Family Planning Program Policy Manual

1100, Contact Information

Revision 22-2; Effective April 1, 2022

Mailing Address 

HHSC Family Planning Program
P.O. Box 149030, Mail Code 1938
Austin, TX 78714-9347

Physical Address for Courier Service 

HHSC Family Planning Program
Office Program Support and Preventive Services, Mail Code 1938
Texas Health and Human Services Commission
701 West 51st Street
Austin, TX 78751

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 22-2; Effective April 1, 2022

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 statewide 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 § 1396-1396v et. seq. Grants to States for Medical Assistance Programs

Funding Sources

All agencies that receive HHSC FPP funding 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 22-2; Effective April 1, 2022

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

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.

Client – A person who is eligible to receive medical care, treatment or services. 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 provided by a health care provider with expertise in a medical or surgical specialty and who, upon request of another appropriate health care provider, assists with the evaluation and/or management of a patient.

Contraception – The means of pregnancy prevention, including permanent and temporary methods.

Contraceptive Methods – A broad range of birth control options, approved by the U.S. Food and Drug Administration, except for emergency contraception.

Contractor – An entity that HHSC has contracted with to provide services. The contractor is the responsible entity even if there is a subcontractor involved who provides the services. The terms contractor and contract may be used interchangeably with grantee and grant in other sources.

Co-pay or Co-payment – Money collected directly from clients for services.

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

Eligibility Date – The date an individual is determined eligible for the program. The eligibility expiration date will be twelve months after the eligibility date.

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

Federal Poverty Level (FPL) – The minimum amount of income that a family needs for food, clothing, transportation, shelter and other necessities, as determined by the U.S. Department of Health and Human Services. FPL varies according to 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 – The payment mechanism for services that are reimbursed on a set rate per unit of service (also known as unit rate).

Fiscal Year – The state fiscal year is from September 1 through August 31.

Health and Human Services Commission (HHSC) – Provides support for the Health and Human Services agencies, administers the state’s Medicaid and other client service programs, sets policies, defines covered benefits, and determines client eligibility for major programs.

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 program administered by HHSC to provide 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 and may also, but are not required to, contract with HHSC to provide support services that enhance the HTW fee-for-service client delivery on a cost reimbursement basis. 

Informed Consent – The process by which a health care provider ensures that the benefits and risks of a diagnostic or treatment plan, the benefits and risks of other options, and the benefits and risks of taking no action are explained to a patient in a manner that is understandable to that patient and allows the person to participate and make sound decisions about her or his own medical care.

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 contraception 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 for in Texas Human Resources Code Chapter 32 and subject to Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq

Minor – In accordance with the Texas Family Code, a person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes (i.e., emancipated).

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

Outreach – Activities that are conducted with the purpose of informing and educating the community about services and increasing the number of individuals served.

Program Income – Money that is collected directly by the contractor, subcontractor or provider for services provided under the contract award (that is, patient co-pay 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 an individual’s personal goals regarding whether to 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 obtain preconception health services, as needed.

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 22-2; Effective April 1, 2022

The contractor must ensure that 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:
    • Individuals who are deemed eligible for HHSC 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 of age 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 an individual’s needs;
  • Provide referral sources for individuals that cannot be served or cannot receive a specific service;
  • Manage funds to ensure that established individuals continue to receive services throughout the budget year (September 1 through August 31); 
  • Inform individuals 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.

HHSC FPP contractors may not deny services to a qualifying individual based on the individual’s inability to pay.

3200, Former Military Service Members

Revision 22-2; Effective April 1, 2022

In addition to HHSC FPP, people who have served in any branch of the U.S. Armed Forces, including Army, Navy, Marines, Air 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 22-2; Effective April 1, 2022

HHSC contractors must obey state laws governing the reporting of suspected abuse and neglect of children, adults with disabilities, or individuals 65 years of age 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 an individual receiving services from certain home and community-based providers be reported. Contractors 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 65 years of age or older, or an individual receiving services from certain home and community-based providers, call the Texas Abuse Hotline at 800-252-5400. For cases that pose an imminent threat or danger to the individual, call 9-1-1 or any local or state law enforcement agency. 

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 65 years of age or older, or an individual 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 22-2; Effective April 1, 2022

Contractors and providers must develop policies and procedures that follow the reporting guidelines and requirements in Texas Family Code, Chapter 261. Contractors 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 contractor's process must ensure that the staff is reporting abuse as required by Texas Family Code, Chapter 261. To verify compliance, QA monitors examine the contractor’s process to assess whether the contractor:
    • Has an internal policy which details how the contractor will determine, document, report and track instances of abuse, sexual and non-sexual, for all individuals under the age of 18 in compliance with the Texas Family Code, Chapter 261;
    • Follows its own internal policy; and
    • Documents staff training on child abuse reporting requirements and procedures.
  • The contractor’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 22-2; Effective April 1, 2022

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

Contractors 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 22-2; Effective April 1, 2022

Intimate partner violence (IPV) describes physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples. IPV can exist regardless of the presence of sexual intimacy.

Contractors 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 22-2; Effective April 1, 2022

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

Contractors must ensure that all employees and volunteers receive training about client confidentiality during orientation and understand that violation of the law regarding confidentiality may result in civil damages and criminal penalties. An HHSC FPP 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 §382.125(c)). All employees, volunteers, subcontractors, board members and/or advisory board members must sign a confidentiality statement during orientation.

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

Additionally, an HHSC FPP health care provider may not require consent for family planning services from the spouse of a married client (1 TAC §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 22-2; Effective April 1, 2022

As outlined in the HHSC Uniform Terms and Conditions – Grant Version 2.16, HHSC contractors must comply with state and federal anti-discrimination laws, including but not limited to:

To ensure compliance with nondiscrimination laws, regulations and policies,
contractors 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 that is applicable to all individuals 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 of the allegation or complaint;
  • Ensure that all contractor staff is trained in the contractor’s nondiscrimination policies, including policies for serving individuals with LEP and individuals with disabilities, and HHSC complaint procedures;
  • Notify all individuals who are applying for family planning services of the contractor’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 individuals 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 22-2; Effective April 1, 2022

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

3620 Termination of Services 

Revision 22-2; Effective April 1, 2022

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

Contractors 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 contractor’s ability to effectively and safely provide services or if the client’s behavior jeopardizes his or her own safety, clinic staff or others. An individual has the right to appeal the denial, suspension or termination of services (1 TAC §382.111).  

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

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

3630 Freedom of Choice

Revision 22-2; Effective April 1, 2022

HHSC 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 22-2; Effective April 1, 2022

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

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

3700, Client Records Management

Revision 22-2; Effective April 1, 2022

HHSC contractors must have an organized and secure client record system. The contractor must ensure that 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 individuals;
  • 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 individual is required for the release of personally identifiable information, except as may be necessary to provide services to the individual, or as required by law, with appropriate safeguards for confidentiality. If the individual 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, contractors 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 individuals. Upon request, individuals 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.

Contractors, providers, subrecipients and subcontractors 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 §354.1003, relating to time limits for submitted claims, and in Title 22, Part 9 TAC §165, relating to maintenance of medical records. Contractors 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 22-2; Effective April 1, 2022

Contractors must develop and maintain personnel policies and procedures to ensure that the clinical staff is hired, trained and evaluated appropriately for clinical job positions. Personnel policies and procedures must include:

  • Job descriptions;
  • A written orientation plan for new staff members that includes a statement of skills and/or competencies that are 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.

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

Contractors shall 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 contracted organization’s HHSC Family Planning Program must be a licensed Texas physician.

Contractors 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 22-2; Effective April 1, 2022

HHSC contractors must maintain a safe environment and must have written policies and procedures that address the handling of hazardous materials, fire safety and medical equipment.

Hazardous Materials 

Contractors must have written policies and procedures that address:

  • 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 

Contractors 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 that provide radiology services must:

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

Smoking Ban

Contractors must have written policies that prohibit smoking in any portion of their indoor facilities. If a contractor subcontracts with another entity for the provision of health services, the subcontractor must comply with this policy.

Disaster Response Plan

Contractors must have written plans that address how staff is to respond to emergency situations (i.e., fires, flooding, power outage and bomb threats, etc.). 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

Contractors 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; and
  • Documentation must be maintained in personnel files that staff have been trained regarding these written plans or protocols.
     

3900, Quality Management

Revision 22-2; Effective April 1, 2022

Contractors must use internal quality assurance and quality improvement (QA/QI) systems and processes to monitor HHSC FPP services. Contractors 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. 

Contractors should integrate QM concepts and methods into the structure of the organization and day-to-day operations. 

Contractors 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. Contractors should have a 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.

Contractors must have a 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.

Contractors 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, 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 quality improvement actions to be implemented; and
  • Reassess outcomes and goal achievement.

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 must:

  • Include clinical and administrative standards by which services will be monitored;
  • Include the process for credentialing and peer review of clinicians;
  • Identify individuals responsible for implementing, monitoring, evaluating and reporting;
  • Establish timelines for quality monitoring 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 of prescriptive authority agreements (PAAs), policies, clinical protocols and standing delegation orders (SDOs) to ensure they are current; and
  • Performance evaluations to include primary license verification, drug enforcement administration and immunization status to ensure they are current.

HHSC contractors 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 subcontracting entities including:

  • 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 subcontractor 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 Co-pay and Fees

Revision 22-2; Effective April 1, 2022

Contractors 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 22-2; Effective April 1, 2022

HHSC FPP contracted agencies 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
  • HHSC 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 22-2; Effective April 1, 2022

Healthy Texas Women (HTW) is a Medicaid 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 legal 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 HHSC 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 individual’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 an individual indicates that 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 individual reports a change in their citizenship or immigration status.

4130 Screening for and Determining FPP Eligibility

Revision 22-2; Effective April 1, 2022

Contractors must determine and document HHSC FPP eligibility before services are rendered. To assess eligibility for HHSC FPP services, contractors must use either Form 1065, Eligibility Application, or an HHSC program-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 individual’s record and must show the individual’s poverty level and the co-pay amount he or she may be charged. An individual’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 individuals must be:

  • Females and males age 64 years and younger;
  • Texas residents (residency is self-declared). Contractors may request residency verification, but such verification should not jeopardize delivery of services;
  • At/or under 250 percent of the federal poverty level. Contractors must require income verification. If the methods used for income verification jeopardize the individual’s right to confidentiality or impose a barrier to receipt of services, the contractor must waive this requirement and approve full eligibility. Reasons for waiving verification of income must be noted in the individual 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 22-2; Effective April 1, 2022

An applicant is considered adjunctively income eligible for HHSC FPP 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)
  • 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 for HHSC FPP through their participation in other income-tested programs. Except for calculating the client’s income, contractors must follow all screening procedures outlined in Section 4100, Client Eligibility Screening Process, before enrolling applicants determined to be adjunctively income eligible in HHSC FPP.

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

Program Documentation
CHIP Your Texas Benefits Medicaid card*
SNAP SNAP eligibility letter
TANF TANF verification of certification letter
WIC WIC 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 CHIP program. 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 contractor 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 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 of age as adults. No children age 18 and older 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. Contractors must have a written FPP income verification policy.
       
    • For unemancipated, unmarried individuals under 18 years of age, 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 $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 percent of the FPL for the household size.
     
  4. Multiply by 100 percent.

See the example below for a family of three, with a monthly income amount of $2,093. The table is based on the 2021 percentage poverty tool, created by the Office of the Assistant Secretary for Planning and Evaluation (ASPE).

