Primary Health Care Program Policy Manual

1200, Purpose of the Manual

Revision 23-2; Effective Sept. 15, 2023

The Texas Health and Human Services Commission (HHSC) Primary Health Care Program Policy Manual is a guide for grantees who deliver primary health care services in Texas. The policy manual is structured to provide grantee staff with information needed to comply with program legislation and rules.

Federal and state laws related to reporting abuse, operation of health facilities, professional practice, insurance coverage and similar topics also impact primary health care services. Grantees are required to be aware of, and comply with, existing laws.

2100, Program Authorization and Services

Revision 23-2; Effective Sept. 15, 2023

Primary Health Care Services Program Background

In the early 1980s, economic recession and cost containment measures on the part of employers and government agencies led to a decrease in the availability and accessibility of health care services for many Texans. A legislative task force identified the provision of primary health care to the medically indigent as a major priority. The task force recommended the following:

  • A range of primary health care services shall be made available to the medically indigent residing in Texas.
  • The Texas Health and Human Services Commission (HHSC) shall provide or contract to provide primary health care services to the medically indigent.
  • These services should complement existing services or should be provided where there is a scarcity of services.
  • Health education should be an integral component of all primary care services delivered to the medically indigent population.
  • Preventive services should be marketed and made accessible to reduce the use of more expensive emergency room services.

Statute

These recommendations become the basis of the indigent health care legislative package enacted by the 69th Texas Legislature in 1985. The Primary Health Care Services Act, House Bill 1844, was part of this legislation and is the statutory authority for Primary Health Care (PHC) Services Program administered by HHSC. The Act delineates the specific target population, eligibility, reporting and coordination requirements for PHC.

Rules

The state rules for PHC services in Texas can be found in the Texas Administrative Code (TAC), Title 26, Part 1, Chapter 364, Subchapter A. PHC program rules require that, at a minimum, a grantee must provide the following six priority PHC services:

  1. Diagnosis and treatment
  2. Emergency medical services
  3. Family planning services
  4. Preventive health services
  5. Health education
  6. Laboratory, x-ray, nuclear medicine or other appropriate diagnostic services

PHC provides services through contracted providers (grantees) for individuals who are at or below 200% of the Federal Poverty Level (FPL) and are unable to access the same care through other funding sources or programs. Grantees must assure that services provided to clients are accessible in terms of cost, scheduling and distance, and are provided in a way that is sensitive to the individual’s culture.

Funding Sources

PHC program services are funded by state general revenue. HHSC PHC funds are allocated through a competitive application process, after which selected applicants negotiate contracts with HHSC to provide services. A variety of types of organizations provide PHC program services, such as local health departments, medical schools, hospitals, private nonprofit agencies, community-based clinics, federally qualified health centers (FQHCs) and rural health clinics. Providers must enroll with the Texas Medicaid & Healthcare Partnership (TMHP) to provide the HHSC PHC program services. State and federal law prohibits the use of contracted funds awarded by HHSC to pay the direct or indirect costs (including overhead, rent, phones and utilities) of abortion procedures.

2200, Definitions

Revision 23-2; Effective Sept. 15, 2023

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

Barrier to Care – A factor that hinders a person from receiving care (i.e., proximity or distance, lack of transportation, documentation requirements, copayment amount, etc.).

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

Confidentiality – The state of keeping information private and not sharing it without permission.

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

Consultation – A type of service provided by a health care provider with expertise in a medical or surgical specialty and who, upon request of another appropriate health care provider, assists with the evaluation or management of a patient.

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

Dental Services – Diagnostic, preventive, and therapeutic dental services that are provided to eligible individuals and are performed in a dental office or clinic. In the context of the Primary Health Care program, dental services are optional and are not included in the six required priority health services. 

Department of State Health Services (DSHS) – The agency responsible for administering physical and mental health-related prevention, treatment and regulatory programs for the state of Texas. 

Dependent Care Deduction – The expense of providing care for a dependent. This expense must be both necessary for employment and incurred by an employed person. Allowable deductions are actual expenses, up to $200 per month for each child under age 2 and $175 per month for each child age 2 or older.  

Diagnosis – The recognition of disease status determined by evaluating the history of the client and the disease process, and the signs and symptoms present. Determining the diagnosis may require some or all the following:  Microscopic (culture), Chemical (blood tests), Radiological examinations (X-rays).

Diagnosis and Treatment – This includes common acute and chronic disease that affect the general health of the client. Services include the first contact with a client for an undiagnosed health concern, as well as continuing care of varied medical conditions not limited by cause or organ system. Services must not be limited to only one service (i.e., family planning, breast and cervical cancer screening or podiatry).

Diagnostic Services – Activities related to the diagnosis made by a physician or other health professional.

Diagnostic Studies or Diagnostic Tests – Tests ordered by a health care practitioner to evaluate a client's health status for diagnostic purposes.

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

Emergency Services – Urgent care services provided for an unexpected health condition requiring immediate attention. Clinical emergency situations include conditions such as anaphylaxis, syncope, cardiac arrest, shock, hemorrhage, and respiratory difficulties and in response to environmental emergencies (including natural and man-made disaster situations).

Family Composition, Household – A person living alone or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and who are legally responsible for the support of the other person.

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

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

Fiscal Year – The state fiscal year is from Sept. 1 through Aug. 31. The federal fiscal year is from Oct. 1 through Sept. 30.

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

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

Health Education – The process of educating or teaching individuals about lifestyles and daily activities that promote physical, mental and social well-being. This process may be provided to an individual or to a group of individuals.

Health Screening – The provision of tests (e.g., blood glucose, serum cholesterol and fecal occult blood) as a means of determining the need for intervention and perhaps a more comprehensive evaluation.

Laboratory (informally, Lab) – A facility that measures or examines materials derived from the human body to provide information on diagnosis, monitoring prevention or treatment of disease.

Laboratory, X-ray or other Appropriate Diagnostic Services – Studies or tests ordered by the client’s health care practitioner(s) (e.g., physicians, dentists and mid-level providers) to evaluate an individual’s health status for diagnostic purposes.

Managing Conservator – A person designated by a court to have daily legal responsibility for a child.

Medicaid – The Texas Medical Assistance Program, a joint federal and state program provided in Texas Human Resources Code Chapter 32 subject to Title XIX of the Social Security Act, 42 U.S.C. Section 1396, et seq. Reimburses for health care services delivered to low-income clients who meet eligibility guidelines.

Minor – In accordance with the Texas Family Code, a person under 18 years old who is not and has not been married or who has not had the disabilities of minority removed for general purposes (i.e., emancipated). In this policy manual, “minor” and “child” may be used interchangeably.

Patient – An individual who is eligible to receive medical care, treatment or services. “Client” and “patient” may be used interchangeably in this policy manual.

Payor Source – Programs, benefits or insurance that pays for the service provided.

Preventive Health Care – Services include, but are not limited to the following: immunizations, risk assessments, health histories and baseline physicals for early detection of disease and restoration to a previous state of health, and prevention of further deterioration or disability. 

Program Income – Money collected directly by the grantee, subgrantee or provider for services provided under the grant award (i.e., third-party reimbursements, such as Title XIX, private insurance and patient copay fees). Program income also includes client donations.

Provider – An individual clinician or group of clinicians who provide services.

Recertification – The process of rescreening and determining eligibility for the next year.

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

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

Telehealth Service – A health service, other than a telemedicine medical service, delivered by a health professional licensed, certified or otherwise entitled to practice in this state and acting within the scope of the health professional’s license, certification or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.

Telemedicine Medical Service – A health care service delivered to a patient at a different physical location than the physician or health professional using telecommunications or information technology by a physician licensed in this state, or a health professional acting under the delegation and supervision of a physician licensed in this state and acting within the scope of the physician’s or health professional’s license.

Texas Resident – An individual who resides within the geographic boundaries of the state of Texas.

Treatment – Any specific procedure used for the cure, or the improvement, of a disease or pathological condition.

Unduplicated Client – An individual counted only one time during the program’s fiscal year, regardless of the number of visits, encounters or services they receive (e.g., one client seen four times during the year is counted as one unduplicated client).

3000, Administrative Policy

Revision 23-2; Effective Sept. 15, 2023

This section helps the grantee conduct administrative activities, such as assuring client access to services and managing client records.

3100, Administrative Policies

Revision 22-4; Effective Sept. 16, 2022

Maintaining Clinic Information on 2-1-1   
Grantees must maintain current and correct clinic information on 211Texas.org for all locations providing services. Grantees will use the Add or Edit Your 2-1-1 Listing link found at the top of the webpage to make any changes to their clinic location information listings. The information that grantees shall maintain in their 2-1-1 listings includes, but is not limited to, clinic phone number, location, hours of operation and services provided.

