
4100Client Eligibility Screening ProcessUpdates language.
4120Screening for HTWUpdates language.
4130Screening for and Determining FPP EligibilityUpdates language.
4140Adjunctive Income Eligibility and Calculation of Applicant IncomeUpdates language. Adds Medicaid for Pregnant Women and CHIP Perinatal as adjunctive income eligibility programs. Revises eligibility verification documentations. Adds documentation for proof of income.
4200Client Fees, Copays and GuidelinesUpdates language. Adds Client Responsibility for Reporting Changes. 
4300Continuation of ServicesUpdates language.
5000Clinical GuidelinesUpdates language.
5100Minors, Consent and ConfidentialityUpdates language.
5200General ConsentUpdates language.
5210Texas Medical Disclosure Panel (TMPD)Updates language.
5220Consent for HIV TestsUpdates language.
5300PharmacyUpdates language. Adds requirement to notify HHSC on clinic pharmacy status. 
5400Client Health Records and Documentation of EncountersUpdates language.
5500Covered ServicesUpdates language.
5510Requirements for Policies to Ensure Appropriate Follow-up and Continuity of CareUpdates language.
5530ReferralsUpdates language. Incorporates information previously in 5540 and 5550. 
5540Prescriptive Authority Agreements Section removed. Contents updated moved to section 5530. 
5550Standing Delegation OrdersSection removed. Contents updated and moved to section 5530.
5600Family Planning and Contraceptive ServicesUpdates language. Removes six steps approach for contraceptive counseling. Removes Relative Method Effectiveness. Revises information on requirements for  patient access methods. Revises references.
5610Preconception ServicesRevises and updates language. Revises references and resources. 
5620Sterilization Procedures, Consent, Billing, and ReportingUpdates language. Removes required 15 percent cap on sterilization expenditures. Adds references. 
5710Cervical Cancer ScreeningUpdates language. Revises general considerations for cervical cancer screening and adds components of screening. Removes references and resources from section.
5720Breast Cancer ScreeningRevises risk screening and individual counseling information. Revises information on frequency and components of breast cancer screening. Updates language and removes references and resources from section. 
5730Sexually Transmitted Disease and Infection (STD and STI) Screening and TreatmentUpdates language. Removes information on Patient Delivered Partnered Therapy and adds information on Expedited Partner Therapy. Revises references.
5740Diabetes Mellitus Screening and TreatmentAdds diabetes treatment requirements. Removes information on who should be screened for diabetes, risk factors and diagnostic criteria. Revises listed references. 
5750Hypertension Screening and TreatmentAdds hypertension treatment requirements. Removes information for classification of blood pressure, diagnosis of hypertension, and instructions for home blood pressure monitoring. Removes information on nonpharmacological intervention for elevated blood pressure. Revises references and resources.
5760High Cholesterol Screening and TreatmentAdds high cholesterol treatment requirements. Removes information on screening for high cholesterol. Revises References and Resources. 
5770Postpartum Depression Screening and TreatmentRemoves information on risk factors and adds treatment requirements for postpartum depression. Revises referral requirements. Removes service coding. Revises references and resources.
5780Suicide Risk ScreeningRemoves section. 
5800Healthful Lifestyle InterventionUpdates language. Revises smoking and tobacco use guidelines. Removes resources.
5900Perinatal Clinical PolicyUpdates Language. Removes information on prenatal and return visit screenings, perinatal histories and laboratory and diagnostic testing. Removes education and counseling information. 
Revises tobacco assessment and Quitline referral section. Adds required information for parents of infants and children and adds required information about umbilical cord blood donation.
6000Program Promotion, Outreach, and InreachRevises section title. Updates language. Removes form 1080 and form 1060 requirements and submission schedule. Adds biannual promotion and outreach survey requirement and schedule. Adds guidance for promotion and outreach.
7000Medicaid Provider Enrollment Revises section. Updates language. 
7100Reimbursement for HHSC Family Planning ServicesUpdates language. Revises section subheadings. Revises budget section. Revises HTW Claims Pending Eligibility Determination requirements. Removes Performing Provider Number and Retroactive Eligibility information. 
8000Required Forms and ReportsUpdates language. Replaces form 1080 requirement with Promotion and Outreach Annual Plan. Replaces Form 1060 requirement with Promotion and Outreach Bi-Annual Survey.
FormsFormsRemoves Forms 1060 and 1080. Adds Form 1065.

23-3, Section 9000 Revised

Revision 23-3; Effective Sept. 5, 2023

The following changes(s) were made:

RevisedTitleChange
9000ResourcesUpdates the Reimbursable Codes for the Texas Health and Human Services Commission Family Planning Program

23-2, Section 9000 Revised

Revision 23-2; Effective Mar. 31, 2023

The following changes(s) were made:

RevisedTitleChange
9000ResourcesUpdates the Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL) for the Texas Health and Human Services Commission Family Planning Program