Total Monthly Income   Maximum Monthly Income
(Household Size of 3)
  Actual Household FPL%
$2,093 ÷ $1,830 = 1.14 X 100% = 114% FPL

4200, Client Fees, Co-pays and Guidelines

Revision 22-2; Effective April 1, 2022

Co-pays 

If an HHSC FPP contractor opts to charge a co-pay for services, a co-pay schedule must be developed and implemented with enough proportional increments so that inability to pay is never a barrier to service. The co-pay guidelines are:

  • 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 co-pay;
  • Individuals may not be charged an added co-pay for services that are provided by referral;
  • Individuals who are assessed a co-pay shall be presented with the bill at the time of service;
  • Contractors must keep records of individual co-pays paid and any balance owed;
  • Contractors must have a system for aging accounts receivable, which must be documented in the contractor’s policy and procedures and must clearly indicate a period for removing balances from an individual’s account due to inability to pay;
  • Contractors must maintain a co-pay schedule, approved by HHSC in advance, which must have proportional FPL increments and co-pay amounts (Note: An example of a co-pay schedule is provided by HHSC to contractors annually, following release of the Federal Poverty Guidelines. Contractors may opt to use the pre-approved PSPS Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL), which can be found in Section 9000, Resources);
  • The maximum co-pay amount must not exceed $30;
  • The co-pay schedule must be updated when the revised Federal Poverty Guidelines are released annually;
  • The co-pay must include all prescriptions;
  • Co-pays collected by the contractor are considered program income and must be used to support the delivery of HHSC FPP services;
  • Contractors must have policies and procedures regarding co-pay collection, which must be approved by the contractor’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 and/or transfer of medical records, copies of immunization records, etc. Contractors can bill clients for services outside the scope of HHSC FPP allowable services if the service is provided at the individual’s request and the client is made aware of their responsibility for paying for the charges.

Insurance 

Services may be provided to individuals 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 Income Total Annual Household Income 5% 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 HHSC 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 Deductible Household Monthly Insurance Deductible Total Monthly Household Income 5% 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 HHSC FPP.

Date Eligibility Begins  

An individual/household is eligible for services beginning with the date the contractor determines the individual/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 HHSC FPP services. Client eligibility must be redetermined every 12 months. Contractors must have a system in place to track client eligibility and renewal status on an annual basis.

4300, Continuation of Services

Revision 22-2; Effective April 1, 2022

Contractors of HHSC FPP are required to continue to serve their existing HHSC FPP clients for the duration of the budget year (September 1 through August 31), regardless if all HHSC awarded FPP 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 22-2; Effective April 1, 2022

This section describes the requirements and recommendations pertaining to the delivery of direct HHSC FPP clinical services to patients. In addition to the requirements and recommendations found within this section, contractors 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: 
    • Long-Acting Reversible Contraceptives (LARCs) 
    • Oral contraceptive pills 
    • Three-month (medroxyprogesterone) injections 
    • Sterilizations
  • Pregnancy testing and counseling
  • Health screenings, as follows:
    • 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 22-2; Effective April 1, 2022

Contractors must obtain the individual’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 an individual’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 individual in a manner that is understandable. This communication must allow the person to participate, make sound decisions about her or his own medical care and address disabilities, if any exist, 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 contractor must obtain the informed consent of the person receiving services for procedures as required by the Texas Medical Disclosure Panel.

HHSC contractors 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 22-2; Effective April 1, 2022

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 patients or persons authorized to consent for their patients; 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).

Contractors that directly perform tubal sterilization and/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 22-2; Effective April 1, 2022

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

5300, Pharmacy

Revision 22-2; Effective April 1, 2022

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

Contractors 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 contractor’s responsibility to ensure that all contraceptive methods and related medications approved for reimbursement by the HHSC FPP are made available at no added charge to the individual.

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 patients.

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 contractor may request an exemption to the requirement to have a Class D pharmacy.

A request for an exemption must be made in writing to the HHSC FPP 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 individuals to an off-site pharmacy benefits the agency and/or individuals.

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 contractors 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 contractor 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 FPP staff and, depending on the justification and circumstances specific to each clinic site, may or may not be granted. The HHSC FPP staff reserves the right to approve or disapprove an exemption request based upon the merit of the justification.

The pharmacy exemption process is not complete until the contractor receives either an approval or a denial in writing from the FPP program.

Note: The contractor 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 22-2; Effective April 1, 2022

Requirement for Documentation of Reproductive Health Services

All individuals should receive services related to reproductive health and/or contraception at least annually. Individuals 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 the HHSC FPP is to improve the reproductive health of individuals to ensure that every pregnancy and every baby is healthy. At each patient encounter, including encounters for treatment of other conditions (for example, an abnormal Pap smear follow-up), the provider must educate the patient on how the service being provided relates to reproductive health or contraception and this must be documented in the patient record.

For individuals 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 patient health record (medical record) is created for every individual who obtains clinical services. See Section 3700, Client Records Management.
All patient 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 patients; and
  • Systematically organized to allow easy documentation and prompt retrieval of information.

The individual health record must include: 

  • The individual’s identification and personal data, including financial eligibility;
  • The individual’s preferred language and method of communication;
  • The individual’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;
  • A person’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 individual’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;
  • An individual’s health risk survey and assessment, including past and current tobacco, alcohol and substance use or misuse, domestic and/or intimate partner violence and/or abuse (for any positive result, the individual 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;
    • An individual’s refusal of testing;
    • A Sterilization Consent Form, 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 of age) 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 22-2; Effective April 1, 2022

HHSC FPP seeks to promote the general and reproductive health of Texas residents by providing safe and effective family planning services to people through 64 years of age 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;
  • Contraceptive services, all methods except emergency contraception, including necessary follow-up and surveillance;
  • Certain health screening and diagnostic services, as indicated:
    • 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 for postpartum depression;
    • Diabetes screening;
    • Hypertension screening;
    • Screening 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).

Initial Clinical Visit

At the first clinical visit or an early follow-up visit, a comprehensive health history 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, adapt as appropriate to the gender of the person:

  • The reason for the visit and current health status;
  • A review of systems with documentation of pertinent positives and negatives;
  • A reproductive health history, as follows:
    • For women, this includes 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 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, whether currently sexually active) and reproductive life plan;
  • For women, cervical and breast cancer screening history, noting any abnormal results and treatment, and dates of the most recent testing;
  • For women, other history of gynecological conditions;
  • Other history of genital and/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 patient 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 based on the individual’s age, risk factors, preferences and concerns.

All individuals must undergo a physical examination annually as part of the family planning visit.  The physical examination may be postponed if the individual’s history and current health status do not indicate issues requiring urgent examination. However, unless the clinician finds a compelling reason for continued postponement, the annual physical examination should not be postponed more than six months and the reason for the postponement must be documented in the individual’s record. 

A breast or pelvic examination may be performed only with the consent of the individual. Individuals 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 individual 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 and the individual’s notification of results as well as an individual’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 individual; 
    • Screening for cervical cancer beginning at 21 years of age regardless of sexual history, and continuing as indicated based on the individual’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 individuals 21 years and older, but for consenting individuals less than 21 years of age, only if indicated by the medical history), to include the following elements:
      • 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 (if the pregnancy test is positive, the person must be given information on good health practices during pregnancy and given or 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 (scrotum, penis and testicles) and visual inspection of the perianal area;
  • Assessment for hernia;
  • Palpation of the prostate as indicated by history 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 individuals regardless of sex:

  • Other examinations as indicated by history, signs and symptoms, and the individual’s concerns, as follows (for example, thyroid, heart, lungs, abdomen, and similar concerns):
    • Diabetes screening as appropriate for age and risk factors;
    • Sexually transmitted infections;
    • Cholesterol and/or 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 individuals must receive accurate person-centered education and counseling in their preferred language, presented in such a way that they can understand and demonstrate their understanding. The education must be documented in the medical record. The intent of individual education is to enable 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 of age, to include the following at a minimum:

  • Counseling of minors, including:
    • All medically approved methods of contraception, including abstinence;
    • Prevention of STDs, STIs and HIV;
    • Domestic, partner, dating and family violence, and the offer of assistance as needed; and
    • Recognition and avoidance of sexual coercion.
  • 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 Section 5100, Minors, Consent and Confidentiality.

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

Revision 22-2; Effective April 1, 2022

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 individual is notified of their results and recommended follow-up;
  • Documentation of all tests and results in the individual’s health record;
  • A mechanism to inform individuals promptly of test results that protects the person’s privacy and confidentiality while supporting and promoting timely, appropriate follow-up;
  • A mechanism to track individual 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 contractor 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 telephone 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 22-2; Effective April 1, 2022

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 individual 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 the HHSC FPP are to be provided only by referral, the contractor must establish a written agreement with a referral resource for the provision of services and for the reimbursement of costs and ensure that the patient is not charged by the referral resource for these services.

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

5540 Prescriptive Authority Agreements

Revision 22-2; Effective April 1, 2022

When services are provided by an advanced practice registered nurse (APRN) and/or physician assistant, it is the responsibility of the contractor to ensure that a properly executed prescriptive authority agreement (PAA) is in place for each provider, as required by Texas Administrative Code, Title 22, Part 9, Chapter 193. This is true whether the provider is employed by the contractor or is providing services by subcontract with, or referral by, the contractor. 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;
  • 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 patient emergencies;
  • Describe the general process for communication and sharing of information between the physician and the APRN or physician assistant to whom the physician has delegated prescriptive authority related to the care and treatment of individuals;
  • 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 physician assistant; and
    • Periodic face-to-face meetings between the APRN or physician assistant and the physician at a location determined by the physician, APRN or physician assistant.

The PAA need not describe the exact steps that an APRN or physician assistant must take with respect to each specific condition, disease or symptom. The PAA and amendments, if any, must be reviewed at least annually, dated and signed by the parties to the agreement. A copy of the current PAA must be kept on-site where the APRN or physician assistant provides care.

5550 Standing Delegation Orders

Revision 22-2; Effective April 1, 2022

When services are provided by unlicensed and licensed personnel other than advanced practice nurses or physician assistants 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. SDOs:

  • Delineate under what circumstances an RN, LVN or non-licensed health care provider (NLHP) may initiate actions or tasks in the clinical setting; and 
  • Provide authority for use with a patient: 
    • When a physician or advance practice provider is not on the premises; and/or 
    • Before a patient 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 individual;
  • Giving immunizations; or
  • Performing pregnancy testing.

At least annually, SDOs must be reviewed, signed and dated 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

American Academy of Family Physicians (2017). Summary of recommendations for clinical preventive services. AAFP Policy Action Order No. 1968. Available at http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/cps-recommendations.pdf.

American College of Obstetricians and Gynecologists (2012). Committee opinion 755: Well-woman visit. Obstet Gynecol 132: 181-186. Available at https://journals.lww.com/greenjournal/Fulltext/2018/10000/ACOG_Committee_Opinion_No__755__Well_Woman_Visit.61.aspx.

Centers for Disease Control and Prevention. Content of care for women website. Available at CDC Planning for Pregnancy

Centers for Disease Control and Prevention. Clinical content of care for men website. Available at https://www.cdc.gov/preconception/men.html.

Centers for Disease Control and Prevention (2014). Providing quality family planning services. MMWR 63(4). Available at http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf.