 

3110 Client Access

Revision 23-2; Effective Sept. 15, 2023

Grantees must observe all Texas Health and Human Services (HHS) policies and federal and state civil rights laws and treat clients and the public with dignity and respect. The grantee must ensure that clients are provided services in a timely and non-discriminatory manner. The grantee must:

  • have a policy in place that delineates the timely provision of services;
  • have policies in place to identify and eliminate possible barriers to client care;
  • comply with all applicable civil rights laws and regulations including Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act (ADA) of 1990, the Age Discrimination Act of 1975, Section 504 of the Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, and ensure services are accessible to persons with Limited English Proficiency (LEP) and speech or sensory impairments;
  • have a policy in place that requires qualified staff to assess and prioritize client needs;
  • provide referral resources for individuals who cannot be served or cannot receive a specific needed service;
  • manage funds to ensure that established clients continue to receive services throughout the budget year, even after allocated funds are expended;
  • ensure that services are provided to clients in a timely manner, preferably within 30 days of the request for services. Clients who request contraception but cannot be immediately provided a clinical appointment must be offered a nonprescription method;
  • ensure clinic or reception room wait times are reasonable and do not present a barrier to care; and
  • display appropriate exterior signage that identifies the entity as a healthcare facility.

3120 Important Information for Former Military Service Members

Revision 23-2; Effective Sept. 15, 2023

Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves or National Guard, may be eligible for additional benefits and services. For more information, visit the Texas Veterans Portal.

3200, Abuse and Neglect Reporting

Revision 23-2; Effective Sept. 15, 2023

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

To report abuse or neglect, call the Texas Abuse Hotline at 800-252-5400 or use the secure Texas Abuse Hotline website. For cases that pose an imminent threat or danger to an individual, call 9-1-1 or any local or state law enforcement agency. 
 

3210 Child Abuse Reporting, Compliance and Monitoring

Revision 23-2; Effective Sept. 15, 2023

Grantees are required to develop policies and procedures that comply with the child abuse reporting guidelines and requirements set forth in Chapter 261 of the Texas Family Code.

Grantees must develop an internal policy specific to:

  • determining, documenting, reporting, and tracking instances of abuse, sexual or non-sexual, for all individuals age 17 and younger  in compliance with Texas Family Code, Chapter 261; and
  • annual staff training requirement, including how staff will be trained.

Additional information for abuse reporting is available at Texas Department of Family and Protective Services.

3220 Human Trafficking

Revision 23-2; Effective Sept. 15, 2023

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

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

References for human trafficking policy development:

3230 Domestic and Intimate Partner Violence

Revision 23-2; Effective Sept. 15, 2023

Intimate partner violence (IPV) describes physical, sexual or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy. 
Grantees must have a written policy related to assessment and prevention of domestic and intimate partner violence, including the provision of annual staff training.

Additional information on intimate partner violence can be found on the CDC website
 

3300, Confidentiality

Revision 23-2; Effective Sept. 15, 2023

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

Grantees must ensure that all employees and volunteers receive training about client confidentiality during orientation and be made aware that violation of the law regarding confidentiality may result in civil damages and criminal penalties. All employees, volunteers, subgrantees, board members and advisory board members must sign a confidentiality statement during orientation.

The client’s preferred method of follow-up to clinic services (cell phone, email, work phone or text) and preferred language must be documented in the client’s record.

Each client must receive verbal assurance of confidentiality and an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as abuse reporting.

3310 Minors and Confidentiality

Revision 23-2; Effective Sept. 15, 2023

Except as permitted by law, a provider is legally required to maintain the confidentiality of care provided to a minor. Confidential care does not apply when the law requires parental notification or consent, or when the law requires the provider to report health information such as in the cases of contagious disease or abuse. The definition of privacy is the ability of the individual to maintain information in a protected way. Confidentiality in health care is the obligation of the health care provider not to disclose protected information. While confidentiality is implicit in maintaining a patient's privacy, confidentiality between provider and patient is not an absolute right.

The HIPAA privacy rule requires a covered entity to treat a “personal representative” the same as the individual with respect to use and disclosure of the individual’s protected health information. In most cases, parents are the personal representatives for their minor children, and they can exercise individual rights, such as access to medical records, on behalf of their minor children (45 Code of Federal Regulations Section 164.502(g)).

For more information, see Adolescent Health – A Guide for Providers.

3320 Nondiscrimination and Limited English Proficiency (LEP)

Revision 23-2; Effective Sept 15, 2023

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

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

Grantees that provide direct services to clients must display certain HHS posters related to civil rights. The posters should 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 HHS services. The following posters are required: 

3330 Termination of Services

Revision 23-2; Effective Sept. 15, 2023

Never deny a qualifying person services due to an inability to pay.

Grantees have the right to terminate services to a client if:

  • the client is disruptive, unruly, threatening or uncooperative to the extent that the client seriously impairs the grantee’s ability to effectively and safely provide services; or
  • if the client’s behavior jeopardizes their own safety, clinic staff or others.  

A person has the right to appeal the denial, modification, suspension or termination of services. See Appeals, in the PHC rules Title 26, Part 1, Chapter 364.

If an aggrieved client requests a hearing, a grantee shall not terminate services to the client until a final decision is rendered by HHSC. 

Any policy related to termination of services must be included in the grantee’s policy manual.

3340 Resolution of Complaints

Revision 23-2; Effective Sept. 15, 2023

Grantees must ensure that clients can express concerns about care received and to further ensure that those complaints are handled in a consistent manner. Grantees’ policy and procedure manuals must explain the process clients may follow if they are not satisfied with the care received.

If a client remains unsatisfied with how the complaint was handled, they can appeal by email to the HHSC PHC Office, or mail PO Box 149030, Austin Tx 78714-9947. More information may be needed.

If a client requests an appeal or hearing, a grantee shall not terminate services to the client until a final decision is rendered by HHSC. Any client complaint must be documented in the client’s record.

3350 Research (Human Subject Clearance)

Revision 23-2; Effective Sept. 15, 2023

Grantees considering clinical or sociological research using PHC Services Program funded clients as subjects must obtain prior approval from their own internal Institutional Review Board (IRB) and HHSC.

The grantee must have a policy in place that indicates that prior approval will be obtained from the HHSC PHC Program, as well as the IRB, prior to instituting any research activities. The grantee must also ensure that all staff are made aware of this policy through staff training. Documentation of training on this topic must be maintained.

3400, Client Records Management

Revision 23-2; Effective Sept. 15, 2023

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

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

Written consent is required for the release of personally identifiable information, except as may be necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. If the client is 17 years old or younger, the client’s parent, managing conservator or guardian, as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release. HIV information should be handled according to law.

When information is requested, grantees should release only the specific information requested. Information collected for reporting purposes may only be disclosed in summary, statistically or in a format that does not identify individuals. Upon request, clients transferring to other providers must be provided with a copy or summary of their record to expedite continuity of care. 

Grantees and subgrantees must maintain for the time specified by HHSC all records pertaining to client services, contracts and payments. Grantees must follow contract provisions, maintain medical records for at least seven years after the close of the contract and follow the retention standards of the appropriate licensing entity. All records relating to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law.

3500, Personnel Policy and Procedures

Revision 23-2; Effective Sept. 15, 2023

Grantees must develop and maintain personnel policies and procedures to ensure clinical staff are hired, trained and evaluated appropriately to their job position. Contracted staff must also be trained and evaluated according to their responsibilities. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. It is recommended that grantees follow the Advisory Committee on Immunization Practices (ACIP) for immunization of healthcare workers. All staff must be appropriately identified with a name badge. Personnel policies and procedures must include:

  • job descriptions, including those for contracted personnel;
  • a written orientation plan for new staff to include skills evaluation and competencies appropriate for the position; and
  • a performance evaluation process for all staff.

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

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

The PHC medical director for the clinic must be a licensed Texas physician and the PHC dental director for the clinic must be a U.S. licensed dentist.

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

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

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

3600, Facilities and Equipment

Revision 23-2; Effective Sept. 15, 2023

HHSC grantees are required to always maintain a safe environment. Grantees must provide clean and well-maintained facilities where services can be delivered with space for exam rooms, client intake, waiting areas, and space for clinical and administrative staff. Clinic sites must be geographically close to the target population(s) it intends to serve. Grantees must have written policies and procedures that address the forementioned requirements, and include a policy that discusses hazardous materials, fire safety and medical equipment.

3610 Hazardous Materials

Revision 23-2; Effective Sept. 15, 2023

Grantees must have written policies and procedures that address:

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

3620 Fire Safety

Revision 23-2; Effective Sept. 15, 2023

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

3630 Medical Equipment

Revision 23-2; Effective Sept. 15, 2023

Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including an Automated External Defibrillator (AED). Documentation must include:

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

3640 Radiology Equipment and Standards

Revision 23-2; Effective Sept. 15, 2023

All facilities providing radiology services, including dental X-rays, must:

For information on X-ray machine registration, see the Texas Department of State Health Services, Radiation Control Program
 

3645 Laboratory Standards

Revision 23-2; Effective Sept. 15, 2023

All facilities providing laboratory services must possess a current Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver. CLIA requires that any facility examining human specimens for diagnosis, prevention, treatment of a disease, or for assessment of health must register with the federal Centers for Medicare & Medicaid Services (CMS) and obtain CLIA certification.

