Revision 24-2; Effective Oct. 15, 2024
5710 Cervical Cancer Screening
Revision 24-2; Effective Oct. 15, 2024
General Considerations for Cervical Cancer Screening
Cervical cancer screening is primarily performed with the Pap test and the HPV DNA test. FPP uses United States Preventive Services Task Force (USPSTF) cervical cancer screening recommendations.
Clinical guidelines for cervical screening are:
- 21-29: Cervical cytology, Pap smear, alone every three years, with reflex HPV testing when cytology reveals atypical squamous cells of undetermined significance (ASCUS).
- 30-64: Cervical cytology, Pap smear, alone every three years, with reflex HPV testing for ASCUS or cervical cytology and HPV co-testing every five years, which is preferred.
- Younger than 21: Not eligible for cervical cancer screening.
Special circumstances may warrant alterations in screening intervals, as determined by a clinician. Special circumstances must always be documented in the client’s medical record. These may include:
- Clients considered high-risk such as HIV positive, immunosuppressed, exposed to diethylstilbestrol (DES) in utero or history of cervical cancer.
- Clients who had a hysterectomy for cervical intraepithelial neoplasia (CIN) disease. These clients may continue screening for 20 years.
- Clients who have had cervical cancer. These clients may be screened indefinitely if they are in good health.
- Applicants who have had a hysterectomy for benign disease and the cervix is still present. These people may be eligible for cervical cancer screening services. Funds can be used to pay for an initial examination to tell if the cervix is still present.
Components of Cervical Cancer Screening
The clinical components of cervical cancer screening are pelvic examination, Pap test, HPV test if indicated, clinical breast examination (CBE) if indicated, client education, tobacco assessment and Quitline referral if indicated. The grantee must document the CBE and cervical cancer screening components in the client’s medical record.
A cervical health history must be included as part of the cervical cancer screening. The health history includes the:
- Date and results of the last pelvic examination and Pap test
- Date and results of any past diagnostic procedures and treatments for cervical disease
- Date of last menstrual period and pregnancy history
- Medication history, including current or previous use of hormones such as hormone replacement therapy and oral contraceptives
- Risk factors for cervical cancer
- Description of present pelvic symptoms
Clinical components of cervical cancer screening must be performed by a physician, physician’s assistant, nurse practitioner, certified nurse midwife or a qualified registered nurse with specialized training as required under standing delegation orders (SDOs). The RN’s specialized training for cervical cancer screening must be documented in the personnel record, such as an educational certificate, a degree or continuing education credits.
Grantees must have policies and procedures to make sure health care providers follow evidence-based clinical guidelines and provide clinical services consistent with current nationally recognized standards of care.
HPV DNA testing is a reimbursable procedure when used for screening with Pap testing, which is co-testing, and for follow-up of abnormal Pap results per the American Society for Colposcopy and Cervical Pathology (ASCCP) algorithms. The following guidelines apply:
- For women 30 through 64 years old, the following screenings are recommended:
- co-testing, which is 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 per interim guidance provided by the ASCCP.
- It is reasonable to perform annual cervical cytology testing in women with in utero exposure to diethylstilbestrol.
- For any client with an abnormal result, more testing and follow-up should be dictated by findings, diagnosis and current evidence-based guidelines, such as that of the ASCCP.
Follow-Up for Abnormal Cervical Screening
When the results of the pelvic exam, cervical cancer screening Pap test, or both are abnormal, further diagnostic follow-up is required. A normal Pap test does not rule out cancer if a woman has a cervical lesion on pelvic examination. A colposcopy, cervical biopsy or both, are allowed if determined appropriate by the clinician after an abnormal pelvic exam.
Grantees must follow the ASCCP algorithms for the management of the specific type of abnormal result and in consideration of special populations such as pregnant women and clients 20 years and younger or at high risk.
5720 Breast Cancer Screening
Revision 24-2; Effective Oct. 15, 2024
The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for FPP, age 64 and younger, and do not include guideline recommendations for clients outside this range.