Centers for Disease Control and Prevention (2016). Update: Providing quality family planning services. Recommendations from CDC and the U.S. Office of Population Affairs, 2015. MMWR 65(9); 231-234. Available at https://www.cdc.gov/mmwr/volumes/65/wr/mm6509a3.htm.

Centers for Disease Control and Prevention. Immunization schedules website. Available at http://www.cdc.gov/vaccines/schedules/.

5600, Family Planning and Contraceptive Services

Revision 22-2; Effective April 1, 2022

Reproductive Life Plan

Providers should encourage all individuals to develop a reproductive life plan, which is an outline of each person’s plan for having children. Questions such as the following can be useful in helping individuals 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 individual’s plan into account when counseling on contraceptive and family planning services. The provider can help the individual 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, individuals must receive patient-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 individuals a wide array of contraceptive options right for the person’s health status and reproductive plan. A six-step approach that engages the person in the decision-making process while addressing individual personal and cultural preferences will improve individual satisfaction and the likelihood that the selected method will be used correctly and consistently.

  • Step One – Establish and maintain rapport with the person. Ways to do this include:
    • Ask open-ended questions;
    • Ensure confidentiality and privacy and explain how confidential information may be used;
    • Listen to and observe the person; and
    • Encourage questions and provide culturally sensitive answers that show knowledge of the subject matter in language the person understands.
  • Step Two – Obtain social and clinical information from the person to include the following:
    • Health history;
    • Current reproductive life plan;
    • Contraceptive experience and possible preferences; and
    • Assessment of sexual health:
      • Past and current contraceptive practices;
      • Partner history (for example, number, gender and whether concurrently monogamous);
      • Current and past STD and STI prevention (for example, limiting partners, use of condoms, barriers to condom use and consistency of use); and
      • Prior treatment for, and possible exposure to, STDs and STIs.
  • Step Three – Work interactively with the person to choose the most appropriate contraceptive method:
    • Educate the person about all contraceptive methods that are safe and appropriate for that individual. Counsel individuals on the relative effectiveness of methods, correct use of methods, potential noncontraceptive-related benefits (for example, reduced risk of iron-deficiency anemia with combination hormonal contraceptives) and method side effects, working with the individual or couple to select the method that best meets their needs;
    • Inform individuals that contraceptive methods other than condoms provide no protection from STDs and STIs, including HIV, and that condoms used correctly and consistently do reduce the risk of STDs and STIs, including HIV; and
    • Help the person to identify barriers to correct contraceptive method use and develop solutions to overcome barriers.
  • Step Four – Perform a physical evaluation appropriate to the method chosen, when warranted. In most cases, no physical examination or laboratory testing is necessary before starting to use a contraceptive method:
    • Blood pressure should be recorded before starting combination hormonal contraception;
    • Current pregnancy status should be determined at the time of service for any woman receiving contraceptive services, but routine pregnancy testing is not necessary if it is possible to be reasonably certain that she is not pregnant. A provider may be reasonably certain that a woman is not currently pregnant if she has no signs or symptoms of pregnancy (either intrauterine or ectopic) and meets at least one of the following criteria:
      • Less than or equal to seven days since the start of normal menses;
      • No sexual intercourse since the beginning of the last normal menses;
      • Has been using a reliable method of contraception correctly and consistently;
      • Less than or equal to seven days since a spontaneous or induced abortion;
      • Less than or equal to four weeks postpartum; or
      • Less than six months postpartum, amenorrhea since delivery, fully or nearly fully breastfeeding (exclusive, frequent breastfeeding with the time between feedings not longer than four hours during the day or six hours at night).
    • Weight assessment is not necessary before starting a contraceptive method because obesity alone is not a contraindication to any method. However, a baseline weight measurement may aid in assessing the possible effect of a chosen method on weight change.
    • Certain tests and components of the physical examination may provide logistical, economic or emotional barriers to contraceptive access or acceptance for some women. In most cases, these interventions can be safely delayed or avoided if delay is necessary to enable a healthy individual to start a suitable and preferred method (although there may be other health care-related indications for the interventions). The following tests and examinations are not necessary before starting a contraceptive method:
      • Pelvic examination, except when fitting a diaphragm or inserting an IUD;
      • Cervical, breast or other cancer screening;
      • HIV screening;
      • Laboratory testing for hemoglobin, glucose, lipid or liver enzyme levels, or for thrombogenic mutations; or
      • Physical examination before dispensing condoms.
  • Step Five – Once a method of contraception is selected, the provider should provide counseling on correct and consistent use, help the individual to develop a plan for correct use and follow-up, and confirm the individual’s understanding. Certain considerations may increase the likelihood of correct and consistent use:
    • Ideally, the method should be dispensed on-site and started at the time of the visit (rather than waiting for the next menses), if the provider can be reasonably certain the woman is not pregnant (see Step Four above for criteria to determine with reasonable certainty that a woman is not currently pregnant);
    • Multiple cycles (ideally a year’s supply) of oral contraceptive pills, the patch or the ring should be prescribed or provided to reduce the number of return visits necessary;
    • Make condoms easily available. Note: All HHSC FPP contractors must make barrier methods and spermicides available on-site; and
    • If the individual’s chosen method is not available immediately or on-site, provide another method on the day of the visit to be used until the chosen method can be started.
  • Step Six – Help the person develop a plan for correct and consistent use of the chosen method and provide a plan for follow-up:
    • Explore possible reasons for incorrect or inconsistent use and help develop strategies to deal with these. For example:
      • Suggest a daily text message or a sign on the bathroom mirror to routinize daily pill taking;
      • Discuss ways to ensure timely return for injections; and
      • Discuss side effects, a common reason for method discontinuation and ways to deal with these.
    • Create a follow-up plan with the person, considering the person’s individual needs and perceived risk of method lapse or discontinuation;
    • Confirm the person’s understanding of the information given and document this in the medical record:
      • The teach-back method, in which the individual shows understanding of the information by repeating back the messages received, is an effective way to confirm understanding and to increase retention of the information received.
      • Provide counseling with teach-back of the following topics, at a minimum:
        • Real-world method effectiveness;
        • Correct method uses and common side effects;
        • Back-up contraceptive methods, including issues related to discontinuation of the chosen method;
        • Whether or not the method protects against STDs and STIs;
        • Signs of rare, but serious, complications and what to do if any of these signs occur;
        • How to find urgent or emergency care, including a 24-hour emergency telephone number; and
        • When to return for follow-up.

Relative Method Effectiveness

Relative method for effectiveness (range of effectiveness for 100 women using the method for one year) for the following HHSC FPP-approved contraceptive methods is indicated in parentheses, if reported values are available. Actual effectiveness depends on correct and consistent use. Higher rates of effectiveness are seen with perfect use. Real-world effectiveness is generally reflected in the lower end of the effectiveness range.

  • Completely effective (100%)
    • Total sexual abstinence
  • Extremely effective (approximately 99%)
    • Contraceptive implant;
    • Intrauterine device (IUD); and
    • Male or female sterilization.
  • Less effective (ranges of effectiveness are shown)
    • Lactational amenorrhea (Less than six months postpartum, amenorrhea since delivery, fully or nearly fully breastfeeding (exclusive, frequent breastfeeding with the time between feedings not longer than four hours during the day or six hours at night);
    • Progestin injection (Depo-Provera, 94%);
    • Hormonal contraceptive pills (91%);
    • Hormonal contraceptive patch (91%);
    • Vaginal ring (91%);
    • Diaphragm (88%);
    • Male condom (82%);
    • Female condom (79%);
    • Cervical cap (77% - 83%); 
    • Sponge (76% - 88%)
    • Fertility Awareness-Based Methods (76%); and
    • Spermicide (72%) 

For more information on implementing a program to provide Long-Acting Reversible Contraception (LARC), see the Texas LARC Toolkit.

Specific Method Access Requirements for Contractors

Contractors must ensure that the following requirements are met with respect to patient access to contraceptive methods:

  • LARC methods must be available on-site or by referral. Providers who are delivering services under a contract with HHSC FPP must use the buy and bill method, which requires providers to order LARC devices directly from the manufacturer or a third-party distributor. The product manufacturer’s website provides information on how to order and pay for the device. These are available in different size lots and a discount may be available for purchasing multiple devices at a time;
  • Male and female sterilization must be made available on-site or by referral;
  • All contractors 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; and
  • Contractors with a Class D pharmacy must also make oral and transdermal hormonal contraceptive agents or vaginal hormonal contraceptive rings available on-site, and contractors 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 HHSC FPP contractors:

Contraceptive Method or Anti-infective Agent On-site Availability Required
  Class D Pharmacy Class D Pharmacy Exempt
Anti-infective agents for treatment of STDs/STIs X  
Barrier methods and spermicides X X
Injectable hormonal contraceptives X X
Oral contraceptives X  
Transdermal hormonal contraceptive (patch) and/or vaginal hormonal contraceptive (ring) X  
Sexual abstinence education and counseling X X

Contraceptive Methods that May Be Provided by Referral

If the clinicians associated with an HHSC FPP contractor do not offer covered contraceptive services that require 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 individual. HHSC FPP contracted clinics that offer 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, §382.113(b), Non-Covered Services, services not provided through the HHSC FPP include:

  • Counseling on and provision of abortion services;
  • Counseling on and provision of emergency contraceptives; 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 costs (including overhead, rent, phones and utilities) of abortion procedures provided. 

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

References and Resources

Centers for Disease Control and Prevention (2014). Provides quality family planning services. MMWR 63(4). Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm (web) http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf.

Centers for Disease Control and Prevention (2016). Update: Provides quality family planning services - Recommendations from CDC and the U.S. Office of Population Affairs, 2015.  MMWR 65(9); 231-234. Available at https://www.cdc.gov/mmwr/volumes/65/wr/mm6509a3.htm.

Centers for Disease Control and Prevention. U.S. selected practice recommendations for contraceptive use, 2016. MMWR 65(No. 4). Available at https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html (web) https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6504.pdf.

American College of Obstetricians and Gynecologists Long-Acting Reversible Contraception program webpage. Provides information, clinical guidance and educational materials on long-acting reversible contraceptives.

5610 Preconception Services

Revision 22-2; Effective April 1, 2022

The goal of preconception care is to establish a foundation for the best possible outcome of every pregnancy. Because almost half of all pregnancies in the United States are unplanned and most pregnancies occur in women who did not have a specific preconception care visit before becoming pregnant, providers should keep preconception care in mind at every encounter with a woman of childbearing potential.

Good preconception care incorporates all components of general health care as described elsewhere 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 that they are euthyroid before and during pregnancy to reduce the risk of miscarriage and preterm birth; and
    • 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 that immunizations are current;
  • Medications (prescription and nonprescription) and potential radiation exposure in early pregnancy:
    • In general, the lowest effective dose of necessary medications is preferred, but individuals should be cautioned against stopping or changing medications without first consulting their doctor, because an untreated or incompletely treated medical condition might pose greater risk to the fetus and mother than the medication prescribed; and
    • Some known teratogenic medications include warfarin, valproic acid, carbamazepine, isotretinoin and angiotensin-converting enzyme inhibitors. Note: For more individual and provider information on risk associated with specific exposures to medications and other environmental factors, consult the website of the Organization of Teratology Information Specialists;
  • Prevention of STDs and STIs;
  • 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; and
  • Mental health.

References and Resources

American Academy of Pediatrics/American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care 7th Ed. (2012). Ch. 5, pp. 95-106.

American College of Obstetricians and Gynecologists. Committee opinion 762: Pre-pregnancy Counseling. Available at https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2019/01/prepregnancy-counseling.pdf.

Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care – United States. MMWR (2006). 55(RR06): 1-23. Available at http://www.cdc.gov/mmWR/PDF/rr/rr5506.pdf.

Centers for Disease Control and Prevention. Recommendations: Women and Folic Acid. Available at https://www.cdc.gov/ncbddd/folicacid/recommendations.html.

Organization of Teratology Information Specialists. Mother to Baby: Medications and more during pregnancy and breastfeeding. Available at http://mothertobaby.org/fact-sheets-parent/. (Provides information for patients and health care providers on teratogenic risk of drugs and other exposures in pregnancy.)

Resources for Patients and Providers

American Society for Reproductive Medicine. Available at http://www.reproductivefacts.org/. (Information for patients on a variety of topics related to fertility and infertility.)

Centers for Disease Control and Prevention. Preconception health and health care website. Contains links to resources for patients, providers and patient educators on planning for a healthy pregnancy. Available at http://www.cdc.gov/preconception/index.html.

5620 Sterilization Procedures, Consent, Billing and Reporting

Revision 22-2; Effective April 1, 2022

Conditions for Sterilization Procedures

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

  • Be age 21 or older;
  • Be mentally competent (individuals 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 in 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 an individual’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 individual’s EDD must be documented when there are less than 30 days between the date of the individual’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 individuals who choose sterilization, two consent forms must be signed by the person after counseling on method-specific risks and benefits is provided and all the person’s questions have been answered:

  • The Sterilization Consent Form (English/Spanish)  The contractor must ensure that the form is complete and correct before submitting it to TMHP. The Sterilization Consent Form is necessary for both abdominal and trans-cervical sterilization; and
  • 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 is provided and all the patient’s questions are answered.

The individual 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 individual’s signature.  

The consent form must be signed and dated by the:

  • Individual 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 individual to be sterilized is:

  • In labor or delivering an infant or infants; or
  • Under the influence of alcohol or other substances that affect the individual’s state of awareness.

Sterilization Billing and Reporting

HHSC FPP contractors can receive reimbursement for vasectomy or tubal ligation/occlusion sterilization procedures through FPP Fee-for-Service. The individual may not be billed for any cost above the reimbursement rates. Individual co-pays for sterilizations must follow the contractor’s established, HHSC-approved co-pay policy and may not exceed the allowable amount.

Contractors must not expend more than 15 percent of their total award on female sterilizations. An exemption may be granted to this policy on a case-by-case basis. Contact famplan@hhsc.state.tx.us for more information.

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

Contractors may request reimbursement through TMHP for costs associated with patient complications related to sterilizations, contraceptive implants or intrauterine devices (IUDs). Contractors may be reimbursed for approved charges up to $1,000 per occurrence. To request reimbursement, contractors 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 individual in question;
  • A narrative summary detailing the procedure performed and related complications, if any;
  • All surgical and progress notes for the individual 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 contractor is seeking reimbursement and date of occurrence. List all procedures related to the complication even if they are not typically reimbursable under the HHSC FPP.

5700, Screenings

5710 Cervical Cancer Screening

Revision 22-2; Effective April 1, 2022

The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for HHSC FPP and does not include guideline recommendations for individuals outside this range.

Guidelines were reviewed from a variety of medical specialty organizations and U.S. government agencies. Where only a slight divergence was found among guidelines from different organizations, the recommendations were synthesized so that all are represented cohesively in the summary below. 

Most cases of cervical cancer occur in women who have never had screening or have had inadequate screening. It is estimated that half of women who receive a diagnosis of cervical cancer have never had cervical cytology testing, and an additional 10 percent have not had a screening in the five years before the diagnosis of cancer. Providers are encouraged to implement and participate in programs aimed at increasing the percentage of women in their communities who receive indicated cervical cancer screening.

General Considerations for Cervical Cancer Screening

  • Cervical cancer screening should begin at age 21. Except for women who are infected with HIV or otherwise immunocompromised, screening should not be performed before age 21.
  • Women with the following risk factors are at higher risk and may require more frequent screening than described in this manual, which is intended for women of average risk:
    • Women with HIV infection or other reason for immunocompromise (for example, history of solid-organ transplant);
    • History of in utero exposure to diethylstilbestrol; and
    • Previous treatment for CIN 2, CIN 3 or cervical cancer.
  • Liquid-based and conventional (Pap smear) methods of cervical cytology are acceptable.
  • When human papillomavirus (HPV) testing is performed, it should include testing to detect only those HPV genotypes with known carcinogenic potential, those considered high-risk HPV genotypes. Testing for low-risk genotypes, those without proven carcinogenic potential, should not be performed. References to HPV testing in the rest of this section are for high-risk HPV only.
  • Screening guidelines should be applied to women who have received the HPV vaccine in the same way the guidelines are applied to women who have not received the vaccine.

Cervical Cancer Screening Frequency and Response to Abnormal Findings

  • Routine annual cervical cancer screening is not needed for women of average risk in any age group. 
  • Women ages 21 through 29 should undergo screening every three years by cervical cytology testing alone, with reflex human papillomavirus (HPV) testing when cytology reveals atypical squamous cells of undetermined significance (ASCUS). Co-testing (cervical cytology combined with routine HPV testing) should not be performed in women younger than 30 years of age.
  • For women ages 25 through 29, the FDA-approved primary HPV screening test may be considered as an alternative to cytology-based screening, although cytology alone with reflex HPV testing when cytology reveals ASCUS is recommended by professional society guidelines. If the primary HPV test is to be used for screening, it should be done according to interim guidance provided by the American Society for Colposcopy and Cervical Pathology (ASCCP) and the Society of Gynecologic Oncology.
  • 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 individual 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.

Updated guidelines from the ASCCP recommend management of patients with abnormal cervical cancer screening results based on that individual’s risk of having or developing CIN 3 or greater.  This means that different patients with the same current screening results may be managed differently, depending on cervical cancer screening results and treatment. Providers can determine recommended management for individual patients by consulting published tables or using an application or website designed for this purpose. Information about management of these types of cases is available under “Cervical Cancer Screening Resource for Providers” at the end of this section.

Discontinuation of Screening for Cervical Cancer

For women age 64 or younger, screening is stopped after a hysterectomy with removal of the cervix in individuals with no history of CIN 2 or greater.

References and Resources for Cervical Cancer Screening

American Society for Colposcopy and Cervical Pathology (2019). 2019 ASCCP Risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. Available at ASCCP Screening Guidelines

Egemen, D., Cheung, L. C., Chen, X., Demarco, M., Perkins, R. B., Kinney, W., Poitras, N., Befano, B., Locke, A., Guido, R. S., Wiser, A. L., Gage, J. C., Katki, H. A., Wentzensen, N., Castle, P. E., Schiffman, M., & Lorey, T. S. (2020). Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines. Journal of lower genital tract disease, 24(2), 132–143. https://doi.org/10.1097/LGT.0000000000000529.

Huh, W. K., Ault, K. A., Chelmow, D., Davey, D. D., Goulart, R. A., Garcia, F. A., Einstein, M. H. (2015). Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance. Gynecol Oncol, 136(2), 178-182.

Practice Bulletin No. 168: Cervical cancer screening and prevention. (2016). Obstet Gynecol, 128(4), e111-e130.

U.S. Department of Health and Human Services Panel on opportunistic infections in HIV-infected adults and adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health and the HIV Medicine Association of the Infectious Diseases Society of America. Available at https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/0.

U.S. Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Wong, J. B. (2018). Screening for cervical cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 320(7), 674-686.

Cervical Cancer Screening Resource for Providers 

American Society for Colposcopy and Cervical Pathology. ASCCP Risk-based management consensus guidelines Mobile App at https://www.asccp.org/mobile-app.

5720 Breast Cancer Screening

Revision 22-2; Effective April 1, 2022

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

Breast Cancer Risk Screening and Individual Counseling

All females should have an assessment of their risk for breast cancer, updated periodically, to include the individual’s age and ethnicity, personal and family history of breast cancer, other relevant genetic predisposition to breast cancer and history of chest radiation (particularly before age 30). A risk calculator is available from the National Cancer Institute for an individual’s five-year risk of developing breast cancer (for women ages 35 and older).

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

Breast Cancer Screening Frequency

The following considerations* apply to women ages 40 and older who do not have preexisting breast cancer or other high-risk breast lesion and who do not have a known underlying genetic mutation (such as BRCA1 or 2 mutations or other familial breast cancer syndrome) or a history of chest radiation at an early age. 

  • All individuals aged 50 through 64 should be offered screening mammography every other year. 
  • The decision for screening mammography in women aged 40 through 49 should be individualized:
    • While screening mammography may reduce breast cancer-related deaths in this population, the number of deaths prevented is less than in older populations and the number of false-positive mammography results and negative biopsies is higher.
    • Women who undergo regular screening mammography face a risk of the diagnosis and treatment of breast cancer that would not otherwise have become apparent or threatened their health during their lifetime (overtreatment).
    • Women with a first-degree relative (parent, sibling or biologically related child) with breast cancer are at increased risk and may benefit more from screening in their 40s than average-risk women.
    • Women who place a higher value on the potential benefits of screening than on the potential harms may choose, and should be allowed to, undergo biennial screening beginning sometime between age 40 and 49.
  • Digital mammography combined with breast tomosynthesis may improve the rate of cancer detection and may decrease call-back rates, although this practice might increase the total radiation dose.
  • There is insufficient evidence to assess the balance of benefits and harms of breast ultrasonography, magnetic resonance imaging or other methods of adjunctive screening with women who have dense breasts identified on an otherwise negative screening mammogram.

More frequent or earlier screening mammography may be considered for women with increased or uncertain individual breast cancer risk and in other circumstances where the balance of potential benefits and harms of screening justifies such mammography.

*Note: The recommendations for frequency of mammography screening described above come from the U.S. Preventive Services Task Force Recommendation Statement on Screening for Breast Cancer. The National Comprehensive Cancer Network recommends annual screening mammography be offered to all asymptomatic women age 40 and older. Links to both guidelines are provided in the following references and resources.

Breast Cancer Screening Follow-up and Referral for Treatment

Individuals 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 individual 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 contracted provider, contractors are encouraged to refer these individuals to an HHSC Breast and Cervical Cancer Services (BCCS) contractor. Information is available at Texas Health and Human Services Breast and Cervical Cancer Services and Texas Works Handbook, X-900, Medicaid Eligibility.

Eligible individuals in need of treatment for biopsy-proven breast cancer may apply for coverage under the Medicaid for Breast and Cervical Cancer Program. Information is in X-900.

Breast Cancer Screening References and Resources

Siu, AL. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279-296. Available at http://annals.org/article.aspx?articleid=2480757

Breast Cancer Screening Information for Patients

National Cancer Institute. Mammograms patient information. Available at http://www.cancer.gov/types/breast/mammograms-fact-sheet.

National Cancer Institute. Breast Cancer – Patient Version. Available at http://www.cancer.gov/types/breast.

Breast Cancer Screening Online Provider Resource

National Cancer Institute. Breast Cancer Risk Assessment Tool. Available at https://bcrisktool.cancer.gov

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

Revision 22-2; Effective April 1, 2022

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the HHSC FPP (age 64 and younger) and do not include guideline recommendations for individuals 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 done for all individuals 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

  • Contractors 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 individuals age 13 to 64 should be screened at least once for HIV according to a policy that provides HIV education and allows individuals to opt out of screening. With an opt-out screening, individuals 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.
  • Individuals who engage in risky sexual practices or share injection drug paraphernalia should be tested annually.
  • Individuals who seek testing or treatment of STDs and STIs should be tested for HIV at the same time.
  • Contractors may provide negative HIV test results to individuals 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.
  • Contractors must always provide positive HIV test results to individuals 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.
  • Individuals 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.  