3650 Smoking Ban

Revision 23-2; Effective Sept. 15, 2023

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

3700, Emergency Responsiveness

Revision 23-2; Effective Sept. 15, 2023

3710 Clinical Emergencies

Revision 23-2; Effective Sept. 15, 2023

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

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

Dental Emergency Responsiveness

The dental office or clinic must have a written emergency plan that includes criteria for management of emergencies. The plan must be reviewed annually and as needed. Requirements for emergencies can be found at the Texas State Board of Dental Examiners website and in the Texas rule for Minimum Standard of Care.
 

3720 Emergency Preparedness

Revision 23-2; Effective Sept. 15, 2023

There must be a written safety plan that includes maintenance of fire safety equipment, an emergency evacuation plan and a disaster response plan.

Disaster Response Plan

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

For additional resources on facilities and equipment, see the Occupational Safety and Health Administration website.

3800, Quality Management

Revision 23-2; Effective Sept. 15, 2023

Grantees must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor PHC services. Grantees must have a Quality Management (QM) program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, quality and continuity of care.

Grantees should integrate QM concepts and methodologies into the structure of the organization and day-to-day operations.

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

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

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

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

The QM Committee, whose membership consists of key leadership of the organization, including the executive director or CEO, medical director, dental director and other appropriate staff, where applicable, annually reviews and approves the quality work plan for the organization.

The QM Committee must meet at least quarterly to:

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

Minutes of the discussion and actions taken by the committee and a list of the attendees must be maintained.

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

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

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

  • ongoing eligibility, billing and clinical record reviews to ensure compliance with program requirements and clinical standards of care;
  • utilization review;
  • client satisfaction surveys;
  • annual review of facilities to maintain a safe environment, including an emergency safety plan;
  • annual review and update of all prescriptive authority agreements (PAAs) for mid-level providers;
  • annual review of all standing delegation orders (SDOs) and clinical protocols; and
  • annual review of all policies and forms.
  • defining, reporting, tracking and follow-up of adverse outcomes;
  • annual performance evaluations to include primary license verification, valid Drug Enforcement Agency (DEA) number, as applicable, and other required licenses or certifications.

 

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

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

  • annual license verification (primary source verification);
  • clinical record review;
  • eligibility and billing review;
  • on-site facility review;
  • annual client satisfaction evaluation process; and
  • compliance with all Abuse and Neglect, and Civil Rights requirements. 

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

4000, Eligibility and Fees

Revision 23-2; Effective Sept. 15, 2023

This section provides policy requirements for eligibility determinations, client fees, and continuity of client services.

4100, Eligibility and Assessment of Co-pay/Fees

Revision 23-2; Effective Sept. 15, 2023

Grantees must develop a policy indicating how staff will determine PHC program client eligibility. The policy must outline the grantee’s procedures for determining program eligibility and who is responsible for eligibility screening.

Grantees must perform an eligibility screening assessment on all clients who present for services using the most recent version of Form 3029, Application for Program Benefits.

An alternate eligibility tool created by the grantee may be used in place of Form 3029 with prior written approval by the PHC program. To apply for approval, the grantee must contact program staff via email to request an Alternate Eligibility Screening Tool Request form. Once completed, grantees will send the request form and a copy of their proposed alternate screening tool to the program mailbox at primaryhealthcare@hhs.texas.gov. The tool must contain, at minimum, all required elements of the Form 3029.

Once a grantee obtains approval for the use of an alternate eligibility screening tool, the following requirements will apply:

  • Grantees must request approval from the PHC program for any revisions to their eligibility screening tool and include a copy of the revised tool.
  • The eligibility screening tool is only approved for the life of the current grant term. If a grantee is awarded funding under a subsequent grant, the grantee must resubmit their eligibility screening tool for review and written approval, even if no changes have been made to the tool since the last written approval.
  • Any required changes made to Form 3029 by the PHC program must be incorporated into the grantee-developed alternate screening tool. Grantees will need to submit their grantee-developed alternate screening tool with the incorporated changes within 60 calendar days for re-review and approval.
  • The PHC program reserves the right to request additional edits or withdraw its approval of the use of an alternate eligibility tool. HHSC program will notify the grantee of the decision in writing and include the date the use of the alternate tool must be discontinued.

The following forms are optional, but may be used to aid in completing the eligibility screening process:

If it is determined that an applicant is ineligible for services after the screening process is complete, give the applicant the Notice of Ineligibility, Form 3047. Grantees must inform the applicant of their right to appeal the eligibility decision by using the process described on the Notice of Ineligibility.

Grantee may use the optional copay table available in Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL).

4200, Client Eligibility Screening Process

Revision 23-2; Effective Sept. 15, 2023

For a person to receive PHC program services, three criteria must be met:

  • Gross family income at or below 200% of the Federal Poverty Level (FPL)
  • Texas resident
  • Not eligible for other programs or benefits providing the same services

Residency is self-declared. Grantees may require residency verification, but such verification should not jeopardize delivery of services. Grantees must require income verification for countable income, except in cases when submitting the income verification jeopardizes the client's right to confidentiality or imposes a barrier to receipt of services, the grantee must waive this requirement. Reasons for waiving verification of income must be noted in the client record.

Eligibility determinations for PHC can be made by conducting interviews over the phone or in person for new applicants and to re-certify current clients. Phone interviews for eligibility determinations must comply with all eligibility guidelines outlined in program policy.

In lieu of a client’s signature on the application in the Acknowledgment section of the Application for Program Benefits or on the Statement of Applicant’s Rights and Responsibilities, the eligibility staff person must read the statements to the applicant and document that the applicant affirms the statements. The documentation must include the date and time of the applicant’s affirmation and the eligibility staff person’s signature. The client must sign the document at the time of their next visit to the clinic.

4300, Procedures and Terminology When Determining PHC Eligibility

Revision 23-2; Effective Sept. 15, 2023

Potential Eligibility and Referral to Other Programs

Screening for other benefit programs must be documented on the Application for Program Benefits form. The PHC program is the payor of last resort. Applicants must be screened for Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal, and any other benefit programs. PHC will not reimburse for services provided to clients who are potentially eligible for another funding source and who do not complete the respective eligibility application process. Applicants who do not fully comply with applying for other benefit programs they appear eligible for, are not eligible for PHC and grantees will not be reimbursed for services provided.  

If a client appears eligible for any of these other benefit programs, they must be granted Presumptive Eligibility for PHC while awaiting benefit determination. The grantee must notify the client they must apply for any program for which they appear eligible. The client is responsible for submitting proof of application or a denial letter before the presumptive eligibility period ends. If a client does not appear eligible for any other program, this must be documented on the application.

All Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal, or other benefit program applications must be submitted promptly following PHC eligibility assessment. If a client was denied Medicaid or CHIP services, the denial letter must be included with the application. Grantees may use the HHSC Your Texas Benefits website to assist in the screening of client eligibility. More information about HHSC benefits can also be obtained by calling 2-1-1.

Household   

The household consists of a person living alone, or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and are legally responsible for the support of the other person. If an unmarried applicant lives with a partner, only count the partner’s income and children as part of the household group if the applicant and their partner have mutual children together. Also include unborn children. 

A child must be under 18 years old to be counted as part of a larger family. Eligibility will end on the last day of the month the child becomes 18 unless the child is:

  • a full-time high school student as defined by the school, attends an accredited GED class or regularly attends vocational or technical training in place of high school; and
  • expected to graduate from one of the above before or during the month of his or her 19th birthday.

Legal responsibility for support exists between:

  • people who are legally married including common-law marriage;
  • a legal parent and a minor child, including unborn children; or
  • a managing conservator and a minor child. A managing conservator is a person designated by a court to have daily legal responsibility for a child.

Documentation of Family Composition

If family relationships are unclear, request one of the following items:

  • Birth certificate
  • Baptismal certificate
  • School records
  • Other documents or proof of family relationship determined valid by the grantee to establish the dependency of the family member upon the client or head of household.

Family members who receive other health care benefits are included in the family count. 

Documentation of Residency

To be eligible for PHC services, a person must: 

  • be physically present within the geographic boundaries of Texas;
  • have the intent to remain within the state, whether permanently or for an indefinite period; and
  • not claim residency in any other state or country.

If a person is less than 18 years old, their parent or legal guardian must be a resident of Texas and meet the criteria above.

There is no requirement for the length of time a person must live in Texas to establish residency for the purposes of PHC eligibility.

If the grantee requires a client to provide proof of residency, the type of proof provided by client should be documented on Form 3029 , Application for Program Benefits. For documentation of residency, one of the following items may be provided:

  • Valid Texas driver license
  • Current voter registration
  • Rent or utility receipts for one month prior to the month of application
  • Motor vehicle registration
  • School records
  • Medical cards or other similar benefit cards
  • Property tax receipt
  • Mail addressed to the applicant, their spouse, or children if they live together
  • Other documents considered valid by the grantee

If none of the listed items are available, residency may be verified through one of the following:

  • Observance of personal effects and living arrangement
  • Statements from landlords, neighbors or other reliable sources

If an applicant’s residency is unclear or questionable, explain and document concerns on Form 3029. If a family is otherwise eligible, but residency is in question, the household is entitled to services until residency information is verified.

