2000, Program Authorization, Services and Definitions
Revision 23-2; Effective Sept. 15, 2023
Revision 23-2; Effective Sept. 15, 2023
Revision 24-2; Effective Sep. 16, 2024
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:
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.
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:
PHC provides services through contracted providers (grantees) for people 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 ensure 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 person’s culture.
PHC program services are funded by state general revenue. HHSC PHC funds are allocated through a competitive application process, and then 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 of abortion procedures. This includes overhead, rent, phones and utilities.
Revision 24-2; Effective Sep. 16, 2024
The following words and terms, when used in this manual, have the following meanings:
Barrier to Care – A factor that hinders a person from receiving care, for example, proximity or distance, lack of transportation, documentation requirements or copayment amount.
Client – A person who has been screened and determined to be eligible for the program.
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, helps with the evaluation or management of a client.
Copayment or Copay – Money collected directly from clients for services.
Dental Services – Diagnostic, preventive, and therapeutic dental services that are provided to eligible client and are performed in a dental office, clinic, or by teledentistry. 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 2 years and $175 per month for each child 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:
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 such as 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 people related by birth, marriage including common law, or adoption, who live 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 subrecipient.
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 people 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 people.
Health Screening – The provision of tests such as blood glucose, serum cholesterol and fecal occult blood, as a means of determining the need for intervention and perhaps a more comprehensive evaluation.
Laboratory or 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) such as physicians, dentists and mid-level providers, to evaluate a client’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 – Per 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 such as emancipated. In this policy manual, minor and child may be used interchangeably.
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, subrecipient or provider for services provided under the grant award such as third-party reimbursements, Title XIX, private insurance and client 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.
Subrecipient— 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 subrecipient may also be a grantee of other state awards directly from a state awarding agency. A subrecipient may also be referred to as a subgrantee or a subcontractor.
Teledentistry- A health service delivered by a dentist, or a health professional acting under the delegation and supervision of a dentist, within the scope of the dentist's or health professional's license or certification to a client at a different physical location than the dentist or health professional using telecommunications or information technology.
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 client at a different physical location than the health professional using telecommunications or information technology.
Telemedicine Medical Service – A health care service delivered to a client at a different physical location than the physician or health professional using telecommunications or information technology. Service is done 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 – A person who lives 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 –A client who is counted only one time during the program’s fiscal year, regardless of the number of visits, encounters or services they receive. Example: one client seen four times during the year is counted as one unduplicated client.