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

Chlamydia and Gonorrhea Testing

  • Contractors 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 patient.
  • Testing should also be done in women 25 years and older asymptomatic women with increased risk and in all symptomatic women. 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 previous12 months; and
    • Sex work or drug use.
  • Treated individuals 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 is not recommended but should be considered in settings where the prevalence of infection is high, such as correctional facilities and clinics focused on services for adolescents.

Herpes Simplex Virus (HSV) Screening

  • Routine screening of asymptomatic individuals for genital HSV infection is not recommended in the general or pregnant population.
  • Testing, counseling and treatment of symptomatic individuals (that is, individuals who have genital lesions), as well as management of affected pregnant individuals, should follow current CDC guidelines.
  • The preferred tests for confirmation of the diagnosis in individuals 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 (that is, culture and PCR) are negative in a symptomatic patient; or
    • For counseling patients about the risk of infection by a partner with known infection, especially during pregnancy.

Syphilis Screening (Men and Nonpregnant Women)

  • Men and nonpregnant 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 are a history of incarceration or commercial sex work.
  • According to 2018 CDC surveillance data, approximately 85.7 percent of syphilis cases occurred in men, with the highest rates in men ages 25 to 29.
  • Routine screening for syphilis in a nonpregnant population that is not at increased risk of syphilis infection is not recommended because 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 individual’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.
  • Individuals under age 25 and women at increased risk should also have chlamydia and gonorrhea testing. 

Patient-Delivered Partner Therapy (PDPT)

PDPT is the practice of providing therapy to the sexual partner or partners of a person being treated for chlamydia or gonorrhea without first developing a patient-clinician relationship with the partner or partners. Untreated partners can re-infect treated individuals and expose others to infection.

Providers are encouraged to implement PDPT by providing individuals who are being treated for either chlamydia or gonorrhea with medications or prescriptions for the partner or partners to reduce the risk of reinfections. 

Providers may not receive reimbursement for providing partner treatment under this policy to persons who have not been patients.

References

American College of Obstetricians and Gynecologists. Committee Opinion No. 811: ACOG Clinical: The initial reproductive health visit. Available at https://www.acog.org/en/Clinical/Clinical%20Guidance/Committee%20Opinion/Articles/2020/10/The%20Initial%20Reproductive%20Health%20Visit.

Branson, BM., et al. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health care settings. MMWR (2006) 55(RR14): 1-17. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

Centers for Disease Control and Prevention. Genital herpes. Available at http://www.cdc.gov/std/Herpes/default.htm.

Centers for Disease Control and Prevention. Pregnant women, infants and children: An opt-out approach to HIV screening. Available at http://www.cdc.gov/hiv/group/l/pregnantwomen/opt-out.html.

Centers for Disease Control and Prevention. Sexually transmitted diseases:
Treatment. Available at http://www.cdc.gov/std/treatment/default.htm.

Centers for Disease Control and Prevention. STD and HIV Screening Recommendations. Available at http://www.cdc.gov/std/prevention/screeningreccs.htm.

U.S. Preventive Services Task Force. Screening for syphilis infection in nonpregnant adults and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA (2016) 315(21): 2321-2327. Available at http://jamanetwork.com/journals/jama/fullarticle/2526645.

Expedited (Patient-Delivered) Partner Therapy (Information for Patients and Providers)

Centers for Disease Control and Prevention. Expedited partner therapy website. Available at http://www.cdc.gov/std/ept/.

Texas Department of State Health Services. Expedited partner therapy website. Available at http://www.dshs.state.tx.us/hivstd/ept/default.shtm.

5740 Diabetes Mellitus Screening

Revision 22-2; Effective April 1, 2022

Who Should Be Screened for Diabetes?

The criteria below apply to nonpregnant patients only.

  • Begin screening all adults at age 45.
  • Screen adults younger than age 45 who are overweight or obese (BMI greater than or equal to 25 kg/m2 [BMI greater than or equal to 23 kg/m2 for Asian Americans]) with one or more risk factors. An adult BMI calculator is available from the Centers for Disease Control and Prevention (CDC).
  • Screen overweight or obese children or minors (age 19 or younger) who have two or more additional risk factors. To determine whether the individual is overweight or obese, see Defining Childhood Obesity and the CDC child and teen BMI calculator.
  • If screening test results are normal, retest at least every three years. Consider more frequent testing in patients with risk factors. 
  • Patients with prediabetes [impaired fasting glucose (IFG), or impaired glucose tolerance (IGT)] should be retested every year. IFG and IGT refer to laboratory values that are above the normal range but do not meet the diagnostic criteria for diabetes. Persons with these results are said to have prediabetes.
  • All women with a diagnosis of gestational diabetes in a recent pregnancy should have a diabetes screening with a two-hour oral glucose tolerance test at six to 12 weeks postpartum, regardless of other risk factors.
  • All women with any history of gestational diabetes should have testing for diabetes and prediabetes at least every three years, regardless of other risk factors.

Risk Factors for Diabetes

  • High-risk race or ethnicity (for example, Alaskan Native American, African American, African Caribbean, Asian American, Hispanic and Latino, Native American, Pacific Islander and South Asian);
  • Diabetes in a first-degree relative;
  • Physical inactivity;
  • Women who have had gestational diabetes or who have delivered a baby weighing greater than nine pounds;
  • History of prediabetes: hemoglobin A1C greater than 5.7 percent (39 mmol/mol), IFG or IGT in previous testing;
  • HDL cholesterol less than 35 mg/dL (0.90 mmol/L) and/or serum triglyceride level greater than 250 mg/dL (2.82 mmol/L);
  • A history of polycystic ovary syndrome;
  • A diagnosis of hypertension;
  • A history of cardiovascular disease; or
  • Any other condition in which insulin resistance is common, such as severe obesity or acanthosis nigricans.

Diabetes Diagnostic Criteria

The following test results, confirmed on repeat testing, meet the criteria for a diagnosis of diabetes (repeat testing for confirmation is not needed in the presence of unequivocal clinical hyperglycemia):

  • Fasting plasma glucose (after no caloric intake for a minimum of eight hours) greater than or equal to 126 mg/dL (7.0 mmol/L);
  • Oral glucose tolerance test (OGTT) with a two-hour postprandial glucose level greater than or equal to 200 mg/dL (11.1. mmol/L) following a 75-g glucose load;
  • Hemoglobin A1C greater than or equal to 6.5% (48 mmol/mol). For diagnosis of type I diabetes in individuals with acute hyperglycemic symptoms, blood glucose testing is preferred; or
  • Random plasma glucose greater than or equal to 200 mg/dL (11.1. mmol/L) in the setting of a hyperglycemic crisis or classic symptoms of hyperglycemia. (Confirmation by repeat testing is not needed in this setting.)
Test Criteria to Diagnose Diabetes Mellitus Comments
Fasting plasma glucose Greater than or equal to 126 mg/dL (7.0 mmol/L) After no caloric intake for a minimum of eight hours.
Oral glucose tolerance test (with a 75-g glucose load) Two-hour postprandial glucose greater than or equal to 200 mg/dL (11.1. mmol/L)  
Hemoglobin A1C Greater than or equal to 6.5% (48 mmol/mol) For diagnosis of type I diabetes in individuals with acute hyperglycemic symptoms, blood glucose testing is preferred.
Random plasma glucose Greater than or equal to 200 mg/dL (11.1. mmol/L) If this occurs in the setting of a hyperglycemic crisis or classic symptoms of hyperglycemia, confirmation by repeat testing is not required.

Table: Diagnostic Criteria for Diabetes Mellitus. All initial results should be confirmed with repeat testing.
Diabetes References and Resources

5750 Hypertension Screening

Revision 22-2; Effective April 1, 2022

All individuals, including those with hypertension, should be advised to practice a healthful lifestyle as described in Section 5800, Healthful Lifestyle Intervention.

Classification of BP and Diagnosis of Hypertension

In the U.S., high blood pressure (BP) is the second leading cause of preventable death after cigarette smoking and is the most important modifiable risk factor for death due to cardiovascular disease. Because hypertension is generally asymptomatic, it is important that all individuals be screened at least annually for elevated BP.

The following table provides parameters and guidance on diagnosis of hypertension in adults. Recent guidelines emphasize greater reliance on home BP monitoring to aid in the diagnosis of hypertension when clinic readings are high normal, borderline high or elevated. It is generally agreed that clinic BP measurements are often higher than home BP measurements, particularly in the higher ranges of BP.

BP (mm Hg) Category
Systolic Diastolic No Data
Less than 120 and Less than 80 Normal
120-129 and Less than 80 Elevated
130-139 or 80-89 Stage 1 hypertension
140 or higher or 90 or higher Stage 2 hypertension
180 or higher and/or 120 or higher Hypertensive crisis

Measurement of BP

To ensure correct measurement and monitoring of BP, follow these guidelines:

  • For diagnosis of hypertension, BP readings should be based on the average of correct measurements taken on two or more occasions using proper technique.
  • Ambulatory or home BP monitoring should be performed to confirm the diagnosis of hypertension.
  • Adults not being treated for hypertension who have office BP readings of 130/80 to 160/100 mm Hg should be screened for white coat hypertension (WCH), high BP in the clinic but normal BP outside the clinic, using ambulatory or home BP monitoring.
  • Periodically monitor adults with WCH using ambulatory or home BP monitoring to assess for development of sustained hypertension.
  • Adults not being treated for hypertension who have office BP readings of 120/75 to 129/79 mm Hg consistently should be screened for masked hypertension (normal BP in the clinic but high BP outside the clinic) using ambulatory or home BP monitoring.

Instructions for Home BP Monitoring

To teach patients to correctly perform home BP monitoring, follow the steps below:

  • Patients should receive instruction for home BP monitoring, including interpretation of results under medical supervision.
  • An automated, validated device should be used, preferably with the ability to store readings in memory. 
  • Correct cuff size should be verified, and the patient should be told to measure BP in the arm with the higher reading if there is a significant difference in the readings for both arms.
  • Instruct the patient to rest quietly for at least five minutes and avoid exercise, caffeine and smoking for at least 30 minutes before taking BP.
  • Instruct the patient to sit upright in a straight-backed chair with feet flat on the floor, legs uncrossed, and the arm supported on a flat surface with the upper part of the arm at heart level.
  • The bottom of the cuff should sit directly above the antecubital fossa.
  • Two readings, taken one minute apart, should be done twice daily, in the morning before taking any medications, and in the evening before eating supper.
  • BP measurements should be done daily, for one week before a clinic visit.
  • Monitors with stored memory should be brought to all clinic appointments.
  • Clinical decision making should be based on the average of readings taken on two or more occasions.

Nonpharmacologic Intervention for Elevated BP or Hypertension

All patients, regardless of BP category should receive instruction in a healthful lifestyle habits, with regular reinforcement of teaching. 

  • Weight loss should be recommended for adults who are overweight or obese.
  • Persons with elevated BP or hypertension should adopt a healthy-heart diet (for example, the DASH diet) to reduce BP.
  • Sodium intake should be reduced.
  • Potassium intake should be increased, preferably by dietary modification.
  • Physical activity should be increased, using a structured exercise program.
  • Alcohol intake should be avoided or moderated (less than or equal to one standard drink daily for women, less than or equal to two standard drinks daily for men).