Individuals do not lose their residency status because of temporary absences from the state. For example, a migrant or seasonal worker who may travel during certain times but maintains a home in Texas and returns to that home after these temporary absences.

Income 

All income received must be included. Income is calculated before taxes or pre-tax deductions (gross). Income is reviewed and determined either countable or exempt (based on the source of the income), as defined in Appendix I, Definition of Income. Grantees must have a written PHC income verification policy.

Documentation of income for PHC services must be provided to complete Form 3029, Application for Program Benefits. Declarations of “unknown” will not be accepted as documentation.

The following are examples of documentation that could be included in the grantees’ verification of income policy:

  • at least two pay periods that accurately represent their earnings dated within the 60 days before the application processing date; or
  • one month’s pay (only if paid same gross amount monthly) unless special circumstances are noted on the application.

The pay periods must accurately reflect the individual’s usual and customary earnings. Proof may include, but is not limited to:

  • copy or copies of the most recent paycheck(s) stub or monthly earning statement(s);
  • employer’s written verification of gross monthly income or Form 3049, Employment Verification;
  • award letters;
  • domestic relation printouts of child support payments received;
  • statement of support;
  • unemployment benefits statement or letter from the Texas Workforce Commission;
  • court orders or public decrees to verify support payments;
  • notes for cash contributions; and
  • other documents or proof of income determined valid by the grantee.

Grantees must require income verification for countable income. In cases when submitting the income verification jeopardizes the client's right to confidentiality or imposes a barrier to receipt of services, the grantee must waive this requirement and document the reason.

Monthly Income Conversions

If income payments are received in lump sums or at longer intervals than monthly, such as seasonal employment, the income is prorated over the time the income is expected to cover. Income received weekly, every two weeks, or twice a month must be converted as follows:

  • Weekly income is multiplied by 4.33
  • Income received every two weeks is multiplied by 2.17
  • Income received twice monthly is multiplied by 2

Calculation of Applicant's Federal Poverty Level (FPL) Percentage 

The grantee must determine the household FPL percentage. The maximum monthly income amounts by household size are based on the U.S.  Department of Health and Human Services federal poverty guidelines . The guidelines are subject to change at the beginning of each calendar year. 

The steps to determine the household FPL percentage are:

  • Determine the household’s total monthly gross income amount.
  • Determine the household size.
  • Divide the household’s total monthly gross income amount by the monthly poverty guideline based on the household size.
  • Multiply by 100. 

Income Deductions 

Dependent care expenses may be deducted from total income. This expense must be both necessary for employment and incurred by an employed person. Documentation must be provided. Allowable deductions are actual expenses up to:

  • $200 per child per month for children under 2; 
  • $175 per child per month for each dependent 2 or older; and 
  • $175 per adult with disabilities per month.

Legally obligated child support payments made by a member of the household may also be deducted from the total income. Documentation of payments must be provided. Convert payments made weekly, every two weeks, or twice a month by using one of the conversion factors listed above.

Documenting Special Circumstances 

There may be special circumstances where an applicant is unable to provide required documentation for verification purposes. These types of special circumstances should be appropriately documented.

Client Fees and Copays 

Grantees may assess a copay for services for PHC clients. If the grantee does assess copays for clients, the grantee must also have a policy that outlines how the copayment amounts are determined, using the following copay guidelines:

  • No PHC client shall be denied services based on an inability to pay.
  • Clients with a household FPL at or below 100% shall not be charged a copay, as calculated using the U.S. HHS Poverty Guidelines.
  • Clients with a household FPL above 100% may be charged a copay of no greater than $30 per visit.
  • Grantees must have a written copay policy which clearly defines how copay amounts will be determined.
  • Clients who are assessed a copay must be presented a billing statement at the time of service and a copy shall be kept in the client’s record.
  • Clients who declare an inability to pay a copay shall not be denied services. Any outstanding balance shall not be turned over to a collection agency or reported delinquent to a credit reporting agency.
  • All policies and procedures regarding copay collection must be approved by the grantee’s Board of Directors. 
  • Copays must be reported as program income in the Monthly Reimbursement Packet (MRP). The grantee must complete B25 and E25. 

Grantees may use the optional copay table available in the Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level .

Other Fees 

Do not charge clients administrative fees for items such as processing or transfer of medical records or copies of immunization records. Grantees can bill clients for services outside the scope of PHC allowable services if the service is provided at the client’s request and the client is made aware of their financial responsibility for the charges before services are provided.

Client’s Responsibility for Reporting Changes

A client must report the following changes no later than 30 days after the client is aware of the change: 

  • income; 
  • family composition; 
  • residence; 
  • current address; 
  • employment; 
  • types of medical insurance coverage; or
  • receipt of Medicaid, CHIP, CHIP Perinatal, or other third-party coverage benefits. 

The client may report changes by mail, phone, in-person, or through someone acting on the person’s behalf. If changes result in the client no longer meeting eligibility criteria, the client’s eligibility will terminate. Upon termination, the grantee must issue Form 3047, Notice of Ineligibility, to the client, including the date of termination. 

Continuation of Services  

Upon expenditure of awarded grant funds, grantees must continue serving their existing PHC clients through the end of their clients’ determined eligibility periods. Any funding sources other than PHC awarded program funds used to provide PHC services, must be reported as “non-HHSC” funds on the Monthly Report Form and the quarterly Financial Status Report (FSR), also known as Form 269A.

Additionally, grantees are required to screen potential new clients for program eligibility once awarded grant funds are exhausted. However, if screenings are completed and potential clients are determined eligible, the grantee must provide services to those clients.

<Date Eligibility Begins 

The program eligibility start date for a person or household is determined by the grantee, and typically begins on the date that a completed and signed application is submitted to the grantee. To notify an applicant of eligibility, the grantee must issue the following forms to the client: 

Presumptive Eligibility  

PHC emphasizes the importance of prevention and early intervention. The goal of PHC is for clients to be part of the health care system and not rely on episodic acute care. An applicant’s medical needs shall be met quickly and appropriately, using available resources in the community.

Presumptive eligibility is the short-term availability and access to health care services (up to 90 days) when the client screens potentially eligible for services but lacks verification to achieve full eligibility. For clients who are determined to be fully eligible during the presumptive period, the eligibility expiration date will include the days of presumptive eligibility (expiration date is 365 days, dating from eligibility determination).

When full eligibility is granted during or at the end of the 90 days, the eligibility period end date is 12 months from the presumptive eligibility start date. The grantee may waive the requirement to submit the eligibility documentation and approve full eligibility on a case-by-case basis, if the grantee determines submitting the documentation will create a barrier to care and no other documentation is available.

Potential Eligibility and Referral to Other Possible Qualifying Programs

In general, individuals are not eligible for the PHC program if they are enrolled in another third-party payer, such as private health insurance, Medicaid or Medicare, TRICARE, Workers’ Compensation, Veterans Affairs Benefits, or other federal, state or local public health care coverage that provides the same services. If an applicant is eligible for another program that covers the same services, they may still be eligible for the PHC program. The grantee should inform the applicant of their possible eligibility for the other program, suggest that they also apply for services from that program, and proceed with the eligibility determination process for PHC. The grantee must document in the applicant’s record that they were informed and referred to the other program.

Supplemental Benefits

In some cases, applicants receiving benefits from other sources, such as Medicaid or Medicare, may be eligible for partial PHC coverage. This supplemental or wraparound coverage is limited to services provided by PHC but not covered by other sources. Whenever federal, state, private or other benefits are available for payment of clients receiving PHC covered services, no PHC funds shall be used to pay for such care. An example of supplemental benefits would be providing health education services to Medicaid-eligible clients since Medicaid does not provide health education services. The grantee must communicate to the client that supplemental services are of limited scope.

Adjunctive Eligibility

An applicant is considered adjunctively (automatically) eligible for PHC program services at an initial or renewal eligibility screening if the applicant is currently enrolled in one or more of the following:

  • Children’s Health Insurance Program (CHIP) Perinatal; 
  • Medicaid for Pregnant Women;
  • Special Supplemental Nutrition Program for Women, Infants and Children (WIC);
  • Supplemental Nutrition Assistance Program (SNAP); or 
  • Healthy Texas Women (HTW) Program. 

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

ProgramDocumentation
CHIP PerinatalCHIP Perinatal benefits card
Medicaid for Pregnant WomenYour Texas Benefits card (Medicaid card)*
WICWIC verification of certification letter, printed WIC-approved shopping list or recent WIC purchase receipt with remaining balance
SNAPSNAP eligibility letter
HTWYour Texas Benefits card with "Healthy Texas Women" printed in the upper right corner

*Note: Presentation of the Your Texas Benefits card does not completely verify current enrollment in the HTW program or the Medicaid for Pregnant Women program. To verify enrollment, grantees must call Texas Medicaid & Healthcare Partnership (TMHP) at 800-925-9126 or access TexMedConnect on the TMHP website at  www.tmhp.com . For a client's current enrollment status, grantees must enter two of the following four data elements for the client:

 

  • patient control number;
  • date of birth;
  • Social Security Number; or
  • last name.
 