Risk Screening and Client Counseling
All women should undergo a risk assessment to find out if they are at high risk for breast cancer. Women considered high risk include those who have:
- a known genetic mutation such as BRCA 1 or 2;
- have first-degree relatives with premenopausal breast cancer or known genetic mutation;
- a history of radiation treatment to the chest area before age 30, typically for Hodgkin’s lymphoma;
- a lifetime risk of 20% or more for development of breast cancer based on risk assessment models that are largely dependent on family history; or
- Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.
Providers can choose the risk assessment method they prefer to determine if a woman is at high risk for breast cancer. Women at high risk for breast cancer should be screened with both an annual mammogram and an annual breast MRI.
All clients should be counseled on breast awareness and advised to be familiar with their breasts and to report any changes such as a mass, lump, thickening or nipple discharge promptly.
All clients should be counseled on the benefits and risks of mammography. If a client has the option of having a 3-D mammogram, she should be counseled on the benefits and risks of 3-D mammograms versus 2-D mammograms to make an informed decision.
Breast Cancer Screening Frequency
The USPSTF recommends biennial screening mammography for women 40 to 74 years old.
FPP recommends that grantees and providers counsel all eligible clients about the benefits, potential harms and limitations of screening, and discuss client risk factors to determine if screening is medically indicated.
Components of Breast Cancer Screening
The grantee must provide a complete breast cancer screening, which includes a mammogram, individualized client education, tobacco use assessment and Quit Line referral if indicated, and may include a clinical breast examination (CBE). The grantee must document the breast cancer screening components in the client’s medical record.
A breast health history must be included as part of the breast cancer screening. The health history includes:
- date and time intervals of previous mammograms
- results of previous mammograms
- date and results of the last CBE
- date and results of any previous breast surgery
- date of last menstrual period
- medication history, including current or previous use of hormones such as hormone replacement therapy and oral contraceptives
- other risk factors for breast cancer such as personal history of breast cancer or family history of first-degree relatives with breast cancer
- description of breast symptoms if any
Breast Cancer Screening Follow-up and Referral for Treatment
Clients with an abnormality found on screening or a specific breast complaint, including a mass, lump, thickening or nipple discharge, should be promptly evaluated as indicated. Providers should have procedures in place to make sure they offer:
- appropriate individual education and counseling,
- referral for further evaluation, including other testing and biopsy when indicated,
- communication and coordination with the client and other providers, and
- proper follow-up through the conclusion of the case.
For clients who require referral for services beyond those available through the grantee, grantees are encouraged to refer these clients to an HHSC Breast and Cervical Cancer Services (BCCS) grantee. Information is available at Texas Health and Human Services Breast and Cervical Cancer Services webpage and Texas Works Handbook, X-900, Medicaid Eligibility.
Eligible clients in need of treatment for biopsy-proven breast cancer may apply for coverage under the Medicaid for Breast and Cervical Cancer Program. More information is available in Section 3354 of the Breast and Cervical Cancer Services Policy Manual and in the Texas Works Handbook, X-900.
5730 Sexually Transmitted Disease and Infection Screening and Treatment
Revision 24-2; Effective Oct. 15, 2024
The summary of cited guideline recommendations in this section reflect the ages of eligibility for FPP, which is 64 years and younger, and do not address clients outside this range.
Screening and treatment of sexually transmitted diseases (STDs) and sexually transmitted infections (STIs) must follow the current guidelines for screening and treatment from the Centers for Disease Control and Prevention (CDC). A risk assessment should be completed for all clients to determine the testing indicated and documented in the medical record. Following is an overview of STD and STI screening recommendations. For detailed information, visit the CDC links above.
HIV Screening
- Grantees must provide HIV testing on-site or by referral.
- If HIV testing is done, verbal or written consent must be documented in the medical record. If the client refuses testing, the refusal must be documented. All clients 13 to 64 years old should be screened at least once for HIV per a policy that provides HIV education and allows clients to opt out of screening. With an opt-out screening, clients are informed, before testing, that HIV testing is done as part of the general consent for care and that they are free to decline testing. The test is performed if they do not decline.