BP/Hypertension References and Resources

Carey, R. M., Whelton, P. K. (2018). Prevention, detection, evaluation and management of high blood pressure in adults: Synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline. Ann Intern Med, 168(5), 351-358. Available at http://annals.org/aim/fullarticle/2670318/prevention-detection-evaluation-management-high-blood-pressure-adults-synopsis-2017.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017). ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Hypertension, 71(6), e13-e115. Available at http://hyper.ahajournals.org/content/71/6/e13.long.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Executive Summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol, 71(19), 2199-2269. Available at https://www.sciencedirect.com/science/article/pii/S073510971741518X?via%3Dihub.

Resources for Patients and Educators

American Heart Association. High blood pressure. Provides information on the meaning and importance of high blood pressure, risks for, and prevention of, high blood pressure, blood pressure monitoring and treatment of high blood pressure. Available at http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/High-Blood-Pressure_UCM_002020_SubHomePage.jsp.

National Heart, Lung and Blood Institute. Description of high blood pressure. Provides a plain language discussion of the prevention, diagnosis and treatment high blood pressure. Available at http://www.nhlbi.nih.gov/health/health-topics/topics/hbp.

Resources for Providers

American Society of Hypertension. Hypertension Guidelines at http://www.ash-us.org/About-Hypertension/Hypertension-Guidelines.aspx.

5760 High Cholesterol Screening

Revision 22-2; Effective April 1, 2022

The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for the HHSC FPP. It does not include guideline recommendations for individuals outside this eligibility range.

The diagnosis and treatment of elevated blood cholesterol is a complex subject and a complete discussion is beyond the scope of this manual. For more information, providers are referred to references and resources, and relevant textbooks outlined in the following section.

Rationale for Screening for High Cholesterol

Evidence shows that a healthful lifestyle (following a healthy-heart diet, maintaining a healthful weight, regular exercise and avoidance of tobacco products) reduces the risk of cardiovascular disease. In certain persons with specific risk factors, cholesterol-lowering medications (that is, statins) can further reduce the risk of an adverse health event. Measurement of blood cholesterol is a part of the individual risk assessment for some patients.

Who Should Be Screened for High Cholesterol?

  • All men aged 35 and older;
  • Men aged 20 through 35 years of age with increased risk for coronary heart disease; and
  • Women aged 20 and older with increased risk for coronary heart disease (CHD).

No recommendation is made regarding routine screening in men aged 20 through 35 or in women aged 20 or older without increased risk of CHD.

High Cholesterol Risk Factors

Increased risk of CHD is defined by the presence of any one of the risk factors below. Greater risk results from the presence of multiple risk factors, such as:

  • Diabetes;
  • Personal history of CHD or noncoronary atherosclerosis;
  • Family history of cardiovascular disease in men before age 50 and in women before age 60;
  • Tobacco use;
  • Hypertension; and
  • Obesity (body mass index great than or equal to 30 kg/m2).

Screening Frequency

The best interval for screening is uncertain. Reasonable options include every five years, shorter intervals for people whose lipid levels are close to those calling for therapy, and longer intervals for those not at increased risk who have had repeatedly normal lipid levels. An age at which to stop screening has not been established.

Screening Method

The preferred screening test for elevated cholesterol is the serum lipid panel [total cholesterol, high-density lipoprotein (HDL) cholesterol, and low-density lipoprotein (LDL) cholesterol] in the fasting or non-fasting state. If non-fasting results are used, only the total cholesterol and HDL cholesterol are reliable. Abnormal screening results should be confirmed by a repeat sample on a separate occasion and the average of both results should be used for risk assessment.

Evaluation of Screening Results

Results of the lipid profile should be interpreted in the context of the individual’s risk factors and 10-year estimated risk of atherosclerotic cardiovascular disease (ASCVD), defined as acute coronary syndrome, myocardial infarction, stable or unstable angina, stroke, transient ischemic attack, coronary or other arterial revascularization procedure, or atherosclerotic peripheral arterial disease. A risk calculator for 10-year ASCVD risk is available from the American College of Cardiology and American Heart Association.

Studies have shown a benefit of statin therapy for individuals:

  • With clinical ASCVD, regardless of lipid profile results;
  • With LDL cholesterol greater than or equal to 190 mg/dL;
  • Age 40 or older with diabetes and LDL cholesterol greater than or equal to 70-189 mg/dL and no clinical ASCVD;
  • Age 40 or older with diabetes and LDL cholesterol 70-189 mg/dL and no clinical ASCVD; or
  • Of any age without diabetes or clinical ASCVD, with LDL cholesterol 70-189 mg/dL and 10-year ASCVD risk greater than or equal to 7.5 percent.

Cholesterol References and Resources

Stone N.J., et al. 2013 ACC/AHA Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation (2014). 129 (25 Suppl. 2): S1-S45 Available at https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.

National Heart, Lung and Blood Institute. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III). NIH Publication No. 01-3670, May 2001. Available at http://www.nhlbi.nih.gov/files/docs/guidelines/atp3xsum.pdf.

U.S. Preventive Services Task Force. The Guide to Clinical Preventive Services, Lipid Disorders in Adults (2014), Page 45. Available at http://www.ahrq.gov/sites/default/files/publications/files/cpsguide.pdf.

Further Reading

Pursnani A, et al. Guideline-based statin eligibility, coronary artery calcification and
cardiovascular events. JAMA (2015) 314:134-141. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754085/.

Resources for Providers

ASCVD Risk Estimator from the American College of Cardiology. Provides an estimate of the 10-year risk of developing ASCVD. Available at http://tools.acc.org/ASCVD-Risk-Estimator/.

5770 Postpartum Depression Screening

Revision 22-2; Effective April 1, 2022

Prevalence and Risk Factors for Postpartum Depression

As much as 80 percent of new mothers experience a brief episode of the “baby blues,” which may last up to two weeks. Approximately 5 percent to 25 percent of new mothers experience postpartum depression that warrants intervention. It typically begins in the first four to six weeks after birth of the infant but may develop any time in the first year. 

Risk factors for postpartum depression include the following:

  • Symptoms of depression (especially in the third trimester) or anxiety during the pregnancy;
  • Prior psychiatric illness or poor mental health, especially postpartum depression with a prior pregnancy;
  • A history of physical, sexual or psychological abuse or domestic violence; 
  • Family history of depression, anxiety or bipolar disorder;
  • Lack of social support;
  • Low socio-economic status or educational level;
  • Immigrant from another country;
  • Medicaid insurance;
  • Poor income or unemployment;
  • Intention to return to work;
  • Single parent status;
  • Poor relationship with a partner or the father of the baby;
  • Unintended pregnancy or a negative attitude toward the pregnancy;
  • Traumatic childbirth experience; 
  • Stress related to child care issues;
  • Medical illness, neonatal intensive care unit admission or prematurity in the infant;
  • Difficulties with breastfeeding;
  • A temperamentally difficult infant;
  • A recent stressful life event or perceived stress;
  • Smoking; or
  • A history of bothersome premenstrual syndrome.

Common signs and symptoms of postpartum depression include the following (some or none of these symptoms may exist):

  • Difficulty sleeping even when the baby is sleeping;
  • Poor appetite;
  • Tearfulness, prone to crying;
  • Excessive worrying about the baby;
  • Excessive anxiety;
  • Feelings of guilt, such as the feeling that she is not a good mother;
  • Flat affect;
  • Irritability;
  • Overwhelming fatigue;
  • Poor concentration;
  • Anger; or
  • Rage.

Screening for Postpartum Depression

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

Because postpartum depression can be a serious and sometimes life-threatening condition, all new mothers should have screening for postpartum depression at the 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 patients:

  • 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

To ensure that all patients are screened without undue interruption of clinic workflow, a convenient approach to screening is the following:

  • Give each postpartum woman a screening tool to complete while she waits for her visit with the provider.
  • Score the tool and assess whether the screen is positive or negative:
    • EPDS: A score of 10 or more suggests depressive symptoms; a score of 13 or more indicates a high likelihood of major depression; a score of one or more on Question 10 is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
    • PHQ-9: A score of 10 or more indicates a high risk of having or developing depression; a score of two or more on Question 9 is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
    • PDSS Full form: A score of 60 or more suggests depressive symptoms; a score of 81 or more indicates a high likelihood of major depression; a score of 6 or more on the SUI (suicidal thoughts) subscale is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
    • PDSS Short form: A score of 14 or more indicates a high risk of major depression; a score of two or more on Question 7 is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
  • The provider should review the screen, discuss it with the woman and ask follow-up questions to evaluate her risk of postpartum depression.

Postpartum Referral for Treatment

Individuals in need of treatment for postpartum depression must be referred to a provider of behavioral health services. Providers must have arrangements in place for appropriate referral of individuals to behavioral health providers in their area. For information on local behavioral health care providers, refer to the website of the Office of Mental Health Coordination, Texas Health and Human Services, Local Mental Health Authorities or Local Behavioral Health Authorities, or call 211.

Coding for Postpartum Depression Services

The following Current Procedural Terminology (CPT) codes are covered under the HHSC FPP: 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 90791 and 90792.

References and Resources

American College of Obstetricians and Gynecologists Committee Opinion No. 757. ACOG Clinical: Screening for Perinatal Depression. Available at https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression.

Hirst K.P. and Moutier C.Y. Postpartum major depression. American Family Physician (2010). 82: 926-933. Available at http://www.aafp.org/afp/2010/1015/p926.html.

Norhayati M.N., et al. Magnitude and risk factors for postpartum symptoms: A literature review. J. Affect Disord. (2015). 175: 34-52.

O’Connor E, et al. Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA (2016). 315: 388-406.

Resources for Patients and Providers

American Academy of Family Physicians. Postpartum Depression webpage, information for patients and providers on postpartum depression. Available at http://familydoctor.org/familydoctor/en/diseases-conditions/postpartum-depression.html.

American Academy of Family Physicians. Postpartum Depression Action Plan. Available at http://familydoctor.org/familydoctor/en/diseases-conditions/postpartum-depression/treatment/postpartum-depression-action-plan.html.

Office of Mental Health Coordination website, Texas Health and Human Services, provides links to information for providers and patients in Texas on a variety of behavioral health topics, and a link to the Substance Abuse and Mental Health Services Administration (SAMHSA) behavioral health treatment services locator. Available at http://mentalhealthtx.org/

Postpartum Depression: What is Postpartum Depression? Understanding, Support, Treatment, Resources. Available at https://www.postpartumdepression.org/ 

Texas Health and Human Services, the Texas Clinician’s Postpartum Depression Toolkit. Contains a review of the diagnosis and treatment of postpartum depression for the primary care provider, including a section on covered services, coding and billing for services provided under Texas state health care programs. Available at https://www.healthytexaswomen.org/provider-resources#family-planning-program.

5780 Suicide Risk Screening

Revision 22-2; Effective April 1, 2022

Individuals with a positive screen based on responses to questions related to suicide risk and individuals who express suicidal thoughts or ideation must be evaluated immediately for suicide risk. If the individual is felt to be acutely at risk of suicide, they must be referred for emergency evaluation and/or hospitalization, as indicated.

5800, Healthful Lifestyle Intervention

Revision 22-2; Effective April 1, 2022

All individuals should receive a health risk survey 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 individual’s current health needs and family planning goals and include information and guidance that is relevant and accessible to the individual.