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

Insurance

Applicants with insurance may be eligible for services provided by PHC when the applicant’s confidentiality is a concern or if the applicant’s insurance deductible is 5% or greater than their income. Most insurance deductibles are given as an annual amount. PHC household incomes are figured as a monthly amount. To compare an annual deductible with a monthly income, multiply the monthly income by 12 and then determine 5% of that amount. See the example below for a monthly household income of $1,000:

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

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

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

The completed eligibility form must be maintained in the client medical record, indicating the client's poverty level and the copay amount the client will be charged.

 

Annual Recertification 

Annual eligibility determination and recertification is required for all clients who receive PHC services. Client eligibility must be redetermined every 12 months, using Form 3029. Grantees must have a system in place to track client eligibility and renewal status on an annual basis.

5000, Clinical Guidelines

Revision 23-2; Effective Sept. 15, 2023

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

All providers must offer the following six priority primary health care services on-site or by referral:

  • Diagnosis and treatment of common acute and chronic diseases affecting the general health of the client, including:
    • initial contact with a client for an undiagnosed health concern; and
    • continuing care of varied medical conditions not limited by cause or organ system.
  • Emergency Medical Services must be for the urgent care of an unexpected health condition requiring immediate attention as determined by the appropriate medical staff. Services must be those that can be treated in a primary care clinic or setting.
  • Family Planning Services - preventive health and medical services that assist a person in controlling fertility and achieving optimal reproductive and general health, including:
    • health check-up and physical exam;
    • birth control methods including pills, IUD, condoms, shot, and ring;
    • natural family planning;
    • lab tests for:
      • sexually transmitted infections (STIs);
      • pregnancy testing;
    • counseling regarding:
      • abstinence;
      • preconception; 
      • nutrition; and
      • infertility.
  • Preventive Health Services may include:
    • immunizations;
    • cancer screenings;
    • screenings for chronic conditions; and
    • health screenings to determine the need for intervention and possibly more comprehensive evaluation.
  • Health Education includes planned learning experiences based on sound theories that provide individuals, groups and communities the opportunity to increase knowledge, and skills needed to make healthy decisions
  • Diagnostic Laboratory and Radiological Services
    • These services must be medically necessary. They are technical laboratory and radiological services ordered and provided by, or under the direction of, a physician in an office or a facility other than a hospital inpatient setting.

Grantees are strongly encouraged to visit the U.S. Preventive Services Task Force website for additional guidance on preventive services.

5100, General Consent

Revision 23-2; Effective Sept. 15, 2023

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

A client’s verbal consent for general treatment through the PHC program may be obtained by phone. This is adequate for routine treatment provided through telemedicine. To record a client’s verbal consent, the staff person obtaining the consent must read the consent form to the applicant and document that the applicant affirms by giving their verbal consent for treatment. The documentation must include the date and time of the applicant’s consent and the signature of the staff person obtaining the consent. The client must sign the consent at the time of their next clinic visit.

Consent information must be effectively communicated to every client in a manner that is understandable to the client. This communication must allow the client to participate, make sound decisions regarding their own medical care, and address any disabilities that impair communication (in compliance with Limited English Proficiency regulations). Only the client receiving services may give consent. When a client is legally unable to consent, a parent (in the case of an unemancipated minor) or court-appointed legal guardian must consent on the client’s behalf. Consent must never be obtained in a manner that could be perceived as coercive. HHSC grantees should consult a qualified attorney to determine the appropriateness of the consent forms used by their health care agency.

5110 Consent for Dental Procedures

Revision 23-2; Effective Sept. 15, 2023

Written, informed consent for dental procedures must be obtained in compliance with 22 Texas Administrative Code Section 108.7 regarding minimum standards of care for dentists.

5120 Consent for Sterilization Procedures

Revision 23-2; Effective Sept. 15, 2023

There are two consent forms required for sterilization procedures:

5130 Texas Medical Disclosure Panel Consent

Revision 23-2; Effective Sept. 15, 2023

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

  • determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their patients or persons authorized to consent for their patients; and
  • establish the general form and substance of such disclosure. The grantee is responsible for assuring that informed consent is obtained from the patient for procedures per TMDP. TMDP has developed List A (informed consent requiring full and specific disclosure) for certain procedures, and is found in 25 TAC Section 601.2.

More information about TMDP can be found on this page, the Civil Practice and Remedies Code, Chapter 74.102 and the Texas Administrative Code (TAC)

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

For all other procedures not included on List A, the physician must disclose through a procedure specific consent, all risks that a reasonable client would need to know. This includes 

  • all risks that are inherent to the procedure, meaning one which exists in and is inseparable from the procedure itself; and 
  • that are material and could influence a reasonable person in deciding whether to consent to the procedure.

5140 Consent for Services Provided to Minors

Revision 23-2; Effective Sept. 15, 2023

Generally, a parent must consent to treatment for minors. A minor is defined as a person under 18 years old who has never been married and has never been declared an adult by a court (emancipated). However, there are certain circumstances under which a minor may consent for their own treatment. Requirements for parental consent for the provision of family planning services to minors vary according to the funding source subsidizing the services. The department and providers may provide family planning services, including prescription drugs, without the consent of the minor’s parent, managing conservator, or guardian only as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations.

Resources and References:

5150 Consent for HIV Tests

Revision 23-2; Effective Sept. 15, 2023

For HIV testing, grantees must comply with Texas Health and Safety Code:

5200, Clinical Policy

Revision 23-2; Effective Sept. 15, 2023

Scope of Services: Six Priority Primary Health Care Services

1. Diagnosis and Treatment

This includes diagnosis and treatment of common acute and chronic disease that affect the general health of the client. Services include first contact with a client for an undiagnosed health concern, as well as continuing care of varied medical conditions not limited by cause or organ system. Services must not be limited to only one service (i.e., family planning, breast and cervical cancer screening or podiatry).

  • Physician Services – Services must be medically necessary and provided by a physician in the doctor's office, clinic, or facility other than a hospital setting.
  • Physician Assistant (PA) Services – These services must be medically necessary and provided by a PA under the direction of a physician and may be billed by, and paid to, the supervising physician.
  • Advanced Practice Nurse (APN) Services – An APN must be licensed as a registered nurse (RN) within the categories of practice, specifically a nurse practitioner, a clinical nurse specialist, a certified nurse midwife (CNM) and a certified registered nurse anesthetist (CRNA), as determined by the Board of Nurse Examiners. APN services must be medically necessary, provided within the scope of practice of an APN, and covered in the Texas Medicaid Program and under the direction of a physician.

2. Emergency Medical Services

Services must be for urgent care for an unexpected health condition requiring immediate attention as determined by the appropriate medical staff and must be services that can be treated in a primary care clinic or setting.

3. Family Planning Services

These are preventive health and medical services that assist a person in controlling fertility and achieving optimal reproductive and general health. Services include:

  • Health check-up and physical exam
  • Birth control methods including pills, IUD, condoms, shot, and ring
  • Natural family planning
  • Lab tests for:
    • Sexually transmitted infections (STIs)
    • Pregnancy testing
  • Counseling regarding:
    • Abstinence
    • Preconception counseling which is planning for a healthy pregnancy
    • Nutrition
    • Infertility

4. Preventive Health Services

Services that may be included are:

  • Immunizations – these services are provided in an appropriate setting for diseases that are preventable by vaccines.
  • Cancer screening services – these must be medically necessary and by clinical recommendation and include:
    • Clinical breast examinations
    • Mammograms
    • Pelvic examinations Note: Must be administered in compliance with Chapter 167A of the Health and Safety Code
    • Cervical cancer screening
  • Screenings for chronic conditions – these may include screenings for hypertension, diabetes, and other chronic conditions, as indicated.
  • Health screening – this is to determine the need for intervention and possibly a more comprehensive evaluation. Health screenings may include taking a personal and family health history and performing a physical examination, laboratory tests or radiological examination, and may be followed by counseling, education, referral or further testing. Examples of these services include blood pressure, blood sugar and cholesterol screening.

5. Health Education

Planned learning experiences based on sound theories that provide individuals, groups and communities the opportunity to increase knowledge, and skills needed to make healthy decisions.

6. Diagnostic Laboratory and Radiological Services  

These services must be medically necessary. They are technical laboratory and radiological services ordered and provided by, or under the direction of, a physician in an office or a facility other than a hospital inpatient setting.

Grantees are strongly encouraged to visit the U.S. Preventive Services Task Force website for additional guidance on preventive services.

Telehealth and Telemedicine

Providers may deliver services via telehealth and telemedicine medical services, if appropriate. Telehealth services are defined as health care services delivered by a health professional to a patient at a different physical location than the health professional, using telecommunications or information technology.

