5000, Clinical Guidelines

Revision 24-2; Effective Oct. 15, 2024

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

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

  • Contraceptive services such as pregnancy prevention and birth spacing, including:
    • long-acting reversible contraceptives (LARCs)
    • oral contraceptive pills
    • three-month medroxyprogesterone injections
    • sterilizations
  • Pregnancy testing and counseling
  • Preconception health screenings for:
    • nutrition and obesity
    • hypertension
    • diabetes
    • cholesterol
    • smoking
    • substance use
    • other high-risk behaviors
    • social issues, non-medical drivers of health
    • mental health
  • Sexually transmitted infection (STI) services, as follows:
    • syphilis, chlamydia and gonorrhea screening and treatment
    • HIV screening
  • Limited pharmacological treatment for the following chronic conditions:
    • hypertension
    • diabetes
    • high cholesterol
    • postpartum depression
  • Breast and cervical cancer screenings and diagnostic services, as follows:
    • radiological procedures including mammograms
    • screening and diagnosis of breast cancer
    • diagnosis and treatment of cervical dysplasia
  • Immunizations
  • Health behavior intervention, including:
    • screening, brief intervention and referral for treatment
    • smoking cessation services
    • medication-assisted treatment
  • Cardiovascular and coronary condition management, including:
    • cardiovascular evaluation imaging and laboratory
    • blood pressure monitoring equipment
    • antihypertensive medications
  • Diabetes management, including:
    • laboratory studies
    • additional injectable insulin options
    • blood glucose testing supplies

5100, Minors, Consent and Confidentiality

Revision 23-4; Effective Nov. 17, 2023

For specific guidance on the treatment of minors within the program, grantees must follow the Responsibilities for Treatment of Minors within the Family Planning Program and Healthy Texas Women Program.
 

5200, General Consent

Revision 24-2; Effective Oct. 15, 2024

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

Consent information must be communicated to every person in a manner that is easy to understand. This communication must allow the person to participate, make sound decisions about their own medical care and address disabilities that impair communication in compliance with Limited English Proficiency regulations. Only the person receiving services may give consent. For situations when the person is legally unable to consent, a parent, in the 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.

The grantee also must obtain the informed consent of the person receiving services for procedures as required by the Texas Medical Disclosure Panel. Refer to Section 5210.

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

5210 Texas Medical Disclosure Panel Consent

Revision 24-2; Effective Oct. 15, 2024

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

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

TMDP developed List A, informed consent requiring full and specific disclosure, for certain procedures, which is in the Texas Administrative Code (TAC) Title 25, Part 7, Chapter 602, Section 602.1.

Grantees that directly perform tubal sterilization, vasectomy or both, which are 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 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, which are risks that exist in and are inseparable from the procedure itself, and that are material and could influence a reasonable person to decide to consent to the procedure.

More details on sterilization procedures, consent and reimbursement are in Section 5620.

5220 Consent for HIV Tests

Revision 24-2; Effective Oct. 15, 2024

Grantees must follow the Texas Health and Safety Code:

5300, Pharmacy

Revision 24-2; Effective Oct. 15, 2024

To facilitate immediate client access to, and compliance with, contraceptive methods, related medications and drugs for treatment of chronic diseases specified in section 5000, grantees must be capable of providing pharmaceutical services to family planning clients at each clinic site funded by HHSC.

Grantees are required to have at least a Class D pharmacy on-site with an expanded drug formulary to include chronic disease management at each HHSC family planning clinic site, have applied for a Class D pharmacy license with expanded drug formulary through the Texas Pharmacy Licensing Board, or have obtained approval for a Class D pharmacy exemption from HHSC.

To petition the Texas State Board of Pharmacy to expand formulary, reference Texas Administrative Code (TAC) Title 22, Part 15, Chapter 291, Subchapter E, Section 291.93 (e)(D).

Grantees who have a Class A or Class C on-site pharmacy are not required to have a pharmacy exemption. However, grantees are required to notify HHSC of their on-site pharmacy type via email at famplan@hhs.texas.gov.

It is the grantee’s responsibility to make sure all contraceptive methods and related medications approved for reimbursement by HHSC are made available .