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. 

The following resources may be helpful when counseling individuals on smoking and tobacco use, including smoking cessation:

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. 

The following resources may be helpful when counseling individuals on healthy eating patterns:

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. 

The following resources may be helpful when counseling individuals on physical activity and fitness:

5900, Perinatal Clinical Policy

Revision 22-2; Effective April 1, 2022

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

Contractors may bill HHSC 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.

Postpartum visits that are medically necessary are reimbursable and include interval history, physical examination, assessment, family planning, counseling, education and referral, as indicated.

Components of Initial Prenatal Interventions/Screening

Prenatal Visit – The first encounter with a pregnant woman includes a complete history, physical examination, assessment, planning, treatment, counseling and education (referral as indicated), routine prenatal laboratory tests and additional laboratory tests as indicated by history, physical exam and/or assessment.

Components of Return Visit Prenatal Interventions/Screening

Return Prenatal Visit – The follow-up prenatal visit includes interval history, physical examination, risk assessment, medical services, nutritional counseling, psychosocial counseling, family planning counseling and patient education about maternal and child health topics. Hemoglobin and/or hematocrit, and urinalysis for protein and glucose are also included.

Perinatal Histories

Prenatal Visit – The comprehensive medical history documented at the initial prenatal visit must
address the following:

  • Current health status, including acute and chronic medical conditions, if any;
  • Significant past illnesses, including hospitalizations;
  • Surgeries and biopsies;
  • Blood transfusions and other exposure to blood products;
  • Mental health history (for example, depression and anxiety);
  • Current medications, including prescription, over the counter (OTC), as well as complementary and alternative medicines (CAMs);
  • Allergies, sensitivities or reactions to medicines and other substances (for example, latex or seafood);
  • Immunization status and/or assessment, including rubella status;
  • Reproductive health history;
  • Pertinent sexual behavior history, including family planning practices (that is, past contraceptive use), number of partners and gender of sexual partners;
  • Sexually transmitted infections (STIs) [including hepatitis B and C], and HIV history, risks and exposure;
  • Pertinent partner history, including injectable drug use and number of partners;
  • Menstrual history, including last normal menstrual period;
  • Obstetrical history, detailed;
  • Gynecological and urological conditions;
  • Cervical cancer screening history (date and results of last Pap test or other cervical cancer screening test, and note any abnormal results and treatment); and
  • Social history and health risk assessment including:
    • Home environment, including living arrangements;
    • Family dynamics, with assessment for family violence (including safety assessment, when indicated) [Mandated by Texas Family Code, Chapter 261 and Rider 19];
    • Tobacco, alcohol and recreational drug use or misuse and/or exposure;
    • Drug dependency (including type, duration, frequency and route);
    • Nutritional history;
    • Occupational hazards or environmental toxin exposure;
    • Ability to perform activities of daily living (ADLs); and
    • Risk assessment including, but not limited to:
      • Diabetes;
      • Heart disease;
      • Intimate partner violence;
      • Other physical or sexual abuse;
      • Human trafficking;
      • Injury;
      • Malignancy; and
      • Injury;
  • Family history, including genetic conditions; and
  • Review of systems with pertinent positives and negatives documented in the health record.

Return Prenatal Visits – The interval history includes:

  • Symptoms of infections;
  • Symptoms of preterm labor;
  • Headaches or changes in vision;
  • Fetal movement (more than 18 weeks); and
  • Family violence screening (repeat more than 28 weeks). 

Physical Assessments

All first and routine prenatal visits must include an appropriate physical exam according to the purpose of the visit and the week of gestation. For any part of the examination that is deferred, the reason or reasons for deferral must be documented in the patient health record.

First Prenatal Visit – The following measurements are taken at the first prenatal visit:

  • Height;
  • Weight, with documentation of pre-pregnancy weight and assessment for underweight, overweight and obesity;
  • Body mass index (BMI);
  • Blood pressure evaluation;
  • Cardiovascular assessment;
  • Clinical breast exam;
  • Visual inspection of external genitalia and perianal area;
  • Pelvic exam, including estimate of uterine size (by bimanual exam for gestational age of 14 weeks or less or by fundal height for gestational age of 14 weeks or more);
  • Fetal heart rate for gestational age greater than 12 weeks; and
  • Other systems, as indicated by history and health risk assessment (for example, evaluation of thyroid, lungs and abdomen).

Return Prenatal Visits – The following measurements are taken at return prenatal visits:

  • Weight;
  • Blood pressure evaluation;
  • Uterine size or fundal height;
  • Fetal heart rate (more than 12 weeks);
  • Fetal lie/position (more than 30 weeks); and
  • Other systems, as indicated by history or other findings.

Laboratory and Diagnostic Tests

All first and return prenatal visits must include appropriate laboratory and diagnostic tests as indicated by the number of weeks of gestation and clinical assessment. Contractors must have written plans to address laboratory and other diagnostic test orders, results and follow-up. to include:

  • Tracking and documentation of tests ordered and performed for each patient;
  • Tracking of test results and documentation in patient records; and
  • A mechanism to address abnormal results, facilitate continuity of care and assure confidentiality, adhering to HIPAA regulations (that is, making results and interventions accessible to the delivering hospital, facility or provider).

First Prenatal Visit Laboratory and Diagnostic Tests – The following laboratory and diagnostic tests are done at the first prenatal visit:

  • Blood type, Rh and antibody screen; and
  • Sexually transmitted infection testing, as indicated by risk assessment, history and physical exam, and the following:
    • Chlamydia and gonorrhea testing should be done on all patients age 25 or younger and on older individuals who are at an increased risk of infection, even if symptoms are not present;
    • Hepatitis B Antigen (HbsAg) [Mandated by Health and Safety Code 81.090]; and
    • HIV, unless declined by the person, who must then be referred to anonymous testing [Mandated by Health and Safety Code 81.090]. CDC recommendations are found at https://www.cdc.gov/hiv/testing/index.html Syphilis serology [Mandated by Health and Safety Code 81.090];
  • Hemoglobin and/or hematocrit;
  • Rubella serology or positive immune status/immunization documented in the chart;
  • Cervical cancer screening test (for example, Pap test) for women age 21 and older, if indicated;
  • Hemoglobinopathy screening, as indicated;
  • Urine culture;
  • TB skin test, as indicated by risk assessment, history or physical exam (see TB in specific populations). CDC: Tuberculosis (TB): Pregnancy. Available at www.cdc.gov/tb/topic/populations/pregnancy/default.htm);  
  • Ultrasound, as clinically indicated; and
  • Other laboratory and diagnostic tests, as indicated by risk assessment, history and physical exam.

Return Prenatal Visits Laboratory and Diagnostic Tests – Recommended laboratory and diagnostic tests for return prenatal visits are as follows:

  • Fetal aneuploidy screening appropriate for the gestational age at the time of testing, along with proper counseling, offered to all patients;
  • Diabetes screen (24 through 28 weeks);
  • Glucose tolerance test (GTT) for abnormal diabetic screen;
  • Antibody screen for Rh negative individuals, not previously known to be sensitized, between 24 through 28 weeks (if negative, repeat Anti-D immune globulin at about 28 weeks and, if positive, refer to a specialist in high-risk obstetrics for evaluation of possible maternal Rh-D alloimmunization);
  • Hemoglobin and/or hematocrit (recommended recheck between 32 and 36 weeks);
  • Group B streptococcus screen, between 36 0/7 and 37 6/7 weeks if using screened-based approach [see The American College of Obstetricians and Gynecologists  revised February 2020 recommendations to prevent perinatal transmission of Group B Streptococcus (GBS) infection to the neonate at ACOG: Clinical: Prevention of Group B Streptococcal Early-Onset Disease in Newborns]. Available at https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/02/prevention-of-group-b-streptococcal-early-onset-disease-in-newborns
  • Ultrasound, as clinically indicated;
  • Non-stress test to assess fetal well-being, as clinically indicated;
  • Biophysical profile or fetal biophysical profile to assess fetal well-being, as clinically indicated; and
  • Other laboratory and diagnostic tests as indicated by risk assessment, history and physical exam. 

Ultrasounds – Obstetrical ultrasounds will be reimbursed when clinically indicated, including the
following:

  • Estimation of gestational age for women with uncertain clinical dates;
  • Verification of dates for women who had a previous cesarean delivery;
  • Vaginal bleeding of undetermined origin;
  • Suspected multiple gestation;
  • Significant discrepancy between actual uterine size and expected uterine size at specific clinical dates;
  • Pelvic mass;
  • Suspected ectopic pregnancy;
  • Suspected fetal death;
  • Suspected uterine abnormality;
  • Intrauterine contraceptive device localization;
  • Abnormal alpha-fetoprotein value;
  • Follow-up observation of identified fetal anomaly;
  • Follow-up evaluation of placental location for suspected placenta previa;
  • History of congenital anomaly;
  • Serial evaluation of fetal growth in multifetal gestation;
  • Evaluation of fetal condition in late registrants for prenatal care; and
  • Other conditions associated with possible adverse fetal outcome.

Complete Ultrasound – A complete evaluation of the pregnant uterus, to include fetal number, viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Complete Ultrasound for Confirmed Multiple Gestation – A complete evaluation of the pregnant uterus that includes viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Follow-up or Limited Ultrasound – A brief, more limited evaluation of the pregnant uterus that may follow a previous complete exam, which could be a first exam before 12 weeks or a first exam at 12 weeks which is limited in scope. It includes fetal number, viability, presentation, dating measurements, limited anatomic assessment, placental localization and characterization, and amniotic fluid assessment.

Repeat D Antibody Test – For all unsensitized D-negative women at 24 through 28 weeks of gestation, followed by the administration of a full dose of D immunoglobulin if they are antibody negative. If the father is known with certainty to be Rh D-negative, this may be deferred.

Special Procedures

Nonstress Test – Fetal well-being assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider believes the procedure to be medically necessary.

Biophysical Profile/Fetal Biophysical Profile – Fetal well-being assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider believes the procedure to be medically necessary.

Education and Counseling Services

Contractors must have written plans for individual education that ensure consistency and accuracy of information provided and that identify mechanisms used to ensure patient understanding of the information.

Education and counseling must be:

  • Documented in the patient health record;
  • Appropriate to the person’s age, level of knowledge and sociocultural background; and
  • Presented in an unbiased manner.

Education and counseling during the first prenatal visit, based on health history, risk assessment and physical exam, must cover the following:

  • Nutrition and weight-gain counseling;
  • Family and intimate partner violence and abuse;
  • Human trafficking;
  • Physical activity and exercise;
  • Sexual activity;
  • Environmental or work hazards;
  • Travel;
  • Tobacco cessation;
  • Alcohol use;
  • Substance abuse;
  • Breastfeeding;
  • When and where to obtain emergency care;
  • Risk factors identified during visit;
  • Anticipated course of prenatal care;
  • HIV and other prenatal tests;
  • Injury prevention, including seat belt use;
  • Cocooning infants and children against pertussis (immunization of family members and potential caregivers of infant);
  • Toxoplasmosis precautions;
  • Referral to Special Supplemental Nutrition Program for Women, Infants and Children (WIC);
  • Use of medications (including prescription, over the counter (OTC), and complementary and/or alternative medicines (CAMs);
  • Information on parenting and postpartum counseling (Mandated by Chapter 161, Health and Safety Code, Subchapter T); and
  • Other education and counseling as indicated by risk assessment, history and physical exam.