Providers who offer telehealth and telemedicine medical services must have written policies and procedures for doing so that include the following:

  • clinical oversight by the medical director or designated physician responsible for medical leadership;
  • contraindication considerations for telemedicine use;
  • qualified staff members to ensure the safety of the person being served by telemedicine at the remote site;
  • safeguards to ensure confidentiality and privacy per state and federal laws;
  • services provided by credentialed, licensed clinicians providing clinical care within the scope of their licenses;
  • demonstrated competency by all staff members involved in the operation of the system and provision of the services before initiating the protocol;
  • priority in scheduling the system for clinical care of individuals;
  • quality oversight and monitoring of satisfaction of the people served; and
  • management of information and documentation for telemedicine services that ensures timely access to accurate information between the two sites.

Client Health Records and Documentation of Encounters

Providers must ensure a patient health record is established for every person who receives clinical services.

All patient health records must be:

  • Complete, legible and accurate documentation of all client encounters, including those by phone, email or text message.
  • Written in ink (without erasures or deletions) or documented in the electronic medical record (EMR) or electronic health record (EHR).
  • Signed by the provider making the entry, including the name of the provider, the provider’s title and the date for each entry:
    • Electronic signatures are allowable to document the encounter, provider review of care or both. 
    • Stamped signatures are not permitted.
  • Readily accessible to assure continuity of care and availability to clients.
  • Systematically organized to allow easy documentation and prompt retrieval of information.

All client health records must include:

  • client identification and personal data, including financial eligibility;
  • the client’s preferred language and method of communication;
  • client contact information, including the best way and alternate ways to reach the client to ensure continuity of care, confidentiality and compliance with HIPAA regulations;
  • a complete medication list, including prescription, nonprescription medications and dietary supplements, updated at each encounter;
  • a complete listing of all allergies and adverse reactions to medications, food and environmental substances (e.g., latex); 
    • if the patient has no known allergies, this should be listed; 
    • this information should be prominently displayed in the patient’s record and updated at each encounter;
  • a plan of care, updated as appropriate, that is 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;
  • documentation of client education and counseling with attention to risks identified through the health risk assessment; and
  • at every visit, the record must be updated as appropriate, documenting the reason for the visit, relevant history, physical exam findings, and pertinent screening and diagnostic tests with results and treatment plan.

Initial Medical History and Risk Assessment

In addition to the elements required for the Client Health Record listed above, a comprehensive medical history must be obtained during the initial or early subsequent clinical visit. It should be appropriately adapted to the age and gender of the client:

  • Reason for the visit and current health status
  • History of present illness, if indicated
  • Past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood and blood products, and mental health history
  • Age-appropriate immunizations:
    • Immunization status or assessment (see Centers for Disease Control and Prevention (CDC) immunization schedules by age)
    • Rubella status, based on a history of rubella vaccination or documented rubella serology. Non-pregnant female clients of childbearing age with unknown or inadequate rubella immunity must be provided vaccination on-site or referred appropriately
    • PHC providers can voluntarily participate in the DSHS Adult Safety Net (ASN) Program or the Texas Vaccines for Children (TVFC). Both programs provide vaccines at no cost
  • Review of systems with pertinent positives and negatives documented in the chart
  • Current and past tobacco, alcohol and substance use or abuse
  • Occupational and environmental hazard exposure
  • Environmental safety (e.g., seat belt use, car seat use, bicycle helmets, etc.), nutritional and physical activity assessment, and living arrangements
  • Assessment for sexual and intimate partner violence (IPV) (mandated by Texas Family Code, Chapter 261). For any positive result, the client should be offered referral to a family violence shelter in compliance with Texas Family Code, Chapter 91
  • Pertinent family history
  • Pertinent partner history, including injectable drug use, number of partners, STIs and HIV history and risk factors, and gender of sexual partners
  • Cervical and breast cancer screening history, noting any abnormal results and treatment, and dates of most recent testing
  • A reproductive health history as detailed below

Reproductive health history in female clients of reproductive age must include:

  • Menstrual history, including last normal menstrual period
  • Pertinent sexual behavior history, including family planning practices (i.e., contraceptive use – past and current), number of partners, gender of sexual partners, last sexual encounter and sexual abuse
  • Obstetrical history
  • Gynecological and urological conditions
  • STIs and STDs
  • HIV history, risks and exposure.

Reproductive health history in male clients of reproductive age must include:

  • Pertinent sexual behavior history, including family planning practices (i.e., contraceptive use – past and current), number of partners, gender of sexual partners, last sexual encounter and sexual abuse
  • Genital and urologic conditions, as indicated
  • STIs or STDs
  • HIV history, risks and exposure

Physical Assessment

A periodic preventive health care visit is an excellent opportunity for clinicians to address issues of wellness and health risk reduction as well as current findings and client concerns. The periodic preventive health care visit must include an update of the person’s health record, as described in the Client Health Record section above. It must also include appropriate screening, assessment, health education and counseling, and immunizations based on the client’s age, risk factors, preferences and concerns.

All clients must be provided an appropriate physical assessment as indicated by health history and health risk assessment. A physical examination is not essential before the provision of most contraceptive methods and should not be a barrier to the client receiving a method of contraception.

The initial physical exam may be deferred if the client history and presentation do not reveal potential problems requiring immediate evaluation. The comprehensive physical exam should be performed within six months of the initial visit unless the clinician identifies a compelling reason for extended deferral. Such reason must be documented in the client record.

Program protocols should be developed accordingly and must be consistent with national evidence-based guidelines.

A new client baseline physical examination must include the following components:

Clients 21 years and older:

  • Height measurement
  • Body Mass Index (BMI), waist measurement or other measurement to assess for underweight, overweight and obesity
  • Blood pressure evaluation
  • Cardiovascular assessment
  • Other systems as indicated by history and health risk assessment (HRA) (e.g., evaluation of thyroid, lungs and abdomen)

A periodic primary health visit physical examination must include the following components:

Clients 21 years and older:

  • Height measurement annually until five years post menarche for females and annually until 20 years old for males
  • Weight measurement annually to assess for underweight, overweight, and obesity
  • Blood pressure evaluation;
  • Other systems as indicated by history including evaluation of thyroid, heart, lungs and abdomen

Baseline and periodic health assessments for clients zero through 20 years old must include the following components*:

  • Health history
  • Health risk assessment
  • Preventive health education to include anticipatory guidance, provided to parent(s) or child, as appropriate
  • Physical exam
  • Immunizations

*See Texas Health Steps Provider Information Periodicity Schedules.

Episodic or acute care visit:

  • History of present illness
  • Physical assessment focused on presenting problem(s)
  • Laboratory tests based on presenting problem(s)
  • Interventions appropriate to current findings

Resources

Healthy Lifestyle Intervention

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

Counseling on Healthy Lifestyle Choices

Advise all clients not to smoke or use tobacco products and to avoid exposure to second-hand smoke as much as possible. Advise those who use tobacco products to quit and assess for their readiness to do so at each encounter.

The Texas Tobacco Quitline provides confidential, free, and convenient cessation services to Texas residents ages 13 and older, including quit coaching and nicotine replacement therapy. Services can be accessed by phone at 1-877-YES-QUIT (1-877-937-7848) or online at YesQuit.org.

Counsel clients on healthy eating patterns and offer access to relevant information.

Advise clients to engage in physical activity or resistance training tailored to their individual health condition and risks.

Diet and Nutrition

There is strong evidence that nutrition plays an important role in our risk of disease. No single diet has been shown to be the best and providers should counsel clients on a variety of healthy eating patterns tailored to their health condition and cultural background.

Laboratory Tests

All clients presenting for an initial, annual, routine follow-up or problem-related visit must be provided appropriate laboratory and diagnostic tests as indicated by history, health risk assessment (HRA), physical examination or clinical assessment.

The following tests or procedures must be provided:

  • Colorectal cancer screening in people age 45 and older
  • Cervical cancer screening for females 21 years and older
  • Human Papillomavirus (HPV) screening for female patients who are 21 years or older after an initial ASC-US Pap result, per American Society for Colposcopy and Cervical Pathology (ASCCP) Management Guidelines
  • HIV screening**
  • STI screening, per CDC guidelines
  • Pregnancy test must be provided on-site
  • Rubella serology, if status not previously established by client history and documented in chart, either on-site or by referral
  • Other labs such as blood glucose, lipid panel, or thyroid stimulating hormone as indicated by HRA, history and physical, either on-site or by referral

Note: Initial tests may be deferred until the initial physical exam is provided.