- Clients who engage in high-risk sexual practices or share injection drug paraphernalia should be tested annually.
- Clients who seek testing or treatment of STDs and STIs should be tested for HIV at the same time.
- Grantees may provide negative HIV test results to clients in person, by phone or by the same method or manner as the results of other diagnostic or screening tests. The provision of negative test results by phone must follow procedures that address a client’s confidentiality, identification of the client and prevention counseling.
- Grantees must always provide positive HIV test results to clients in a face-to-face encounter with an immediate opportunity for counseling and referral to community support services. Test results must be provided by staff who are knowledgeable about HIV prevention and HIV testing.
- Clients whose risk assessment reveals high-risk behaviors should be provided directly, or referred for, more extensive risk reduction counseling by a Department of State Health Services (DSHS) HIV-STD program trained risk reduction specialist.
Clients with a diagnosis of HIV should be referred to a DSHS HIV-STD program grantee for treatment and monitoring. To find a DSHS HIV-STD program grantee, visit DSHS HIV-STD Program.
Chlamydia and Gonorrhea Screening
- Grantees must provide chlamydia and gonorrhea screening.
- Annual chlamydia and gonorrhea screening should be provided for all sexually active women younger than 25 years. If a pelvic examination is not performed, as in asymptomatic women younger than 21 and other women who decline a pelvic examination, screening can be performed with a nucleic acid amplification technique on a urine sample or a vaginal swab obtained by the client.
- Testing should be provided for all symptomatic women and asymptomatic women with increased risk at 25 years and older. Indications include:
- new or multiple sex partners;
- a partner who has another partner;
- exposure to an STD or STI;
- symptoms or signs of cervicitis or an STD or STI;
- history of pelvic inflammatory disease;
- a positive test for an STD or STI in the previous 12 months; and
- sex work or drug use.
- Treated clients should be retested three to four months after treatment to assess evidence of reinfection.
- All women who are pregnant or attempting pregnancy should be tested.
- Routine screening of males for chlamydia and gonorrhea should follow current CDC guidelines.
Herpes Simplex Virus (HSV) Screening
- Routine screening of asymptomatic clients for genital HSV infection is not recommended in the general or pregnant population.
- Testing, counseling, and treatment of symptomatic clients who have genital lesions, and management of affected pregnant clients should follow current CDC guidelines.
- The preferred tests to confirm the diagnosis in clients with active genital ulcers or mucocutaneous lesions are cell culture and polymerase chain reaction (PCR) assay.
- Type-specific serologic testing is appropriate in some circumstances:
- for clients presenting for evaluation of an STD, STI or both, especially those who report multiple sexual partners, and clients 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 client; or
- for counseling clients about the risk of infection by a partner with known infection, especially during pregnancy.
Syphilis Screening for Men and Non-pregnant Women
- Men and non-pregnant women who are at an increased risk of infection should undergo screening for syphilis.
- Men younger than 29, men who have sex with men, and men and women who are living with HIV have a higher risk for syphilis infection.
- Other factors associated with increased prevalence of syphilis infection include a history of incarceration or transactional sex work, geography and race or ethnicity.
- Routine screening for syphilis in a non-pregnant population that is not at increased risk of syphilis infection is not recommended as it may yield a high false-positive rate, leading to overtreatment.
- Screening should follow current CDC guidelines.
Other Screening and Pregnant Women
Screening for other infections and more frequent screening should be considered as appropriate based on the person’s condition, risk factors and concerns.
Pregnant Women
- All pregnant women should undergo screening for syphilis, HIV by an opt-out policy, and hepatitis B surface antigen as early as possible in the pregnancy.
- Clients younger than 25 and women at increased risk should also have chlamydia and gonorrhea testing.
Expedited Partner Therapy
Expedited Partner Therapy (EPT) is the clinical practice of treating the sex partners of clients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the client to take to their partner without the health care provider first examining the partner.