Education and counseling during the return prenatal visits should be appropriate to the number of gestational weeks and be based on health history, risk assessment and physical exam, including but not limited to:

  • Signs and symptoms of preterm labor beginning in second trimester;
  • Signs and symptoms of labor as the patient nears term gestation;
  • Warning signs and symptoms of pregnancy induced hypertension (PIH);
  • Selecting a provider for the infant; and
  • Postpartum family planning.

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 American Cancer Society Quitline is 877-YES-QUIT or 866-228-4327 (hearing impaired). 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, Information for Parents of Newborn Children, requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care to pregnant women during gestation or at delivery to provide 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, it must be documented in the person's chart that they received this information, and 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 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 age five. 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 child care.

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, shall provide the woman with an informational brochure before the third trimester of the woman’s pregnancy or as soon as reasonably feasible, that includes 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. The brochure is available at https://www.dshs.state.tx.us/mch/

Education and counseling during postpartum visits should include, but not be limited to:

  • Physiological changes;
  • Signs and symptoms of common complications;
  • Care of the breast;
  • Care of perineum and abdominal incision, if indicated;
  • Physical activity and exercise;
  • Breastfeeding and infant feeding;
  • Resumption of sexual activity;
  • Family planning and contraception;
  • Preconception counseling; and
  • Depression and postpartum depression.

Referral and Follow-up

Agencies must have written policies and procedures for follow-up on referrals that are made because of abnormal physical examination or laboratory test findings. These policies must be sensitive to patients’ concerns for confidentiality and privacy and must follow state or federal requirements for transfer of health information.

For necessary services that are beyond the scope of the agency, patients must be referred to other providers for care. Whenever possible, patients should be given a choice of providers from which to select. When a patient is referred to another provider or for emergency clinical care, the agency must:

  • Provide pertinent individual information to the referral provider and obtaining required patient consent with proper safeguards to ensure confidentiality (that is, adhering to HIPAA regulations);
  • Advise the individual about his or her responsibility to comply with the referral; and
  • Counsel the individual about the importance of the referral and follow-up plan.
     

6000, Program Promotion and Outreach

Revision 22-2; Effective April 1, 2022

Within 45 days from the start of each contract year, contractors must submit Form 1080, Health and Developmental Services (HDS) Promotion and Outreach Annual Plan. This plan should outline the contractor’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 should be based on an assessment of the needs of the community and contain an evaluation strategy. Contractors should consider a variety of program promotion and client 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 outreach activities, contractors must monitor and evaluate the planned activities and implementation and record these evaluations on Form 1060, Health and Developmental Services (HDS) Promotion and Outreach Quarterly Report. This report is due quarterly, within 15 days from the close of each quarter. 

  • Quarter 1 Report Due December 15 
  • Quarter 2 Report Due March 15 
  • Quarter 3 Report Due June 15 
  • Quarter 4 Report Due September 15 

Both the plan and quarterly reports should be submitted to FamPlan@hhs.texas.gov.

7000, Medicaid Provider Enrollment

Revision 22-2; Effective April 1, 2022

All HHSC FPP contractors must enroll as Medicaid (Title XIX) providers with Texas Medicaid & Health Care Partnership (TMHP). The contractor 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.

Family planning agencies do not have to enroll as a physician group, which includes an application for performing provider number. To enroll as a family planning agency, all that is needed is a supervisory practitioner. The supervisory practitioner may be a physician or nurse practitioner and may be the same person for all clinic sites. Changes in supervisory practitioner must be reported in writing to TMHP. An application must be submitted for the new supervisory practitioner.

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 22-2; Effective April 1, 2022

Family planning contractors may seek reimbursement for costs using one of the following two methods:

  • Contractors may submit monthly vouchers for expenses outlined in a categorical budget approved by HHSC, as required for categorical cost reimbursement; or
  • Contractors 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.

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

HHSC FPP Categorical Reimbursement

The categorical portion of the HHSC FPP funding is used to develop and support contractor infrastructure for the provision of family planning services. These funds may be used for support services that enhance HHSC FPP 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 that the contractor 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 contractor’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 percent of the HHSC FPP funds may be disbursed to contractors through a voucher system as expenses are incurred during the contract period. Program income must be expended before categorical funds are requested through the voucher process. Contractors must still submit vouchers monthly, even if program income equals or exceeds program expenses, or if the contract reimbursement limit has been met. When program expenses exceed program income, the monthly voucher will result in a payment. Program income includes all patient copays and donations. 

To request reimbursement for the categorical contract, 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.

HHSC FPP Categorical Budget Revisions

HHSC, at its sole discretion, may approve fund transfers between categories upon a contractor’s written request. That request must include a detailed explanation that supports the need for the fund transfer. The contractor must seek HHSC’s written approval before making any fund transfers. The approved budget for the state award summarizes the financial aspects of the program as approved during the state award process. It may include either the state and non-state share or only the state share, depending upon the state awarding agency’s requirements. It must be related to performance for program evaluation purposes, whenever appropriate. The local government is required to report deviations from budget or project scope or objective and request prior approval from the state awarding agency for budget and program plan revisions. For more information, visit the Texas Grant Management Guide. Contractors must submit a revised budget to HHSC for review any time a budget revision is made.

HHSC FPP Fee-for-Service Reimbursement

The fee-for-service component of the HHSC FPP funding pays for direct medical services on a fee-for-services basis. Up to 100 percent of HHSC FPP funds may be reimbursed on a fee-for-service basis. Each contracting agency is responsible for determining an individual’s eligibility for clinical services. HHSC FPP reimburses contractors on a fee-for-service basis for services and supplies that have been provided to eligible individuals. HHSC FPP contractors must continue to provide services to established individuals and to submit and appeal claims for individual services even after the contract funding limit has been met.

All contractors are required to submit claims for all HHSC FPP 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.

Effective May 1, 2017, HHSC FPP providers can submit claims electronically using a modified CMS-1500 electronic claim form.

HHSC FPP 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 contract period.
  • All claims must continue to be billed and denied claims appealed even after the contract funding limit has been met.

For answers to questions about claims and payment status, HHSC FPP contractors 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

Contractors must hold claims for HHSC FPP for 45 calendar days from the date of application for individuals who have pending applications for HTW. If an individual’s HTW eligibility has not been determined after 45 calendar days, the contractor may bill the service to: 

  • HHSC FPP, if the individual has a current HHSC FPP eligibility form on file; or
  • HTW Cost Reimbursement (if the contractor receives this funding as well). Additional guidance regarding anticipated eligibility for HTW and pending claims is available in the Healthy Texas Women Cost Reimbursement Manual.

The contractor can file for reimbursement through HHSC FPP or HTW Cost Reimbursement before the 45-day waiting period if a copy of the HTW program denial letter, or a reason for denial, has been provided by the client and is in the individual’s record before filing the claim. 

HHSC FPP Codes for Reimbursement

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

HHSC FPP contractors may submit claims for individuals’ 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 contractor’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 individual 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 individual to receive an injection of Medroxyprogesterone acetate (Depo-Provera/DMPA/depo) injection. Rather, contractors should bill the injection fee (96372) with the Depo-Provera contraceptive method (J1050).

Retroactive Eligibility

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

The contractor’s HHSC FPP R&S Reports reflect the retroactive Title XIX adjustment with EOB message “Recoupment is due to Title XIX retro eligibility.” Contractors 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.

Performing Provider Number and Retroactive Eligibility – HHSC family planning claims do not require a performing provider number for reimbursement. However, if a Title XIX retroactive eligibility claim does not have a performing provider number in a TPI format, TMHP will deny the services. A common EOB message for this specific denial is “EOB 00118: Service(s) require performing provider name/number for payment.” A request for reconsideration of claim reimbursement may be sent to TMHP through the appeal methods. Note: The performing provider number requirement applies to all Title XIX submissions.

Claims Submitted with Laboratory Services

If a Title XIX retroactive eligibility claim includes laboratory services and the HHSC FPP contractor 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. Contractors must arrange with their contracted laboratory to recoup any funds paid to the laboratory for lab services for HHSC FPP individuals 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 contract general provisions. All donations must be documented by source, amount and date they were received by the contractor. Contractors must have a written policy on the collection of donations. Individual donations collected by the contractor must be used to support the delivery of family planning services.

8000, Required Forms and Reports

Revision 22-2; Effective April 1, 2022

Required Form or Report (1): Monthly Voucher Packet

  • Description: Includes Form B-13X, Form 4116, Authorization for Expenditures, 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 contract 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 contracted providers 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 contract 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 amount 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 contract term. The final quarter report includes all final charges and expenses associated with the program contract. 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 contract 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 contract limit has been reached.
  • Note: Appeals must be submitted within 120 days of rejection during the contract term. All appeals must be submitted and finalized within 45 days after the end of the contract term.

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

  • Submission Date: No later than 60 days after the end of the contract 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 contractor has only a fee-for-service component without a cost reimbursement component. 

Required Form or Report (5): Form 1080, Health and Developmental Services (HDS) Promotion and Outreach Annual Plan

  • Description: This plan should outline the contractor’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. 
  • Submission Date: The report is due within 45 days of the start of the contract period.
  • Accepted Method of Submission: Email
  • Submit Copy to: famplan@hhs.texas.gov 
  • Original Signature Required: No
  • Number of copies: Not applicable
  • Instructions: Submit completed plan annually by due date outlined.

Required Form or Report (6): Form 1060, Health and Developmental Services (HDS) Promotion and Outreach Quarterly Report

  • Description: This report should include summary of the efficacy of program promotion and client outreach activities outlined in Form 1080, Health and Developmental Services (HDS) Promotion and Outreach Annual Plan.
  • Submission Date: The report is due within 15 days of the close of each quarter.
  • Accepted Method of Submission: Email
  • Submit Copy to: famplan@hhs.texas.gov 
  • Original Signature Required: No
  • Number of Copies: Not Applicable
  • Instructions: Submit completed reports quarterly by the due date outlined. 
     

Forms

ES = Spanish version available.

Form Title  
1060 Health and Developmental Services (HDS) Promotion and Outreach Quarterly Report  
1080 Health and Developmental Services (HDS) Promotion and Outreach Annual Plan  
4116 Authorization for Expenditures  

22-4, Section 9000 Revised

Revision 22-4; Effective May 10, 2022

The following changes(s) were made:

Revised Title Change
9000 Resources Updates the PSPS Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL).

22-3, Section 9000 Revised

Revision 22-3; Effective April 14, 2022

The following changes(s) were made:

Revised Title Change
9000 Resources Updates the Reimbursable Codes for the Texas Health and Human Services Commission Family Planning Program.

22-2, Entire Manual Revised

Revision 22-2; Effective April 1, 2022

The following changes(s) were made:

Revised Title Change
Entire manual Family Planning Program Policy Manual Updates information throughout the FPP manual and reorganizes the information to reduce the number of sections. The revised manual has Sections 1000 through 9000 instead of the previous manual’s sections numbering 1000 through 15000.

22-1, Changes to Sections 12121 and 14200

Revision 22-1; Effective January 1, 2022

The following changes(s) were made:

Revised Title Change
12121 Annual Comprehensive Family Planning Visit, Physical Examination and Testing Updates the information for the annual physical examination.
14200 Medical Provider Enrollment Clarifies contractors 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. Adds annual award determination and reallocation of funds will be based in part on those contractors that leveraged a higher percentage for direct services.