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

Class D Pharmacy Exemption

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

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

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

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

  • A signed and fully executed memorandum of understanding (MOU) with referral pharmacy or pharmacies which includes the purpose of cooperation and details coordination between the grantees and the referral pharmacy or pharmacies to provide the following medications:
    • non-clinician administered hormonal contraceptive methods such as:
      • oral contraceptives,
      • transdermal hormonal patch contraceptives, and
      • vaginal hormonal ring contraceptives.
    • medications for treatment of:
      • uncomplicated diabetes,
      • elevated cholesterol,
      • uncomplicated hypertension, and
      • postpartum depression.
    • other medications necessary to treat the health care needs of the family planning client population.
  • The agreement made with a 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 grantee has a written policy that ensures clients can obtain prescribed medication refills from the cooperating pharmacy or pharmacies without an additional clinic visit unless post-medically indicated or necessary.

HHSC staff will review an exemption request. Depending on the justification and circumstances specific to each clinic site, HHSC staff may or may not grant the request. HHSC staff reserves the right to approve or deny an exemption request based on the merit of the justification.

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

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

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

5400, Client Health Records and Documentation of Encounters

Revision 24-2; Effective Oct. 15, 2024

Requirement for Documentation of Reproductive Health Services

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

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

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

Individual Health Records and Documentation of Encounters

Providers must make sure a client health record, the medical record, is created for every person who obtains clinical services. See Section 3700, Client Records Management.

All client health records must be:

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

The client health record must include:

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

5500, Covered Services

Revision 24-2; Effective Oct. 15, 2024

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

The following services are covered:

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

Grantees may request more services be added to the program by emailing the program mailbox at famplan@hhs.texas.gov and requesting a Topic Nomination Form.   

5510 Initial Clinical Visit

Revision 24-2; Effective Oct. 15, 2024

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

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

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

Annual Comprehensive Family Planning Visit, Physical Examination and Testing

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

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

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

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

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

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

Recommended components for examinations for females:

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

Recommended components for examinations for males:

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

Recommended components for examinations for all clients regardless of sex:

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

Counseling and Education

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

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

  • Counseling of minors, including:
    • all medically approved methods of contraception, including abstinence;
    • prevention of STDs, STIs and HIV;
    • recognition and avoidance of sexual coercion; and
    • domestic, partner, dating and family violence, offering help as needed.
  • Minors must be provided individualized family planning counseling and family planning medical services that meet their specific needs.
  • Counseling and clinical services to minors must be expedited so appointments are made available as soon as possible.
  • Appointment schedules are flexible enough to accommodate access for minors who request services.
  • Grantees must obtain parental consent before they provide counseling for minors who seek family planning services.
  • Minors must be assured their privacy and confidentiality will be protected within the parameters of applicable law, including the Health Insurance Portability and Accountability Act (HIPAA), Texas Family Code, Chapter 32, and 5100, Minors, Consent and Confidentiality.

5520 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 24-2; Effective Oct. 15, 2024

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

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

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

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

5530 Visits About a Particular Medical Concern, Problem Visits

Revision 24-2; Effective Oct. 15, 2024

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, and an assessment and prescribed treatment.

5540 Referrals

Revision 24-2; Effective Oct. 15, 2024

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

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

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

5550 Telemedicine

Revision 24-2; Effective Oct. 15, 2024

Providers may offer services by telemedicine if appropriate.

Providers who offer telemedicine services must follow all rules of the Texas Occupations Code 111.001 and must have written policies and procedures for doing so that include:

  • informed consent;
  • appropriate, quality care;
  • prevention of abuse and fraud in the use of telemedicine services;
  • adequate supervision of health professionals who are not physicians and who provide telemedicine care; and
  • establish the maximum number of health professionals a physician may supervise through telemedicine services.

5560 Prescriptive Authority Agreements

Revision 24-2; Effective Oct. 15, 2024

When services are provided by an advanced practice registered nurse (APRN) or physician assistant (PA), it is the responsibility of the grantee to make sure a properly executed prescriptive authority agreement (PAA) is in place for each mid-level provider. The PAA must meet all the requirements delineated in Texas Occupations Code, Chapter 157, including the following criteria:

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

References

5570 Standing Delegation Orders

Revision 24-2; Effective Oct. 15, 2024

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

The grantee must have SDOs in place for unlicensed and licensed personnel other than APRNs or PAs that include the following:

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

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

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

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

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

References

5600, Family Planning and Contraceptive Services

Revision 24-2; Effective Oct. 15, 2024

Reproductive Life Plan

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

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

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

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

Contraceptive Counseling and Education

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

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

Specific Method Access Requirements for Grantees

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

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

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

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

Contraceptive Methods that May Be Provided by Referral

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

Non-Covered Services

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

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

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

Grantees must implement adequate controls to make sure claims submitted for FPP services do not seek reimbursement for any benefit not covered by the program.

Distinguishing Federal Title X Family Planning Program Funds

The Title X Family Planning Program is a funding program established by Congress in 1970 to provide comprehensive family planning and related preventative services to low income and uninsured people. This program is administered by the Office of Population of Affairs (OPA) under the U.S. Department of Health and Human Services.

The Title X Family Planning Program is federally funded and operates nationwide. FPP is a state-specific initiative designed to provide similar services but within the framework and regulations set by the State of Texas.

HHSC recognizes grantees may be recipients of funds from both Title X and FPP. As allowable services differ between the programs, grantees are strongly encouraged to use the following language in their clinical operations policy to make sure a clear delineation of service delivery, claims and billing covered by FPP:

Clients may be dual eligible for both the HHSC FPP and Federal Title X programs. Allowable billing codes that are approved through HHSC FPP must match the services rendered. Upon request, an FPP grantee must provide HHSC with all information HHSC requires to determine the provider's compliance with this section.

References and Resources

American College of Obstetricians and Gynecologists Clinical Information

5610 Preconception Services

Revision 24-2; Effective Oct. 15, 2024

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

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

References and Resources

American College of Obstetricians and Gynecologists Clinical Information

5620 Sterilization Procedures, Consent, Billing and Reporting

Revision 24-2; Effective Oct. 15, 2024

Conditions for Sterilization Procedures

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

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

Date of Sterilization

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

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

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

Consent for Sterilization Required Forms

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

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

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

The consent form must be signed and dated by the:

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

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

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

Sterilization Billing and Reporting

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

Complications and Reimbursement

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

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

References

American College of Obstetricians and Gynecologists Clinical Information

Texas Administrative Code Title 25, Part 7, Chapter 601, Section 601.4 

5700, Screenings

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 Oct. 15, 2024

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 24-2; Effective Oct. 15, 2024

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

While treatment protocols for hypertension are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as the:

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 24-2; Effective Oct. 15, 2024

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

While treatment protocols for high cholesterol are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as the:

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 24-2; Effective Oct. 15, 2024

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

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

As 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 are encouraged to 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.

It is recommended that clinicians 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: 

5800, Healthful Lifestyle Intervention

Revision 24-2; Effective Oct. 15, 2024

All clients should receive a risk assessment at least annually to find 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 toward the client’s current health needs and family planning goals. Counseling should include relevant information and guidance accessible to the client.

Smoking and Tobacco Use

Based on the needs of each client, they should be advised on the impact of smoking, the use of tobacco products and to avoid exposure to second-hand smoke.

Healthy Eating Patterns

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

Physical Activity and Fitness

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

5900, Perinatal Clinical Policy

Revision 24-2; Effective Oct. 15, 2024

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

Grantees may bill FPP for allowable services provided in clinical prenatal care visits for women during the Medicaid for Pregnant Women and the CHIP Perinatal Program enrollment processes. Medically necessary postpartum visits are reimbursable and include interval history, physical examination, assessment, family planning, counseling, education and referral as indicated.

Diagnostic Testing During Pregnancy

Grantees must follow Texas Health and Safety Code, Chapter 81, Subchapter A, Sec. 81.090:

All pregnant women should be tested for the following STIs as early as possible in the pregnancy:

  • syphilis,
  • HIV infection, and
  • hepatitis B infection.

The record of the tests should be retained in the client’s chart.

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

Information for Parents of Newborns Requirement

Chapter 161, Health and Safety Code, Subchapter T requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care to pregnant women during gestation or at delivery to give the woman and the infant’s father 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.

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

Information for Parents of Newborn:

Information for Parents of Children

Chapter 161, Health and Safety Code, Subchapter T also requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care during gestation or at delivery to pregnant women on Medicaid to provide the woman and the infant’s father or other adult caregiver for the infant with a resource guide that includes information about the development, health and safety of a child from birth until 5 years old. The resource guide must provide information about medical home, dental care, effective parenting, child safety, importance of reading to a child, expected developmental milestones, health care and other resources available in the state, and selecting appropriate childcare.

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

Provision of Information about Umbilical Cord Blood Donation Requirement

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

Referral and Follow-up

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

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

  • provide pertinent client information to the referral provider and obtain required client consent with proper safeguards to ensure confidentiality by adhering to HIPAA regulations;
  • advise the client about their responsibility to comply with the referral; and
  • counsel the client about the importance of the referral and follow-up plan.