Agencies must have written plans to address laboratory and other diagnostic test orders, results and follow-up to include:

  • Tracking and documentation of tests ordered and performed for each client
  • Tracking test results and documentation in clients’ records
  • Mechanism to notify clients of results in a manner that ensures confidentiality, privacy, and prompt appropriate follow-up
  • Provider must comply with state and local STI reporting requirements

*HIV screening must be provided on-site. Providers should follow CDC recommendations that all clients 13-64 years be screened at least once for HIV infection and that all people likely to be at high risk for HIV be rescreened at least annually. CDC also recommends that screening is provided after notifying the patient that testing will be performed as part of general medical consent unless the patient declines (opt-out screening (PDF)). The provision of negative test results by phone must follow procedures that address patient confidentiality, identification of the client and prevention counseling. Providers must always provide positive HIV test results to patients 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 knowledgeable about HIV prevention and HIV testing. Provide clients whose risk screenings assessment reveals high risk behaviors directly with risk reduction counseling or refer for more extensive risk reduction counseling by a Department of State Health Services (DSHS) HIV/STD program trained risk reduction specialist. Visit the DSHS HIV/STD website to find a DSHS HIV/STD program provider.

Resources

Expedited Partner Therapy

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

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

Radiology Procedures

PHC clients must be provided appropriate radiologic tests to include the technical procedure and the interpretation of the X-ray, as indicated by history and clinical assessment related to the current reason for visit. If a provider is unable to provide radiological services on-site, the provider must have a Memorandum of Understanding (MOU) with another provider and make the services available through referral.

Family Planning Services

Contraceptive Method Counseling

Clients who are provided contraceptive method-specific information must receive individualized dialogue that covers:

  • Results of physical exam and assessments
  • Correct use of the contraceptive method(s) selected for personal use by the client, as well as possible side effects and complications
  • Back up methods, including information about emergency contraception and discontinuation issues
  • Scheduled revisits
  • Access for urgent and emergency care, including a 24-hour emergency phone number
  • Appropriate referral for more services as needed

Providers are encouraged to present the most effective methods of contraception first before presenting information on less effective methods. This information should state that long-acting reversible contraception (LARC) methods are safe and effective for most women, including those who have never given birth.

LARCs, i.e., intrauterine devices (IUDs) and implants, have definite benefits related to client contraceptive efficacy, client convenience and long-term costs. Providers should discuss and offer these methods for consideration to all women, as medically appropriate. As with all methods, the client’s preference after receiving unbiased, factual nondirective education should be respected.

A specific contraceptive method that requires more clinical expertise outside the training of the PHC contracted clinicians (e.g., sterilization) may be provided by referral.

If a provider offers a method or service by referral, the method or service must be provided to clients at the referral site at no fee or at the same discounted client fee that would be charged if the method or service were provided on-site. The referring site must have a written agreement with the referral site to provide the method or service to clients under this condition.

Sterilization procedures, when performed or arranged for by the provider, must comply with consent requirements for sterilization of persons in federally assisted family planning projects. The federally mandated consent form is necessary for both abdominal and trans-cervical sterilization procedures in women and vasectomy in men (see section on consent).

Note: Primary Health Care Program grantees must follow current state and federal laws as they pertain to abortion services.

Counseling Adolescents

Provide adolescents 17 and younger individualized family planning counseling and medical services that meet their specific needs. Appointments should be available to them for counseling and medical services as soon as possible. Grantees must address these issues in counseling adolescents:

  • All methods of contraception, including abstinence
  • Discussion about contraceptive options and safe sex practices that reduce risk of STI, HIV and pregnancy
  • Identifying and resisting sexual coercion
  • Discussion about partner, dating and family violence, and available resources and assistance

Perinatal Clinical Guidelines

Provide prenatal and postpartum services based on American Congress of Obstetricians and Gynecologists (ACOG) or other nationally recognized, evidence-based guidelines.

State-Mandated Education

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 people during gestation or at delivery to provide them, and additional parent(s), or other adult caregiver(s) with a resource pamphlet for the infant including information on postpartum depression, shaken baby syndrome, immunizations, newborn screening, pertussis and sudden infant death syndrome. Also, document in the client's chart that they received this information and the documentation must be retained for a minimum of five years. It is recommended that the information be given twice, once at the first prenatal visit and again after delivery.

Information for Parents of Newborns

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 people on Medicaid to provide them, and additional parent(s) or other adult caregiver(s), with a resource guide for the infant including information about the development, health and safety of a child from birth until age five. The resource guide must provide information about medical home, dental care, effective parenting, child safety, importance of reading to a child, expected developmental milestones, health care and other resources available in the state, and selecting appropriate childcare.

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

Dental Clinical Policy

Provide dental services based on American Dental Association (ADA) or other nationally recognized, evidence-based guidelines.

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

Grantees must assist clients to meet identified PHC needs, either directly or by referral. When services required as part of the HHSC PHC grant are to be provided by referral, the grantee must establish a written agreement with a referral resource for the provision of services and reimbursement of costs. They must assure that the client is charged no more than the appropriately assessed copay fee.

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

  • tracking pending tests until results are reviewed by the provider and the individual is notified of their results and recommended follow-up;
  • documentation of all tests and results in the individual’s health record;
  • a mechanism to inform individuals promptly of test results that protects the person’s privacy and confidentiality while supporting and promoting timely, appropriate follow-up and complies with state or federal requirements for transfer of health information;
  • a mechanism to track individual compliance with recommended follow-up care, schedule return visits and follow-up on missed appointments; and
  • A process to ensure compliance with all applicable state and local laws for Sexually Transmitted Infections (STI) reporting requirements.

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

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

For services determined to be necessary, but which are not provided by the grantee, refer clients to other resources for care.

For referral purposes, grantees are expected to have established communications with Federally Qualified Health Centers (FQHCs) or HHSC funded organizations that provide breast cancer and cervical cancer services, if there are any such providers within their service area. Whenever possible, clients should be given a choice of referral resources from which to select.

When a client is referred to another resource because of an abnormal finding or for emergency clinical care, the grantee must:

  • Plan for the provision of pertinent client information to the referral resource (obtaining required client consent with appropriate safeguards to ensure confidentiality, i.e., adhering to HIPAA regulations).
  • Advise the client about her or his responsibility in complying with the referral.
  • Follow up to determine if the referral was completed.
  • Document the outcome of the referral.

Clients who have an abnormal clinical breast exam (CBE) or cervical cytology findings may be scheduled to return for repeat exams if this is to be an appropriate follow up by the clinician. For clients whose cervical cytology test or CBE result in an abnormal finding that requires referral for services beyond those available through PHC, grantees are encouraged whenever possible to refer to an HHSC Breast and Cervical Cancer Services (BCCS) grantee. In order to promote the most effective use of limited resources, PHC grantees’ clinicians should be familiar with nationally recognized guidelines and algorithms describing recommended practices for abnormal cervical cytology and CBE results.

5300, Prescriptive Authority Agreements, Clinical Protocols, Standing Delegation Orders and Client Education

Revision 23-2; Effective Sept. 15, 2023

Grantees that provide clinical services must develop and maintain written clinical prescriptive authority agreements (PAAs), protocols and standing delegation orders (SDOs) in compliance with statutes and rules governing medical, dental, and nursing practice and consistent with national evidence-based clinical guidelines. When HHSC revises a policy, grantees need to incorporate the revised policy into their written procedures.

5310 Prescriptive Authority Agreements

Revision 23-2; Effective Sept. 15, 2023

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

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

References

5320 Protocols

Revision 23-2; Effective Sept. 15, 2023

Grantees that employ advanced practice nurses or physician assistants must have written protocols to delegate authorization to initiate medical aspects of client care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than have two documents, this delegation can now be included in a prescriptive authority agreement (PAA) if both parties agree to do so. The PAA or protocols need not describe the exact steps that an APRN or a PA must take with respect to each specific condition, disease or symptom.

The protocols must be reviewed, agreed upon, signed and dated by the supervising physician and the PA or APRN at least annually and maintained on-site as mandated by Texas Administrative Code, Title 22, Part 11, Chapter 221, Rule 221.13

5330 Standing Delegation Orders

Revision 23-2; Effective Sept. 15, 2023

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

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

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

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

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

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

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

References

5340 Client Education

Revision 23-2; Effective Sept. 15, 2023

In addition to the above, grantees must have written plans for client education that include goals and content outlines to ensure consistency and accuracy of information provided. Grantees’ plans for client education must be reviewed and signed by the clinic medical director.

6100, Reimbursement, Data Collection, and Reports

Revision 23-2; Effective Sept. 15, 2023

Categorical Reimbursement

PHC categorical funding (cost reimbursement) is used to develop and maintain grantee infrastructure for the provision of primary health care and related health services. The funding can be used to support clinic facilities, staff salaries, utilities, medical and office supplies, equipment, travel and direct medical services. All services will be reimbursed on a cost reimbursement basis. Costs may be assessed against any of the following categories the grantees in the submitted budget workbook:

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

PHC funds are disbursed to grantees through an invoicing system as expenses are incurred during the grant period. Program income must be expended before categorical funds are requested through the reimbursement process. Grantees are required to submit a Monthly Reimbursement Packet (MRP) once their awarded funds are spent. When all awarded funds are spent, no additional funds will be available to the grantee for reimbursement.

When program expenses exceed program income, the invoice will result in a payment. Program income includes all fees paid by PHC program clients, client copay collection, and non-HHSC funds such as grants and donations. Budget revision must be submitted to HHSC for approval.

Accurate financial records must be maintained for quality assurance, fiscal monitoring, and programmatic evaluation by HHSC.

Monthly Reporting Packet (MRP)

At the start of each contract year, grantees will access their organization’s personalized Monthly Reporting Packet (MRP) from the SharePoint Contractor Portal.

The MRP and the required supporting documentation which must include a detailed general ledger and any documents that support the requested reimbursement are required to be completed and submitted monthly within 30 calendar days after the last day of the preceding month. All late submissions require a justification. MRPs that are incomplete or incorrect will be returned for corrections. All corrections are due within five business days.

MRP’s that have been altered will not be accepted.

Quarterly Submission Requirements

In addition to the monthly submission requirements, the following are required to be submitted quarterly:

  • Form 225, section B - Service Category
  • Signed Financial Status Report (Form 269A)

Quarterly requirements are due by the last business day of the month following the end of each quarter. The exception is the final quarter, which is due 45 calendar days after the end of the contract period (Oct. 15).

Reconciling Errors on Previously Submitted MRPs

If expenses are overstated on one month’s invoice, the following month’s expenses should be reduced accordingly. 

Submission and Reporting after Entire Contract Award is Expended

Grantees must continue to submit the MRP even after grant award amount has been reached. Any cost over the grant award after deducting program income should be reflected under “Non-HHSC Funding.” This reporting is required to provide HHSC with statistical information about the use of services.

Submission of Final MRP

Grantees may have claims after the submission of their August billing. Any additional invoices must be received by Oct. 15. Mark this as FINAL.

Submit all claims for reimbursement for services delivered within 45 calendar days of the end of the contract. Reimbursement requests submitted more than 45 calendar days following the end of the grant term will not be paid.

Forms

ES = Spanish version available.

FormTitle 
3029Application for Program BenefitsES
3045Presumptive Eligibility NoticeES
3046Statement of Applicant’s Rights and ResponsibilitiesES
3047Notice of IneligibilityES
3048Notice of EligibilityES
3049Employment VerificationES
3051Statement of Self-Employment IncomeES
3056Request for InformationES
4116Authorization for Expenditures 

23-2, Miscellaneous Revisions

Revision 23-2; Effective Sept. 15, 2023

SectionTitleChange
HandbookPrimary Health Care Services Program Policy ManualUpdates handbook title to Primary Health Care Program Policy Manual.
1100Contact InformationRemoves physical address for courier service and helpline information.
1200Purpose of ManualUpdates language.
2100Program Authorization and ServicesUpdates language. 
2200Definitions Updates definitions throughout.
3100      Administrative PoliciesUpdates language. Revises civil rights requirements. Adds requirement to maintain appropriate exterior signage.
3110Client AccessUpdates language.
3120Important Information for Former Military Service MembersUpdates language.
3200Abuse and Neglect ReportingUpdates language. Revises abuse, neglect and exploitation requirements.   
3210Child Abuse Reporting, Compliance and Monitoring Updates title to Child Abuse or Neglect and updates language.
3220Human TraffickingUpdates language.
3230Domestic and Intimate Partner ViolenceUpdates language.
3300ConfidentialityUpdates language. 
3310Minors and ConfidentialityUpdated link to resource.
3320Nondiscrimination and Limited English Proficiency (LEP)Updates language. Adds requirement to display civil rights posters.
3330Termination of ServicesUpdates language.
3340Resolution of ComplaintsUpdates language.
3350Research (Human Subject Clearance)Updates language.
3400Client Records ManagementUpdates language.
3500Personnel Policy and ProceduresUpdates language. Revises immunization guidance.
3600Facilities and EquipmentUpdates language. Revises facility requirements. 
3610Hazardous MaterialsUpdates language. 
3620Fire SafetyUpdates language.
3630Medical EquipmentUpdates language.
3640Radiology Equipment and StandardsNo changes
3645Laboratory StandardsCreates section on laboratory requirements.
3650Smoking BanUpdates language.
3660Disaster Response PlanDeletes this section and moves information to 3720.
3700Emergency ResponsivenessUpdates language.
3710Clinical EmergenciesUpdates language. Adds Dental Emergency Responsiveness. 
3720Emergency PreparednessUpdates language. Adds Disaster Response Plan.
3800Quality ManagementUpdates language. Revises Quality Management requirements.
4100Eligibility and Assessment of Copay and FeesUpdates language. Adds a process to apply for approval to use an Alternate Eligibility Tool. Added reference to Appendix II.
4200Client Eligibility Screening ProcessUpdates language. 
4300 Procedures and Terminology When Determining PHC EligibilityUpdates language. Revises potential eligibility and referral requirements. Adds requirement to document special circumstances.
5000Clinical GuidelinesUpdates language. Describes required and additional services that may be provided. 
5100General ConsentUpdates language. 
5110Consent for Dental ProceduresUpdates language.
5120Consent for Sterilization ProceduresUpdates text.
5130Texas Medical Disclosure Panel ConsentUpdates language.
5140Consent for Services Provided to MinorsUpdates language. Adds resources.
5150Consent for HIV TestsUpdates title to Consent for Human Immunodeficiency Virus (HIV) Tests. Updates language.
5200Clinical PolicyUpdates language. Defines telehealth services. Includes quit line information. Revises colorectal cancer screening age. Updates links to resources. Revises requirements for appropriate follow-up and continuity of care. Removes duplicate requirement for maintaining 2-1-1 information.
5300Prescriptive Authority Agreements, Clinical Protocols, Standing Delegation Orders and Client EducationUpdates language. 
5310Prescriptive Authority Agreements Updates title to Prescriptive Authority Agreements (PAAs). Updates language. Revises PAA requirements.
5320ProtocolsUpdates language.
5330Standing Delegation OrdersUpdates language. Revises SDO requirements. 
5340Client EducationUpdates language. Removes resources.
6000Reimbursement, Data Collection and ReportingUpdates language.
6100Reimbursement, Data Collection and ReportsUpdates language. Removes information from this section and adds to section 4000. 
FormsFormsUpdates form titles.

23-1, Appendix II Revised

Revision 23-1; Effective Mar. 31, 2023

RevisedTitleChange
Appendix IIOptional Co-Pay Table Based on Monthly Federal Poverty Level (FPL)Updates the co-pay table based on the 2023 monthly Federal Poverty Level (FPL).

22-4, Miscellaneous Revisions

Revision 22-4; Effective Sept. 16, 2022

The following change(s) were made:

Revised Title Change
1100 Contact Information Updates Helpline contact information.
3100 Administrative Policies Includes information for contractors about maintaining clinic information on 2-1-1.
3330 Termination of Services Revise when and how services can be terminated and the client's right to appeal.
3340 Resolution of Complaints Updates contact information for client appeal and the process to follow.
4000 Eligibility and Fees Updates policy for eligibility determination.
4100 Eligibility and Assessment of Co-Pay/Fees Clarifies when an applicant can appeal and eligibility decision.
4200 Client Eligibility Screening Process Updates the eligibility determination process.
4300 Procedures and Terminology When Determining PHC Eligibility Updates the eligibility procedures and terminology.
5000 Clinical Guidelines Updates the clinical guidelines to reword.
5100 General Consent Updates the general consent.
5200 Clinical Policy Updates the clinical policy.
6000 Reimbursement, Data Collection and Reporting Updates the reimbursement, data collection, and reporting.
6100 Reimbursement Updates the reimbursement.

22-3, Appendix II Revised

Revision 22-3; Effective April 14, 2022

The following change(s) were made:

Revised Title Change
Appendix II Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL) Updates the 2022 FPL co-pay amounts effective April 14, 2022.

22-2, Miscellaneous Changes

Revision 22-2; Effective April 8, 2022

The following change(s) were made:

Revised Title Change
1100 Contact Information Revises the Primary Health Care Services Program mailing address ZIP code.
2100 Program Authorization and Services Updates a link to Texas Administrative Code (TAC).
3330 Termination of Services Updates a TAC link.
Appendix II Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL) Updates the 2022 FPL co-pay amounts effective March 1, 2022.

22-1, Section 1100 Revised

Revision 22-1; Effective February 7, 2022

The following change(s) were made:

Revised Title Change
1100 Contact Information Updates the mailing address, physical address for courier service, Helpline extension, phone number, email and website for the Primary Health Care Services Program.

21-2, Section 5200 Revised

Revision 21-2; Effective September 15, 2021

The following change(s) were made:

Revised Title Change
Section 5200 Clinical Policy Adds pelvic examinations must be administered in compliance with Chapter 167A of the Health and Safety Code, updates links to the 2021 CDC Guidelines and 2021 Morbidity and Mortality Weekly Report Sexually Transmitted Diseases Treatment Guidelines, deletes a reference to the Recommendations for Providing Quality Sexually Diseases Clinical Services, and adds prenatal and postpartum services must be provided based on ACOG or other nationally recognized, evidenced-based services and dental services must be provided based on ADA or other nationally recognized, evidence-based services.