Texas Administrative Code, Title 22, Section 190.8(1)(L)(ii) allows the use of EPT for STI treatment. Clinic sites that implement EPT should develop necessary policies, procedures and standing delegation orders (SDOs) to reflect the CDC guidelines. Visit the DSHS HIV/STD website for more information on EPT implementation.
Reference
American College of Obstetricians and Gynecologists Clinical Information
5740 Diabetes Mellitus Screening
Revision 24-2; Effective Jan. 29, 2025
Grantees must evaluate all clients for risk factors for diabetes annually and provide screening lab work as appropriate. Grantees must have a process and policy in place for the diagnosis and treatment of clients with uncomplicated diabetes.
While treatment protocols for diabetes are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as the:
Providers must have a policy and process in place to refer clients with complex needs that are not covered services under FPP.
5750 Hypertension Screening
Revision 25-1; Effective Jan. 29, 2025
Grantees must screen all clients for hypertension annually. Grantees must have a process and policy in place for the diagnosis and treatment for clients diagnosed with uncomplicated hypertension.
While treatment protocols for hypertension are beyond the scope of this manual, providers can seek information from trusted sources such as the:
Providers must have a policy and process in place to refer clients with complex needs that are not covered services under FPP.
5760 High Cholesterol Screening
Revision 25-1; Effective Jan. 29, 2025
Grantees must screen all clients for high cholesterol annually. Grantees must have a process and policy in place for the diagnosis and treatment for clients diagnosed with high cholesterol.
While treatment protocols for high cholesterol are beyond the scope of this manual, providers can seek information from trusted sources such as the:
Providers must have a policy and process in place to refer clients with complex needs that are not covered services under FPP.
5770 Postpartum Depression Screening
Revision 25-1; Effective Jan. 29, 2025
Postpartum depression screening must be performed if a client was pregnant in the past year.
Providers can review The Texas Clinician’s Postpartum Depression Toolkit for a detailed review of screening for postpartum depression.
Postpartum depression can be a serious and sometimes life-threatening condition. All new mothers should be screened for postpartum depression at their initial postpartum visit. For those who screen negative, screening should be repeated at a later visit.
A standardized self-administered screening tool with review and follow-up questions in a face-to-face interview with the provider will ensure consistency and efficiency in the screening process. The following postpartum depression screening tools are available online and have been validated for use in postpartum clients:
- Edinburgh Postnatal Depression Scale (EPDS); Cox, Holden and Sagovsky, 1987
- Patient Health Questionnaire-9 (PHQ-9); Spitzer, Kroenke and Williams, 1999
- Postpartum Depression Screening Scale (PDSS); Tatano Beck and Gable, 2002
Postpartum Referral for Treatment
FPP covers screening and initial treatment for postpartum depression diagnosis.
While treatment protocols for postpartum depression are beyond the scope of this manual, providers can seek information from trusted sources such as the:
Providers must have a policy and process in place for the referral of clients with complex needs that are not covered services under FPP.
The Perinatal Psychiatry Access Network (PeriPAN), can enhance provider capacity to provide the perinatal mental health standard of care FPP clients need. There is no cost to FPP providers or clients for this evidence-based, clinician-to-clinician program. Texas PeriPAN offers real-time access to a multidisciplinary network of mental health experts, including reproductive psychiatrists for peer-to-peer consults by phone and vetted and personalized referrals and resources. Contact information and details on how to access this resource are on the PeriPAN website.
For severe and persistent behavioral health issues, consult with Local Mental Health Authorities or Local Behavioral Health Authorities or call 211.
Clinicians are recommended to use their preferred screening tool for Suicide Risk Assessment for clients served.
5780, Suicide Screening
Revision 24-2; Effective Oct. 15, 2024
Suicide Prevention Signage
Grantees are encouraged to display signage related to suicide prevention, including the 988 Suicide and Crisis Lifeline. If a grantee elects to display such signage, it must be displayed in areas where clients and the public can easily see them, such as lobbies, waiting rooms, front reception desks, and locations where people apply for and receive services.
Examples of a suitable flyers are available on the Substance Abuse and Mental Health Services Administration (SAMHSA) webpages:
More mental health and suicide prevention resources are at the: