Title V Maternal and Child Health Fee-for-Service Program Policy Manual

1000, Grant Information and Purpose of Manual

Revision 23-2; Effective Sept. 8, 2023

1100 Grant Information

Revision 23-2; Effective Sept. 8, 2023

Mailing Address

Title V MCH Fee-For-Service Program
North Austin Complex
4601 W Guadalupe Street, Mail Code 0224
Suite number- 4.507
Austin Texas 78751-2920

Email

titlevffs@hhs.texas.gov

Websites

Title V Maternal & Child Health Fee for Service Program

1200 Purpose of Manual

Revision 24-2; Effective Sept. 30, 2024

The Texas Health and Human Services Commission (HHSC) Title V Maternal and Child Health Fee-for-Service (TVFFS) Program Policy Manual is a guide for grantees who deliver TVFFS in Texas. The manual is structured to provide 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 TVFFS health care services. Grantees are required to be aware of and comply with existing laws.

2000, Program Authorization, Services and Definitions

Revision 23-2; Effective Sept. 8, 2023

2100 Program Authorization and Services

Revision 24-2; Effective Sept. 30, 2024

Title V Maternal and Child Health Fee-for-Services (TVFFS) Program Background

The purpose of the Maternal and Child Health (MCH) Services Title V Block Grant is to create federal and state partnerships. These partnerships provide direct services to low-income women and children not eligible for Medicaid, Children’s Health Insurance Program (CHIP), CHIP Perinatal, or another payor source that covers these same services. TVFFS grantees provide services:

significantly reducing infant mortality;
including comprehensive care for women before, during, and after pregnancy and childbirth; and
including preventive and primary care services for infants, children and adolescents.

Legal Authority

Through Title V of the Social Security Act (SSA) of 1935, the federal government pledged to support state efforts to improve the health of all mothers and children. The MCH Block Grant Program under Title V of the SSA was created in 1981 to consolidate multiple programs. These programs support a more comprehensive, coordinated approach to meeting states’ individual needs consistent with the applicable health status goals and national health objectives now identified in Healthy People 2030.

Within Texas, TVFFS operates within a framework articulated by the Texas Legislature and Texas Health and Human Services Commission (HHSC).

States are required to use awarded federal funds as follows:

30% for preventive or primary care services for children
30% for services for children with Special Health Care Needs
Up to 10% on administrative costs
Remaining funds to support other MCH populations, such as pregnant women and mothers

Funding Sources

TVFFS program services are funded both by state general revenue and federal funds through the Title V MCH Block Grant. HHSC TVFFS funds are allocated through a competitive application process. After the funds are allocated, selected applicants negotiate contracts with HHSC to provide services.

2200 Definitions

Revision 24-2; Effective Sept. 30, 2024

The following terms, when used in this manual, mean the following:

Barriers to Care – A factor that hinders a person from receiving health care. For example, distance, lack of transportation, documentation requirements and copayment amounts.

Case Management – Relating to pregnant women, this means services to assure access to quality prenatal, delivery, and postpartum care. With respect to infants, children, and adolescents, it means services to assure access to quality preventative and primary care services.

Children’s Health Insurance Program (CHIP) – A health insurance program for non-Medicaid eligible children with a family income up to 198% Federal Poverty Level (FPL).

CHIP Perinatal Program – An HHSC program that provides medical coverage for perinatal care of unborn children of non-Medicaid eligible women with an income up to 202% FPL.

Children and Adolescents – People from their first birthday through the 21st year of age.

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.

Consultation – A type of service provided by a health care provider with expertise in a medical or surgical specialty. These providers help with the evaluation or management of a patient when requested by another appropriate health care provider.

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

Dental Services – Diagnostic, preventive, and therapeutic dental services that are provided to clients and are performed in a dental office or clinic.

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 of 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: microscopic (culture), chemical (blood tests), or radiological examinations (x-rays).

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

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 per family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines. Public assistance programs, such as Medicaid, define eligibility income limits as some percentage of FPL.

Fee-for-Service (FFS) – Payment mechanism for services that are reimbursed on a set rate per unit of service (also known as unit rate).

Fiscal Year – The state fiscal year is from 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.

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 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.

Nutritional Services – The provision of services to identify the nutritional status of a person, and instruction which includes appropriate dietary information based on the client’s needs such as age, sex, health status and culture. This may be provided to a person on a one-to-one basis or to a group of people.

Payor Source – Programs, benefits or insurance that pays for the service provided.
Prescription Drugs, Devices and Durable Supplies – Medically necessary pharmaceuticals and medical supplies that are capable of withstanding wear, which are needed for the treatment of a diagnosed condition.

Prescription Drugs, Devices and Durable Supplies – Medically necessary pharmaceuticals and medical supplies that are capable of withstanding wear, which are needed for the treatment of a diagnosed condition.

Preventive Health Care – Services include but are not limited to 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 or provider for services provided under the grant award.

Promotores or Community Health Worker (CHW) – A person who, with or without compensation, is a liaison and provides cultural mediation between health care and social services and the community. A certified CHW is a person with current certification as a CHW issued by DSHS.

Provider – A person clinician or group of clinicians who provide services.

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

Referral Agency – An agency that provides a service for the TVFFS client that the TVFFS grantee does not provide, and it is not a reimbursable TVFFS service.

Subrecipient  – A non-state entity that receives a subaward from a pass-through entity to carry out part of a state program. It does not include a person 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.

Teledentistry – A health service delivered by a dentist, or a health professional acting under the delegation and supervision of a dentist. They are acting within the scope of the dentist's or health professional's license or certification to a patient at a different physical location than the dentist or health professional using telecommunications or information technology.

Telehealth – A health service, other than a telemedicine medical service or a teledentistry dental 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 – A health care service delivered 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 to a patient at a different physical location than the physician or health professional using telecommunications or information technology.

Texas Resident  – A person who lives within the geographic boundaries of the state of Texas.

Transportation  – Services that may be provided to transport a client for receiving required health care services. Transportation could be provided by private vehicle, public transportation, project site vehicle or emergency medical vehicle.

Unduplicated Client  – A client who is counted only one time during the program’s fiscal year for each Title V program they participate in which include Prenatal Medical, Prenatal Dental, Child Health, and Child Dental. If a client participates in more than one Title V program, only their first visit of the fiscal year will be counted as an unduplicated client for each program they participate in.

3000, Administrative Policy

Revision 23-2; Effective Sept. 8, 2023

This section assists the grantee in conducting administrative activities such as assuring client access to services and managing client records.

3100 Accessibility

Revision 24-2; Effective Sept. 30, 2024

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 accurately maintain in their 2-1-1 listings includes, but is not limited to, clinic phone number, location, hours of operation, and services provided.

Client Access

Grantee 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. Grantees must ensure that clients are provided services in a timely and nondiscriminatory 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, and ensure services are accessible to people 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 people who cannot be served or cannot receive a specific needed service.
Maintain appropriate exterior signage identifying the entity as a health care facility.
Ensure clinic or reception room wait times are reasonable and do not present a barrier to care.

3200 Abuse and Neglect Reporting

Revision 24-2; Effective Sept. 30, 2024

Grantees must obey state laws governing the reporting of suspected abuse and neglect.

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

Grantees must have written policies and procedures in place to identify and appropriately report abuse, neglect, and exploitation of:

the elderly and adults with disabilities (The Texas Human Resources Code, Chapter 48); and
child abuse and neglect (Chapter 261 of the Texas Family Code).

In addition, grantees must have written policies and procedures in place to identify and respond to:

human trafficking; and
domestic and intimate partner violence (in Texas Family Code- Chapter 91).

Grantees must provide annual staff training on each separate policy and procedure.

Child Abuse and Neglect

Child Abuse and Neglect Policies must include:

Medical professionals to make a report by the 48th hour after first suspecting a child has been abused or neglected or is a victim of an offense.
Guidelines on determining, documenting, reporting, and tracking instances of abuse, sexual or non-sexual, or neglect for all people 17 years and younger to comply with Texas Family Code, Chapter 261.

Additional information for abuse reporting: Texas Department of Family and Protective Services.

Human Trafficking

Grantees must comply with all state and federal anti-trafficking laws, including the Trafficking Victims Protection Act of 2000 (22 USC Section 7101, et seq.) and Texas Occupations Code Sections 116.002 and 116.003, which requires health practitioners to complete a HHS-Approved Human Trafficking Course for every licensure renewal period.

Grantee written policies on human trafficking must include:

human trafficking definition;
how to identify possible situations of human trafficking;
the screening tool used to identify possible situations of human trafficking;
what to do and who to report to if human trafficking is suspected;
mandatory reporting of suspected child human trafficking; and
victim support resources.

Resources for Human Trafficking Policy Development 

Texas Health and Human Services Human Trafficking Resource Center 
Texas Health and Human Services Health Care Practitioner Training Page
Human trafficking into and within the United States: A review of the literature on human trafficking in the U.S. for the U.S. Department of Health and Human Services. 
Polaris Project website: Contains links to victim and survivor support, other resources for health care providers and victims, and lists of common identifiable features of human trafficking victims in multiple settings. 
Resource Library on the National Human Trafficking website.  
HEAL Trafficking. 
Rescue and Restore Campaign by the U.S. Department of Health and Human Services. Contains multiple resources for health care providers, social service personnel and law enforcement for identifying and aiding trafficking victims. Includes slide presentations for training purposes.

Domestic and Intimate Partner Violence (IPV)

IPV describes physical, sexual, or psychological harm by a current or former partner or spouse. Per Texas Human Resources Code, Chapter 51, family violence may also include emotional harm and a threat of harm. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.

Grantees must comply with all requirements listed in Texas Family Code- Chapter 91 and have a written policy about assessment and prevention of domestic and IPV.

Find more information on IPV on the Centers for Disease Control and Prevention website. The National Domestic Violence Hotline is 800-799-7233. It operates 24/7 and provides interpretation services in over 200 languages.

3300 Confidentiality

Revision 24-2; Effective Sept. 30, 2024

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

Grantees are required by HIPPA Privacy Rule to develop and distribute a notice that provides a clear explanation of privacy rights and practices.  This Notice of Privacy Practices must be given to clients at the first appointment, upon request, and at minimum, every three years. The notice must also be posted in a clear and easy to find location for clients to view and must be posted on the organization’s website. Review Notice of Privacy Practices for Protected Health Information | HHS.gov, Notice of Privacy Practices | HHS.gov  for more information.

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, subrecipients, board members and advisory board members must sign a confidentiality statement during orientation.

A Grantee must document the person’s preferred method of communication such as cell phone, email, work phone or text, and preferred language 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 mandatory reporting. A health care provider must not require consent for services from the spouse of a married client.

Minors and Confidentiality

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 person 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 uses and disclosures 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. Review Code of Federal Regulations - 45 CFR Section 164.502(g).

Review Adolescent Health – A Guide for Providers for more information (PDF).

3310 Civil Rights

Revision 24-2; Effective Sept. 30, 2024

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

Title VI of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d et seq.);
Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Section 794);
Americans with Disabilities Act of 1990 (42 U.S.C. Section 12101 et seq.);
Age Discrimination Act of 1975 (42 U.S.C. Sections 6101-6107);
Title IX of the Education Amendments of 1972 (20 U.S.C. Sections1681 et seq.); and
Administrative rules for HHS agencies, as set forth in the Texas Administrative Code (TAC), Title 1, Part 15, Chapter 395 Civil Rights.

These laws partially provide that no people in the United States may, on the grounds of race, color, national origin, sex, age, disability, political beliefs, or religion, be excluded from participation in or denied any aid, care, service, or other benefits provided by federal or state funding, or otherwise be subjected to discrimination.

State and federal civil rights laws require contractors provide alternative methods to ensure access to services for applicants and recipients who cannot express themselves fluently in English. Grantee agrees to take reasonable steps to provide services and information, both verbally and in writing, in appropriate languages other than English, to ensure that people with limited English proficiency are effectively informed and can have meaningful access to programs, benefits and activities.

Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights website.

3320 Required Signage

Revision 24-2; Effective Sept. 30, 2024

Grantees providing direct services to clients must display certain HHS posters related to civil rights.  The posters must be displayed in areas where clients and the public can easily view them, such as lobbies, waiting rooms, front reception desks, and locations where people apply for and receive HHS services. The following posters are required:  

Grantees are encouraged to display signage about suicide prevention, including the 988 Suicide and Crisis Lifeline. If grantee elects to display such signage, it must be displayed in areas where it is easily viewed by clients and the public, such as lobbies, waiting rooms, front reception desks, and locations where people apply for and receive services. Examples of a suitable flyers are available here: 

Additional mental health and suicide prevention resources are available here:  

3330 Complaints and Termination of Services

Revision 24-2; Effective Sept. 30, 2024

Termination of Services

A grantee must never deny services to an eligible client 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
the client’s behavior jeopardizes their own safety, or the safety of clinic staff or others.

A termination of services policy must be included in the grantee’s policy manual.

If a grantee denies, modifies, suspends, or terminates services to a client, an explanation must be documented in the client’s record. A client has the right to appeal the denial, modification, suspension, or termination of services by following the Resolution of Complaints process.

Resolution of Complaints

Grantees must ensure that clients can express concerns about care received and 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.

1. Grantees must investigate and resolve a complaint or concern within 30 business days, beginning on the day they are notified by the aggrieved client.

2. Clients may contact the grantee during and after the resolution of an investigation to receive more information on the grantee's decision or help to correct the issue.

3. Grantees must provide the client with contact information to the HHS Office of the Ombudsman. If a client has requested additional assistance from the Ombudsman, a grantee must not terminate services to that client until a final decision is rendered by HHSC, unless there is a viable risk to the safety of the aggrieved client, clinic staff, or others.

4. All complaints and concerns must be documented in the client's record.

3340 Research (Human Subjects Clearance)

Revision 24-2; Effective Sept. 30, 2024

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

The grantee must have a policy in place indicating prior approval will be obtained from the HHSC TVFFS Program, as well as the IRB, before 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 24-2; Effective Sept. 30, 2024

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 when necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. If the client is 17 years 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 per federal and state law.

When information is requested, grantees should release only the specific information requested. Information collected for reporting purposes may be only 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, providers, and subrecipients must maintain all records pertaining to client services, contracts and payments, for the time specified by HHSC. 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 Policies and Procedures

Revision 24-2; Effective Sept. 30, 2024

Grantees must develop and maintain personnel policies and procedures to ensure that clinical staff are hired, trained and evaluated appropriately to their job position. Contracted staff must also be trained and evaluated per their responsibilities. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. Grantees should follow the Advisory Committee on Immunization Practices (ACIP) for immunization of health care 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 including skills evaluation or competencies appropriate for the position; and
a performance evaluation process for all staff.

Grantees must show evidence that employees meet all required qualifications and have 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 in ways 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 TVFFS medical director for the clinic must be a Texas-licensed physician and the TVFFS dental director for the clinic must be a Texas 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 or 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 24-2; Effective Sept. 30, 2024

Grantees must always maintain a safe environment and provide clean and well-maintained facilities where services are 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) the grantee intends to serve. Grantees must have written policies and procedures that address hazardous materials, fire safety and medical equipment.

Hazardous Materials

Grantees must have written policies and procedures that address:

the handling, storage, and disposal of hazardous materials and waste per 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.

Fire Safety

Grantees must have a written fire safety policy that includes a schedule for testing and maintenance of fire safety equipment. Clearly post evacuation plans for the premises. They must be visible to all staff and clients.

Medical Equipment

Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment. This includes the 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 care and use of medical equipment.

Radiology Equipment and Standards

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

have a current Certificate of Registration from the Texas Department of State Health Services, Radiation Control Program;
have operating and safety procedures as required by Title 25 Texas; Administrative Code Chapter 289, Texas Regulations for Control of Radiation; and
post Notice to Employees, Texas Regulations for Control of Radiation.

Review the Texas Department of State Health Services, Radiation Control Program for information on X-ray machine registration.

Laboratory Standards 

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 get CLIA certification.  

Smoking Ban

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

3700 Emergency Responsiveness

Revision 24-2; Effective Sept. 30, 2024

Clinical Emergencies

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.
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 are trained in regarding the written plans or protocols.

Dental Emergencies

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. 

Emergency Preparedness

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 such as fires, flooding, power outage and bomb threats. The disaster plan must identify the procedures and processes that will be initiated during a disaster and the staff position(s) 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 verbally to employees. 

Review the  Occupational Safety and Health Administration website for more resources on facilities and equipment. 

3800 Quality Management

Revision 24-2; Effective Sept. 30, 2024

Grantees must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor TVFFS 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 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 the subcontracting entities.

The QM Committee, whose membership consists of key leadership of the organization, including the executive director or CEO, the medical director and 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 must, at minimum:

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 people responsible for implementing monitoring, evaluating and reporting;
establish timelines for quality monitoring activities;
identify tools and forms to be utilized; and
outline reporting to the QM Committee.

Although each organization’s QA program is unique, the following activities are required by all agencies that provide client services:

ongoing eligibility, billing, and clinical record reviews to assure compliance with program requirements and clinical standards of care;
utilization review:
client satisfaction surveys;
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;
annual review of facilities to maintain a safe environment, including an emergency safety plan; 
annual review and update of all prescriptive authority agreements (PAAs), including protocols, for mid-level providers;
annual review of all standing delegation orders (SDOs) and clinical protocols; and
annual review of all policies and forms.

The review or revision date must be clearly noted on each policy, form, agreement, and order that is in use. 

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;
utilization 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 QM Committee and should be documented.

4000, Eligibility and Fees

Revision 23-2; Effective Sept. 8, 2023

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

4100 Eligibility and Assessment of Co-pay and Fees

Revision 24-2; Effective Sept. 30, 2024

Grantees must:

Develop a policy to show how staff will determine TVFFS program client eligibility. The policy must outline the grantee’s procedures to determine program eligibility and responsible party for eligibility screening. 
Use the most recent version of Form 3029, Application for Benefits to screen applicants for program eligibility, or an HHSC-approved alternate eligibility screening tool.

Alternate Eligibility Screening Tools

An alternate eligibility screening tool created by the grantee may be used in place of Form 3029 with prior written approval by TVFFS program. To apply for approval, the grantee must send a request for an Application for Alternate Eligibility Tool to the TVFFS program mailbox. The alternate eligibility tool must contain, at minimum, all required elements of the Form 3029. 

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

Grantees must request approval from TVFFS 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 contract cycle. If a grantee is awarded funding under a later contract, 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 HHSC 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 TVFFS program reserves the right to request more edits or withdraw its approval of the use of an alternate eligibility tool. TVFFS program will notify the grantee of the decision in writing and include the date that the alternate tool must be discontinued.

Information for Former Military Service Members

Women and men who served in any branch of the United States Armed Forces, Reserves or National Guard, may be eligible for additional benefits and services. They must be referred to the Texas Veterans Portal for more information.

Client Eligibility Screening Process

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

gross family income at or below 185% of the Federal Poverty Level (FPL);
Texas resident; and
not eligible for other programs or benefits providing the same services.

The TVFFS Child Health and Dental program serves people from birth until their 22nd birthday. The TVFFS Prenatal Medical and Dental program serve pregnant women of any age through three months postpartum, including following pregnancy loss.

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

Instead 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. 

If an applicant is unable to provide the information required to determine eligibility, eligibility staff should ask the applicant to designate a contact person to provide the information.

Upon award expenditure, grantees are not required to screen new clients for TVFFS eligibility. However, if a screening is completed, the grantee must provide services to eligible clients.

Potential Eligibility and Referral to Other Programs

Screening for other benefit programs must be documented on the Application for Program Benefits form. 

The TVFFS Program is the payor of last resort. Applicants must be screened for Medicaid, CHIP, CHIP Perinatal, and any other benefit programs. TVFFS will not reimburse for services provided to people 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 for which they appear eligible are not eligible for TVFFS, 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 TVFFS 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 TVFFS eligibility assessment. If a client was denied Medicaid or CHIP services, the denial letter must be included with the application. 

All pregnant women served by TVFFS must apply for Medicaid or CHIP Perinatal programs. 

Providers are required to inform, encourage, and assist pregnant women in the CHIP Perinatal and Medicaid for Pregnant Women application process. A maximum of two clinical prenatal care visits are allowed for women in the process of applying for and enrolling in the CHIP Perinatal and Medicaid for Pregnant Women programs.  

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. 

TVFFS clients who enroll in a Managed Care Organization (MCO) that does not provide any dental benefits will remain eligible for TVFFS Prenatal Dental benefits. These clients must provide documentation that their MCO does not provide dental benefits to continue receiving TVFFS dental benefits. This documentation must be maintained in the client record.

Household

The household includes a person living alone, or a group of two or more people related by birth, marriage which includes common law, or adoption, who live 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 his or her partner have mutual children together. Unborn children should also be included. A child must be under 18 years old to be counted as part of a larger family. Once a child turns 18, they should complete their own program application, listing themselves as the applicant.

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 Date of Birth

Documentation of date of birth must be provided for clients applying for the Child Health or Child Dental programs. One of the following should be provided and a copy should be kept with the client’s application:  

birth certificate;
baptismal certificate;
school records; or
other documents or proof of date of birth determined valid by the grantee.

Documentation of Family Composition

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

birth certificate;
baptismal certificate;
school records; or
other documents or proof of family relationship determined valid by the grantee to establish the dependency of the family member with the client or head of household.

Family members who receive other health care benefits are included in the family count. The grantee has discretion to document special circumstances in the calculation of family composition. Additionally, if a separate family group is established within the household based on the documentation gathered, document the basis used for determining separate households, if applicable.

Documentation of Residency

To be eligible for TVFFS services, a person must be physically present within the state of Texas and:

have the intent to remain within the state, whether permanently or for an indefinite period;
not claim residency in any other state or country; or
if a person is less than 18 years old, a parent, managing conservator, caretaker or guardian is a resident of Texas as defined above.

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

Document proof of residency provided by the client on Form 3029, Application for Program Benefits. Explain why residency is questionable, if necessary. For documentation of residency, provide one of the following items:

valid Texas driver license;
current voter registration;
rent or utility receipts for one month before 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; or
other documents considered valid by the grantee.

If none of the listed items are available, verify residency through:

observance of personal effects and living arrangement; or
statements from landlords, neighbors or other reliable sources.

If a family is otherwise eligible, but residency is in question or dispute, the household is entitled to services until residency information is verified. 

People 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.

Documentation of Income

Include all income. Income is calculated before taxes (gross). Income is reviewed and determined either countable or exempt and is based on the source of the income, as defined in Appendix I, Definition of Income. Grantees must have a written TVFFS income verification policy.

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

Provide the following documentation:

at least two pay periods that accurately represent their gross 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 person’s usual and customary earnings. Proof may include, but is not limited to:

copy(ies) of the most recent paycheck(s) or 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;
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 period the income is expected to cover. Income received weekly, every two weeks or twice a month must be converted as follows:

weekly income is multiplied by 4.33;
income received every two weeks is multiplied by 2.17; and
income received twice monthly is multiplied by 2.

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

The grantee must determine the household FPL percentage, using current U.S Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change around the beginning of each calendar year.

The steps to determine the household FPL percentage are:

determine the household's total monthly income amount;
determine the household size;
divide the household’s total monthly poverty guideline based on the household size; and
multiply by 100.

There may be special circumstances where an applicant cannot provide required documentation for verification purposes. Document these types of special circumstances appropriately.

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 required child support payments made by a member of the household group may be deducted from 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 cannot provide required documentation for verification purposes. Document these types of special circumstances appropriately.

Copayments

Grantees may assess a copay for services from TVFFS clients. Grantees who choose to collect copays must have a copay policy using the following guidelines:

No TVFFS client shall be denied services based on an inability to pay.
Clients with a household FPL at or below 100% should 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 more 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 statement at the time of service and a copy should be kept in the client’s record.
Clients who declare an inability to pay a copay shall not be denied services. Any outstanding balance may 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 on the Monthly Reimbursement Packet (MRP). The grantee must complete B25 and E25.

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

Other Fees

Do not charge clients administrative fees for items such as processing or transfer of medical records and copies of immunization records.

Grantees can bill clients for services outside the scope of TVFFS allowable services if the service is provided at the client’s request and the client is made aware of 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 change:

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

The client may report changes by mail, phone, in person or through someone acting on the client'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.

Eligibility

Full program eligibility begins on the date the grantee determines a person or household is eligible for the program and all following requirements are met:

all program eligibility requirements are met;
program application is completed and signed; and
all verification documents are submitted.

To notify an applicant of eligibility, the grantee must issue Form 3012, Verification of Eligibility, to the client.

Presumptive Eligibility

Presumptive eligibility provides short-term access to healthcare services for up to 90 days when an applicant completes an application and screens as eligible and has a medical or dental need but lacks the required verification documentation. For clients who submit all required verification documentation during their presumptive eligibility period, full eligibility is given and the eligibility expiration date is calculated from the first day that presumptive eligibility began. The expiration date is 365 days from the first day of presumptive eligibility except for Perinatal benefits which expire at 3 months postpartum. 

If a medical condition makes eligibility determination impossible, make an appointment to complete the process at the first possible opportunity.

To notify an applicant of Presumptive Eligibility, the grantee must issue Form 3045, Presumptive Eligibility Notice to the client.

If the client enrolls in Medicaid or CHIP during the presumptive eligibility period, bill the services to Medicaid.

Ineligibility

If an applicant is determined to be ineligible for program services after the screening process is complete, the applicant must be given the Notice of Ineligibility, Form 3047. The applicant must also be informed of their right to appeal the eligibility decision using the process described on the Notice of Ineligibility.

Optional Forms

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

Form 3049, Employment Verification; and 
Form 3051, Statement of Self-Employment Income.

Annual Recertification

Annual eligibility determination is required for all clients who receive TVFFS services. Client eligibility must be determined every 12 months, using the most recent version of Form 3029, Application for Program Benefits. Perinatal benefits expire at three months postpartum.

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. 8, 2023

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

5100 General Consent

Revision 24-2; Effective Sept. 30, 2024

Grantees must get the client’s written, informed, voluntary general consent to receive services before receiving any clinical services. A general 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 when 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 may be obtained by phone. This type of consent is enough 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 consent. The client must sign the consent at the time of their next visit to the clinic. 

Consent information must be effectively communicated to every client in an understandable manner. This communication must allow the client to participate, make sound decisions about their own medical care, and address any disabilities that impair communication, in compliance with Limited English Proficiency regulations. Only the client may consent, except when the client is legally unable to consent, such as a minor or a person with a development disability, to which a parent, legal guardian or caregiver must consent on his or her behalf. Consent must never be obtained in a manner that could be perceived as coercive. 

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

Consent for Dental Procedures

Written informed consent for dental procedures must be obtained to comply with 22 Texas Administrative Code Section 108.7 about minimum standards of care for dentists.

Texas Medical Disclosure Panel Consent

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

determine which medical care and surgical procedure risks and hazards must be disclosed by health care providers or physicians to their patients or people 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 client for procedures per TMDP. TMDP has developed List A which is informed consent requiring full and specific disclosure, for certain procedures. It is found in 25 TAC Section 601.2.

For all other procedures not listed on List A, the physician must disclose, through a procedure specific consent, all risks that a reasonable client would want to know. These risks include all that:

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

Consent for Services Provided to Minors

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 never been declared an adult by a court (emancipated). However, there are certain circumstances when a minor may consent for their own treatment. Requirements for parental consent for provision of family planning services to minors vary per the funding source subsidizing the services. The department and providers may provide pregnancy testing, HIV testing, STI testing, and treatment for an STI, 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

Adolescent Health - A Guide for Providers (PDF)
Chapter 151 of the Texas Family Code: Rights and Duties in Parent-Child Relationship
Chapter 32 of the Texas Family Code: Consent to Treatment or Child by Non-Parent or Child
Pelvic Examinations – Chapter 167A of the Health and Safety Code

Consent for Human Immunodeficiency Virus (HIV) Tests

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

5200 Clinical Policy

Revision 24-2; Effective Sept. 30, 2024

Telemedicine

Providers may provide services by telemedicine, if appropriate.

Providers who give telemedicine services must follow all rules of the Texas Occupations Code, Chapter 111 and must have written policies and procedures for doing so including:

informed consent;
confidentiality of the client’s clinical information;
ensure appropriate, quality care;
prevent abuse and fraud in the use of telemedicine services;
ensure adequate supervision of health professionals who are not physicians and who provide telemedicine care;
establish the maximum number of health professionals that a physician may supervise through telemedicine services

Client Health Records and Documentation of Encounters

Providers must ensure that a client health record is established for every person who receives clinical services and must meet the requirements of the TAC Title 22, Part 9, Chapter 165, Rule 165.1.

All client 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 and title of the provider, the date for each entry.
Electronic signatures are allowable to document the encounter or provider review of care.  
Stamped signatures are not allowable.
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 and nonprescription medications, as well as dietary supplements, updated at each encounter;
a complete listing of all allergies and adverse reactions to medications, food and environmental substances such as latex;
if the client has no known allergies, this should be listed.
this information should be prominently displayed in the client’s record and updated at each encounter;
a plan of care, updated as appropriate, consistent with diagnoses and assessments, which 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 a treatment plan.

Case Management

Grantees must provide case management services on an as-needed basis to clients who require help accessing community resources.

For community services determined to be necessary, but not provided by the grantee, clients must be referred to other resources for assistance. Referrals and case management services must be documented in the clinical record.

Referral and Follow-Up

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

Whenever possible, clients should be given a choice of referral resources to choose from. 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 such as getting required client consent with appropriate safeguards to ensure confidentiality, including adhering to HIPAA regulations;
advise the client about her or his responsibility to comply with the referral;
follow up to determine if the referral was completed; and
document the outcome of the referral.

Before a grantee can consider a client as lost to follow-up, the grantee must have at least three documented attempts to contact the client.

The provider must comply with state and local sexually transmitted infection (STI) reporting requirements.

For services determined to be necessary, but not provided by the grantee, clients must be referred to other resources for care.

5300 Perinatal Clinical Guidelines

Revision 24-2; Effective Sept. 30, 2024

Perinatal Services

Provide prenatal and postpartum services based on American College of Obstetricians and Gynecologists (ACOG) guidelines. Perinatal visits include medical history, physical examination, laboratory and diagnostic testing, and education and counseling.  

Grantees may bill TVFFS for allowable services provided in clinical prenatal care visits for women during the CHIP Perinatal Program enrollment process. Review Monthly Reporting Packet (MRP) for reimbursable procedure codes.

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

Perinatal Laboratory and Other Diagnostic Tests

Include appropriate laboratory and diagnostic tests, as indicated by weeks of gestation and clinical assessment, in all prenatal visits. Grantees 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 of test results and documentation in client records; and
a mechanism to address abnormal results, facilitate continuity of care, and assure confidentiality, adhering to HIPAA regulations (i.e., making results and interventions accessible to the delivering hospital, facility, or provider).

Ultrasounds

Obstetrical ultrasounds will be reimbursed as recommended by ACOG guidelines.

Complete ultrasound – A complete evaluation of the pregnant uterus, performed between 18 and 22 weeks’ gestation, to include fetal number, viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.
Limited ultrasound – A brief, more limited evaluation to determine the number of fetuses, viability, presentation, dating measurements, limited anatomic assessment, placental location and characterization, and amniotic fluid assessment.

Non-Stress Test (NST)

Perform fetal assessment as medically necessary and may be billed as often as the provider deems the procedure to be medically necessary.

Biophysical Profile (BPP)/Fetal Biophysical Profile (FBPP)

The test combines fetal heart rate monitoring (nonstress test) and fetal ultrasound to evaluate a baby's heart rate, breathing, movements, muscle tone and amniotic fluid level. It may be done when results of other tests are non-reassuring.

Perinatal Education and Counseling Services

Grantees must have written plans for client education that include goals and content outlines to ensure consistency and accuracy of information provided. Education must be appropriate to client’s age, level of knowledge, socio-cultural background, and be presented in an unbiased manner.

Depression and Anxiety Screening

ACOG recommends that all clients be screened at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. Additional screening should occur during the comprehensive postpartum visit. For ease of administration in obstetric practices, Lifeline for Moms created a composite screener, with separate screeners for both the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9). Both screeners include the Mood Disorder Questionnaire (MDQ), General Anxiety Disorder (GAD-7), and Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). An additional safety screener is available to assess suicide risk.

Combined EDPS Screener and Scoring Sheet

Combined PHQ-9 Screener and Scoring Sheet

Patient Safety Screener

Tobacco Assessment and Quit Line Referral

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

Nutrition Counseling

Nutritional counseling by a licensed dietitian is not billable to TVFFS. Clients may be referred to Women, Infants and Children (WIC) for nutritional counseling.

State-Mandated Education

Information for Parents of Newborns

Chapter 161.501, Health and Safety Code, Subchapter T requires hospitals, birthing centers, physicians, nurse-midwives, and midwives who provide prenatal care to pregnant women during gestation or at delivery to give the woman and the father of the infant or other adult caregiver for the infant with Information for Parents of Newborns. This guide includes information about immunization, newborn screening, postpartum depression, and shaken baby syndrome.

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

A Parent’s Guide to Raising Healthy, Happy Children

A Parent’s Guide to Raising Healthy, Happy Children (PDF) is designed for parents and adult caregivers of children. The guide provides information about the development, health, and safety of children from birth to 5 years.

Provision of Information about Umbilical Cord Blood Donation Requirement

Chapter 162 .018, Health and Safety Code, Subtitle H requires that a physician or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant will give the woman an informational brochure before the third trimester of the woman’s pregnancy, or as soon as reasonably feasible. It should include information about the uses, risks, and benefits of cord blood stem cells for a potential recipient, options for future use or storage of cord blood, the medical process used to collect cord blood, any costs that may be incurred by a pregnant woman who chooses to donate or store cord blood after delivery, and average cost of public and private storage. An Umbilical Cord Blood Banking and Donation Brochure is available through DSHS.

Resources

Maternal and Child Health Publications
Someday Starts Now – Website that offers tools for health care providers to help clients make healthy decisions today so they can be ready for a baby in the future.
American College of Obstetricians and Gynecologists (ACOG).
Pelvic Examinations – Chapter 167A of the Health and Safety Code.
The Texas Clinician’s Postpartum Depression Toolkit (PDF)

5310 Initial Prenatal Visit Requirements

Revision 24-2; Effective Sept. 30, 2024

Comprehensive Medical History – Initial Visit

A comprehensive medical history documented at the initial prenatal visit must address at least the following:

current health status, including:
- symptoms of pregnancy; and
- acute and chronic medical conditions;
significant history, including:
- hospitalizations;
- surgeries;
- biopsies; and
- blood transfusions and other exposure to blood products;
current medications, including prescription, over the counter, and complementary and alternative medications;
allergies, sensitivities or reactions to medicines or other substance(s);
immunization status or assessment, including Rubella status;
mental health history including current and past mental health conditions;
pertinent history of immediate family, including genetic conditions;
pertinent partner history, including:
- injectable drug use;
- number of partners STI and HIV history; and
- other risk factors;
reproductive health history must include:
- menstrual history, including last normal menstrual period;
- sexual behavior history, including:
  - family planning practices;
  - number of partners;
  - gender of sexual partners; and
  - sexual abuse, as indicated;
- detailed obstetrical history;
- gynecological and urologic conditions;
- STIs, including hepatitis B and C, and HIV risks and exposure;
- cervical cancer screening history:
  - date and results of last Pap test or other cervical cancer screening test; and
  - note of any abnormal results and treatment;
social history and health risk assessment:
- home environment, including living arrangements;
- family dynamics with assessment for family violence including safety assessment, when indicated which is mandated by Texas Family Code, Chapter 261);
- human trafficking;
- tobacco, alcohol, medications, recreational drug use or abuse and exposure, drug dependency including type, duration, frequency and route;
- nutritional history;
- occupational hazards or environmental toxin exposure;
- ability to perform activities of daily living (ADL);
- risk assessment, including but not limited to:
  - diabetes;
  - heart disease;
  - intimate partner violence; and
  - injury or malignancy; and
systems review documenting pertinent positives and negatives in the health record.

Physical Examination - Initial Visit

For any part of the examination that is deferred, document the reason(s) for deferral in the client health record.

height measurement;
weight measurement, with documentation of pre-pregnancy weight and assessment for underweight, overweight and obesity;
blood pressure evaluation;
cardiovascular assessment;
visual inspection of external genitalia and anus;
pelvic exam, including estimate of uterine size per Chapter 167A of the Health and Safety Code;
fetal heart rate for gestational age more than 12 weeks; and
other systems, as indicated by history and the health risk assessment.

Laboratory and Diagnostic Tests – Initial Visit

Perform lab tests as recommended by accepted standards of care for client’s weeks of gestation or as indicated by risk assessment, history or physical exam. Review Monthly Reporting Packet (MRP) for covered lab tests.

The following tests are state-mandated:

Hepatitis B Antigen (HbsAg), mandated by Health and Safety Code 81.090.
HIV, unless declined by client, who must then be referred to anonymous testing, mandated by Health and Safety Code 81.090,
Syphilis serology, mandated by Health and Safety Code 81.090.

Education – Initial Visit

Base client education on history, risk assessment and physical exam. It must cover the following:

nutrition and weight gain;
physical activity and exercise;
sexual activity;
environmental or work hazards;
travel;
alcohol use and substance abuse;
when and where to get emergency care;
anticipated course of prenatal care, including prenatal testing;
injury prevention, including seat belt use;
cocooning infants and children against pertussis including immunization of family members and potential caregivers of the infant;
toxoplasmosis precautions;
referral to WIC;
use of medications; and
other education and counseling as indicated by state mandate, risk assessment, history and physical exam.

5320 Return Prenatal Visits Requirements

Revision 24-2; Effective Sept. 30, 2024

Interval Medical History – Return Visit

Interval history, including:

symptoms of infections;
symptoms of preterm labor;
headaches or visual changes;
fetal movement at more than18 weeks;
family violence screening when client is more than 28 weeks; and
intimate partner violence assessment at least once each trimester;

Physical Exam – Return Visit

For any portion of the examination that is deferred, document the reason(s) for deferral in the client health record.

weight measurement;
blood pressure evaluation;
uterine size and fundal height;
fetal heart rate at more than 12 weeks;
fetal lie or position at more than 30 weeks; and
other systems, as shown by history or other findings.

Laboratory and Diagnostic Tests – Return Visit

Perform lab tests as recommended by accepted standards of care for client’s weeks of gestation, those mandated by law, and indicated by risk assessment, history or exam. Review Monthly Reporting Packet (MRP) for covered lab tests. 

Return Prenatal Visit Education

Education should be appropriate to weeks of gestation and based on history, risk assessment and physical exam, including but not limited to:

signs and symptoms of preterm labor beginning in the second trimester;
warning signs and symptoms of pregnancy induced hypertension (PIH);
breastfeeding;
selecting a provider for the infant; and
postpartum family planning.

5330 Postpartum Visits Requirements

Revision 24-2; Effective Sept. 30, 2024

Interval Medical History – Postpartum Visit

Interval history, including:

labor and delivery history, noting maternal and neonatal complications;
infant bonding;
breastfeeding and infant feeding issues;
symptoms of infections;
symptoms of excessive or abnormal vaginal bleeding;
assessment for postpartum depression  (The Texas Clinician’s Postpartum Depression Toolkit (PDF);
intimate partner violence assessment; and
family planning and contraception including current method or future plans;

Postpartum Visit Physical Exam

Document the reason(s) for deferral in the client health record, for any portion of the examination that is deferred.

weight;
blood pressure evaluation;
breast and axilla exam;
abdomen exam;
pelvic exam, including uterine size per Chapter 167A of the Health and Safety Code; and
systems indicated by history or risk profile and other findings.

Laboratory and Diagnostic Tests – Postpartum Visit

Education - Postpartum Visit 

Client education should include:

physiologic changes;
signs and symptoms of common complications;
care of the breast;
care of perineum and abdominal incision, if indicated;
physical activity and exercise;
breastfeeding and infant feeding;
resumption of sexual activity;
family planning and contraception; and
depression and post-partum depression.

5340 Perinatal Dental Services

Revision 24-2; Effective Sept. 30, 2024

Providers are expected to follow rules and regulations established by the Dental Practice Act.

Review Monthly Reporting Packet (MRP) for reimbursable procedure codes.

Perinatal dental services are provided to pregnant women through three months post-partum. These include:

comprehensive and periodic oral evaluations;
radiographs; and
preventive and therapeutic dental services.

Procedure Code Limitations

Space maintainers are designed to prevent tooth movement and may help after premature loss of a deciduous primary first or second molar(s) in the following situations:

TID: A, B, I and J- for clients who are 1 through 12 years old using procedure codes D1510 and D1516.
TID: K, L, S and T - for clients who are 1 through 12 years old using procedure codes D1510 and D1517.

The following procedure codes have age restrictions and limitations:

D2950 Not allowed on primary teeth; restricted to ages 4 and older
D2952 Not allowed on primary teeth; restricted to ages 13 and older and not payable with D2950
D3310, D3320 and D3330 Restricted to 6 and older, reimbursement for a root canal includes all appointments necessary to complete the treatment
D2933 and D2934 are benefits for anterior primary teeth only (TID C- H and M R
Direct restoration of a primary tooth with the use of a prefabricated crown is a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pre-treatment X-ray images, intra-oral photos, and narrative documentation clearly support the medical necessity for the replacement of the prefabricated crown (D2930, D2933, D2934).

Perinatal Dental Visit History

Document a medical and dental history at the initial dental visit. Update a history and reason for the visit at each visit. Dental history must include:

history of the present problem;
relevant past medical history, including reproductive history and pregnancy status;
allergies, sensitivities or reactions to medicines or other substances;
current medications, prescriptions, over the counter and complementary and alternative medicines; 
use of tobacco and alcohol, including type, duration, frequency and route; and
screening and reporting, if indicated, for abuse and neglect per Texas Family Code, Chapter 261.

Perinatal Dental Examination

All dental visits must include an oral examination. Initial and return dental visit must include:

limited head and neck examination for the initial visit and as indicated for return visits;
blood pressure and pulse, as indicated;
radiographs and photographs, as indicated;
prescription(s), if indicated;
treatment plan of care; and
procedure(s) and treatment provided.

Perinatal Dental Education and Counseling

Dental education and counseling is provided by dentists or dental hygienists as it relates to prevention of dental disease and achieving oral health. Education should include:

oral hygiene instruction;
healthier eating and drinking habits to reduce the risk of tooth decay;
safety of dental treatment while pregnant;
impact of the mother’s oral health on the pregnancy and infant;
oral hygiene for infants and children; and
individualized education based on history, exam, procedures or risks.

Resource

5400 Child and Adolescent Clinical Guidelines

Revision 24-2; Effective Sept. 30, 2024

Child and Adolescent Services

Provide services based on recommendations of the American Academy of Pediatrics (AAP), Texas Health Steps Checkup Components, and the  Texas Health Steps Periodicity Schedule. All staff who perform child health exams must have completed the online Texas Health Steps module entitled Texas Health Steps: Overview.

Review Monthly Reporting Packet (MRP) for reimbursable procedure codes. Grantees may not bill for a Texas Health Steps medical checkup until all required components are completed. Only one visit may billed per day, per client. If a client returns on a different day to complete required components of a Texas Health Steps exam, an additional visit may not be charged.

Well Child and Adolescent History and Risk Assessment

New client initial health history must be retained in the medical record for reference at future checkups and does not need to be repeated at subsequent checkups. It must include the following:

If less than five years old, history related to pregnancy, delivery and neonatal conditions
Family medical history
Personal medical history

Established client interval health history must include:

reason for visit;
current health status, including any changes in personal health history;
current medications, including prescription, over-the-counter, and complementary and alternative medicines;
allergies, sensitivities or reactions to medicines or other substance(s);
exposure or use of tobacco, alcohol and illicit drugs, including type, duration, frequency and route;
review of systems;
assessment for family violence including a safety assessment when indicated;
reproductive health history, when appropriate, must include:
- menstrual history, including last normal menstrual period;
- sexual behavior history, including:
  - family planning practices;
  - sexual abuse;
- gynecological and urologic conditions;
- STIs and HIV risks and exposure; and
- cervical cancer screening, beginning at 21 years.

Comprehensive Child and Adolescent Physical Examination

For well child and adolescent visits, a complete physical examination is required at each visit. A comprehensive unclothed physical examination includes all the components listed below. For any portion of the examination that is deferred, document the reason(s) for deferral.

Comprehensive exam (unclothed) including secondary sex characteristics.
Measurements and percentiles, as appropriate, should be documented including:
- length, height and weight measurements;
- frontal-occipital head circumference for 2 years and under;
- body Mass Index (BMI) beginning at 2 years; and
- blood pressure beginning at 3 years old.
Screening, as appropriate, should be documented including:
- Complete developmental screening at checkups from birth through 6 years. Providers should follow the Texas Health Steps Periodicity Schedule (PDF) and must use one of the following validated, standardized tools found at Developmental and Autism Screening Tools.
- Conduct mental health screening at each checkup using one of the following tools. Providers should follow the Texas Health Steps Periodicity Schedule (PDF) and must use one of the following validated, standardized tools found at Mental Health Screening Tools.
- Perform screening for maternal postpartum depression at infant checkups up to 12 months. Find screening tools in The Texas Clinician’s Postpartum Depression Toolkit (PDF). 
- Sensory screening should include vision acuity and audiometric hearing screening at various ages following the Texas Health Steps Periodicity Schedule.
- Documentation of test results from a school vision or hearing screening program may replace the required screening if conducted within 12 months of the checkup.
- Limited oral screening for caries and general health of the teeth and oral mucosa is part of the physical examination. Refer to a dentist at 6 months and every six months thereafter.
- Nutritional screening or counseling by a licensed dietitian is completed for children with a high-risk condition and for children 3 years and older with an abnormal Body Mass Index (BMI). Nutritional screening must be performed at every visit.
- Risk screening, including family violence, lead, tuberculosis and adolescent lifestyle.
Age-appropriate immunizations
- Vaccines must be administered per the current Advisory Committee on Immunization Practices (ACIP). Find the ACIP schedule at the CDC Immunization Schedules website.
- TVFFS grantees are recommended to become a Texas Vaccines for Children (TVFC) provider. Providers may get vaccines free of charge from the Texas Vaccines for Children (TVFC) Program for clients birth through 18 years old. Providers must not charge the client for the vaccines.
Age-appropriate laboratory tests
- Well child and adolescent laboratory tests should follow the Texas Health Steps Periodicity Schedule. Tests should be appropriate to age and risk. Review TVFFS MRP for covered lab tests.
- Documented laboratory results within the past month are acceptable for use for children 2 years and younger and up to 90 days for those 3 years and older.

Sick Child Visit

Other sources of funding should be used to provide medications for the treatment of acute and minor illness at little or no cost to the client. A sick child visit includes problem-oriented history, physical exam, and lab tests, as indicated by condition.

Resources

World Health Organization (WHO) growth charts for infants and children birth to 2 years old.
Centers for Disease Control and Prevention (CDC) growth charts for children who are 2 years or older.
Pelvic Examinations – Chapter 167A of the Health and Safety Code.
The Texas Clinician’s Postpartum Depression Toolkit (PDF)

Child and Adolescent Laboratory and Other Diagnostic Tests

Grantees can submit all TVFFS laboratory testing to the laboratory of their choice, with the exception of Newborn Screening (NBS) Tests which must be submitted to the Texas DSHS laboratory.

Grantees and subrecipients must have a Texas Department of State Health Services (DSHS) laboratory submitter number to submit specimens to the DSHS laboratory.

Laboratory specimens sent to the DSHS laboratory will be charged at the DSHS laboratory’s published fee schedule rate.

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

Tracking and documentation of tests ordered and performed for each client.
Tracking test results and documentation in client’s records.
A mechanism to notify clients of results in a manner to ensure confidentiality, privacy and prompt, appropriate follow-up.

Resources

Child and Adolescent Education and Counseling

Client education must be face to face. 
Bright Futures literature is preferred.
Base education and counseling on health history, risk assessment, and physical exam and must cover the following:
- age-appropriate anticipatory guidance including injury prevention, behavior, health promotion and nutrition.
- the recommended Anticipatory Guidance: A Guide for Providers offers age-appropriate guidance for children, birth through 20 years, and mirrors anticipatory guidance topics included on the THSteps Child Health Clinical Record Forms.
- child development;
- immunizations;
- when and where to get emergency care;
- risk factors identified during the visit;
- referral to WIC;
- information on parenting and postpartum counseling, as indicated and mandated by Chapter 161, Health and Safety Code, Subchapter T; and
- other education and counseling, as indicated.

5410 Child and Adolescent Dental Services

Revision 24-2; Effective Sept. 30, 2034

Providers must follow rules and regulations established by the Dental Practice Act, provided to children from birth through 21 years. These include:

diagnostic services including comprehensive and periodic oral evaluations and radiographs;
preventive services including fluoride treatment and placement of dental sealants to any tooth at risk of dental decay; and
therapeutic services including restorative treatment.

Review Monthly Reporting Packet (MRP) for reimbursable procedure codes.

For children under 6 months, medically necessary dental services may be provided due to oral trauma early childhood caries, or both.

Procedure Code Limitations

Space maintainers are designed to prevent tooth movement. They may help in the following situations:

After premature loss of a deciduous primary first or second molar(s), TID: A, B, I and J, for clients who are 1 through 12 years old using procedure codes D1510 and D1516.
After premature loss of a deciduous primary first or second molar(s), TID: K, L, S and T, for clients who are 1 through 12 years old using procedure codes D1510 and D1517.

The following procedure codes have age restrictions and limitations:

D2950 is not allowed on primary teeth. Is restricted to 4 and older.
D2952 is not allowed on primary teeth. Is restricted to 13 and older and is not payable with D2950.
D3310, D3320 and D3330 is restricted to 6 and older. Reimbursement for a root canal includes all appointments necessary to complete the treatment.
D2933 and D2934 are benefits for anterior primary teeth only (TID C-H, M-R).
Direct restoration of a primary tooth with a prefabricated crown is a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pre-treatment X-ray images, intra-oral photos, and narrative documentation clearly support the medical necessity for the replacement of the prefabricated crown (D2930, D2933, D2934).

Child and Adolescent History

Document medical and dental history at the first dental visit. History and reason for the visit must be updated at each visit. Dental history must include:

history of the present problem;
relevant past medical history, including pregnancy status, as applicable;
allergies, sensitivities or reactions to medicines or other substances;
current medications, prescriptions, over the counter and complementary and alternative medicines; and   
use of tobacco and alcohol including type, duration, frequency and route; and
screening for abuse and neglect and reporting, if indicated as mandated by Texas Family Code, Chapter 261).

Child and Adolescent Dental Examination

All dental visits must include an oral examination. The initial or return dental visit must include:

limited head and neck examination for the initial visit and as indicated for return visits;
blood pressure and pulse, as indicated;
radiographs and photographs, as indicated;
prescription(s), if indicated;
treatment plan of care; and
procedure(s) and treatment provided.

Child and Adolescent Dental Education and Counseling

Dental education and counseling is provided by dentists or dental hygienists for the prevention of dental disease and achieving oral health. Education should include:

oral hygiene instruction;
healthier eating and drinking habits to reduce the risk of tooth decay; and
individual education based on history, exam, procedures or risks.

Resources

5500 Prescriptive Authority Agreements, Clinical Protocols and Standing Delegation Orders

Revision 24-2; Effective Sept. 30, 2024

Grantees that provide clinical services must develop and maintain written clinical prescriptive authority agreements, protocols and standing delegation orders to comply 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.

Prescriptive Authority Agreements (PAAs)

When services are provided by an advanced practice registered nurse (APRN) or physician assistant (PA), the grantee must 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, and practice locations or settings; 
identify the types or categories of drugs or devices that may or may not be prescribed; 
provide a general plan for addressing consultation and referral; 
provide a plan for addressing client emergencies; 
describe the general process for communication and sharing of information between the physician and the APRN or PA the physician has delegated prescriptive authority related to the care and treatment of people; 
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 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 

Texas Occupations Code Title 3, Subtitle B, Chapter 157 about Authority of Physicians to Delegate Certain Medical Acts 
Texas Administrative Code Title 22, Part 11, Chapter 222  Texas Board of Nursing Rules
Texas Administrative Code Title 22, Part 9, Chapter 193 Texas Medical Board Rules
Protocols

Grantees that employ APRNs or PAs 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 be included in a PAA if both parties agree to do so. The protocols do not need to describe the exact steps that an APRN or a PA must take for 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. They must be maintained on-site, as mandated by Texas Administrative Code, Title 22, Part 11, Chapter 221, Rule 221.13.

Standing Delegation Orders (SDOs)

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: 

SDOs must include 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 names 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 person; 
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 

Texas Administrative Code Title 22, Part 9, Chapter 193 Standing Delegation Orders 

Dental Delegation

Grantees must abide by delegation rules set forth by the Dental Practice Act and Texas State Board of Dental Examiners Rules. A licensed dentist may delegate verbally or in writing a service, task or procedure to a dental hygienist under the supervision and responsibility of the dentist, per the Dental Practice Act. A dentist is not required to be on the premises when the dental hygienist performs a delegated act. A licensed dentist may delegate to a qualified and trained dental assistant acting under the dentist’s general or direct supervision any dental act that is reasonable, and a prudent dentist would find is within the scope of sound dental judgment to delegate specified by the Dental Practice Act. Physical presence does not require the supervising dentist be in the treatment room when the dental assistant performs the service if the dentist is in the dental office or clinic. A delegating dentist is responsible for a dental act performed by the person the dentist delegates the act.

References 

6000, Reimbursement, Data Collection and Reporting

Revision 23-2; Effective Sept. 8, 2023

This section provides policy requirements for submitting for reimbursement, data collection and required reports.

6100 Reimbursement, Data Collection and Reports

Revision 24-2; Effective Sept. 30, 2024

Submission of the Monthly Invoice and Monthly Reporting Packet (MRP)

The reimbursement officer sends the MRP for both programs by email at the start of each state fiscal year. Each MRP submission should only include services provided in the preceding month as applicable to the grant. Late or absent submissions can impact HHSC midyear utilization determination, which is decided during the second quarter of the state fiscal year. The September MRP for both programs must be submitted and reimbursed by Dec.1. Submissions that do not meet the above requirement will not be processed.

Send monthly submissions to HDS.ADS@hhs.texas.gov. They are due within 30 business days after the end of the preceding service month. Billing or reporting forms may not be altered in any manner. 

Grantees need to:

complete the date and contact information on the Monthly Reimbursement Request (MRR);
supply supporting documentation (billing strip);
complete the service quantities on the 185 and 186 tabs; and
complete demographic data and unduplicated number of clients on the Monthly Activity tab.

Appropriate Supporting Documentation

Grantees must maintain a monthly billing log, also known as billing strips, either automated or manual, to support their Monthly Reporting Packet (MRP) submissions. The log should contain a unique client number, client’s age at time of service, date of service, and procedure code for each service billed.

Reconciling Discrepancies on Previously Submitted Monthly Reporting Packets (MRP)

Incorrect or missing information that requires clarification or follow-up by HHSC staff may delay payment. A response is required within five business days of the initial outreach to the grantee. Discrepancies can occur that result in a grantee receiving payment for services not billed appropriately during a service month. This can be corrected by subtracting the amount from the next month, adjusting all information. 

If an MRP requires a correction, grantees should resubmit a corrected MRP with supporting documentation as a new email submission to HDS.ADS@hhs.texas.gov.

Grantees must maintain records that document the necessary information for services provided and billed for reimbursement.

Supplemental Invoices

Instances can occur that result in missed reporting of a prior month’s services that have not yet been billed TVFFS. Any services performed before the current service month must be submitted as a supplemental invoice, with a separate invoice for each service month applicable. Use your MRP to submit the supplemental invoice to HDS.ADS@hhs.texas.gov. Include supplemental in the message’s subject line. 

Submission and Reporting After Entire Contract Award is Expended

Grantees must continue to submit the MRP even after the contract award has been expended. Grantees bill for allowable services provided to eligible clients and will receive reimbursement up to their grant award amount. Once all award funds have been expended, no other funds will be available for reimbursement. Grantees who have exhausted their awarded funds must continue to serve their existing clients. 

An MRP must be submitted even if the reimbursement requested amount is zero. Any cost over the contract award after deducting program income should be reflected under Non-HHSC Funding. This submission must continue reporting expenditures on any program income collected monthly and to provide HHSC with statistical information about the use of services.

Submission of Final Invoice and MRP

Grantees may have claims after the submission of their August billing. Additional services must be submitted within 45 calendar days after the end of the contract term. Mark this as final. Submit the final invoice and MRP before this date if the 45-day deadline falls on a weekend. Reimbursement requests submitted over 45 days after the contract term end will not be paid.

Submission of Financial Reconciliation Report (FRR)

The FRR must include all reimbursements and adjustments in payment for the contract term and must submit them to HDS.ADS@hhs.texas.gov 60 calendar days from the end of the contract year, which is Oct. 31.

Appendices

Appendix I, Definition of Income

Revision 23-2; Effective Sept. 8, 2023

Definition of Income

Types of Income	Countable	Exempt
Adoption Payments		X
Cash Gifts and Contributions*	X
Child Support Payments*	X
Child's Earned Income		X
Crime Victim's Compensation*		X
Disability Insurance Benefits	X
Dividends, Interest and Royalties*	X
Educational Assistance		X
Energy Assistance		X
Foster Care Payment		X
In-Kind Income		X
Job Training		X
Loans (Noneducational)*	X
Lump-Sum Payments*	X	X
Military Pay*	X
Mineral Rights*	X
Pensions and Annuities*	X
Reimbursements	X
Retirement, Survivors and Disability(RSDI)/Social Security Payments*	X
Self-Employment Income*	X
Social Security Disability Income (SSDI)	X
Supplemental Security Income (SSI) Payments		X
Temporary Assistance for Needy Families (TANF)		X
Unemployment Compensation*	X
Veterans Affairs (VA)*	X	X
Wages and Salaries, Commissions*	X
Workers’ Compensation*	X

*Explanation of countable income provided below.

Cash Gifts and Contributions – Count unless they are made by a private, nonprofit organization based on need and total $300 or less per household in a federal fiscal quarter. The federal fiscal quarters are January through March, April through June, July through September and October through December. If these contributions exceed $300 in a quarter, count the excess amount as income in the month received.

Exempt any cash contribution for common household expenses, such as food, rent, utilities and items for home maintenance if it is received from a noncertified household member who:

lives in the home with the certified household member;
shares household expenses with the certified household member; and
no landlord or tenant relationship exists.

Child Support Payments – Count as income after deducting $75 from the total monthly child support payments the household receives.

Disability Insurance Payments/SSDI – Countable. SSDI is a payroll tax-funded, federal insurance program of the Social Security Administration.

Dividends, Interest and Royalties – Countable. Exception: Exempt dividends from insurance policies as income. Count royalties, minus any amount deducted for production expenses and severance taxes.

In-Kind Income – Exempt. An in-kind contribution is any gain or benefit to a person that is not in the form of money or check payable directly to the household, such as clothing, public housing or food.

Loans (Noneducational) – Count as income unless there is an understanding that the money will be repaid, and the person can reasonably explain how they will repay it.

Lump-Sum Payments – Count as income in the month received if the person receives it or expects to receive it more often than once a year. Exempt lump sums received once a year or less, unless specifically listed as income.

Military Pay – Count military pay and allowances for housing, food, base pay and flight pay, minus pay withheld to fund education under the G.I. Bill.

Mineral Rights – Countable. A payment received from the excavation of minerals, such as oil, natural gas, coal, gold, copper, iron, limestone, gypsum, sand, gravel, etc.

Pensions and Annuities – Countable. A pension is any benefit derived from former employment, such as retirement benefits or disability pensions.

Reimbursements – Countable, minus the actual expenses. Exempt a reimbursement for future expenses only if the household plans to use it as intended.

RSDI/Social Security Payments – Count the RSDI benefit amount, including the deduction for the Medicare premium, minus any amount that is being recouped for a prior RSDI overpayment.

Self-Employment Income – Count the total gross earned, minus the allowable costs of producing the self-employment income.

SSI Payments – Exempt SSI benefits.

Terminated Employment – Count terminated income in the month received. Use actual income and do not use conversion factors if terminated income is less than a full month’s income. Income is terminated if it will not be received in the next usual payment cycle.

Unemployment Compensation Payments – Count the gross benefit less any amount being recouped for an Unemployment Insurance Benefit (UIB) overpayment.

VA Payments – Count the gross VA payment, minus any amount being recouped for a VA overpayment. Exempt VA special needs payments, such as annual clothing allowances or monthly payments for an attendant for disabled veterans.

Wages, Salaries, Tips and Commissions – Count the actual (not taxable) gross amount.

Workers’ Compensation – Count the gross payment, minus any amount being recouped for a prior workers’ compensation overpayment or paid for attorney’s fees. Note: Texas Workforce Commission (TWC) or a court sets the amount of the attorney’s fee to be paid.

Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL)

Revision 24-1; Effective May 1, 2024

Title V Fee-for-Service, Optional Co-Pay Table Based on 2024 Monthly Federal Poverty Level (PDF)

Forms

ES = Spanish version available.

Form	Title
3012	Verification of Eligibility ES
3029	Application for Program Benefits ES
3045	Presumptive Eligibility Notice ES
3047	Notice of Ineligibility ES
3049	Employment Verification ES
3051	Statement of Self-Employment Income ES

Policy Revisions

24-2, Miscellaneous Revisions

Revision 24-2; Effective Sep. 30, 2024

Section	Title	Change
1200	Purpose of Manual	Adds program acronym.
2100	Program Authorization and Services	Clarified how states are required to use TVFFS federal funds and updated abbreviation of program name to TVFFS
2200	Definitions	Updates language from client to subrecipient. Updates definitions of teledentistry, telehealth and telemedicine.
3100	Administrative Policies	Changes title to Accessibility. Updates language.
3200	Abuse and Neglect Reporting	Updates text and deletes certain definitions. Adds resource information.
3300	Confidentiality	Updates HIPPA resources.
3310	Civil Rights	Adds section.
3320	Required Signage	Adds section.
3330	Complaints and Termination of Services	Adds section.
3340	Research (Human Subjects Clearance)	Adds section.
3400	Client Records Management	Updates language.
3500	Personnel Policies and Procedures	Updates language.
3600	Facilities and Equipment	Updates language.
3700	Emergency Responsiveness	Updates language.
3800	Quality Management	Updates language.
4100	Eligibility and Assessment of Co-pay and Fees	Updates and clarifies language.
5100	General Consent	Updates language. Includes resources for HIV testing consent requirements.
5200	Clinical Policy	Defines requirements for telemedicine. Updates language.
5300	Perinatal Clinical Guidelines	Updates language. Updates ACOG-recommendations for depression and anxiety screening
5310	Initial Prenatal Visit Requirements	Updates language.
5320	Return Prenatal Visits Requirements	Updates language.
5330	Postpartum Visits Requirements	Updates language.
5340	Perinatal Dental Services	Updates procedure code limitations and education requirements.
5400	Child and Adolescent Clinical Guidelines	Updates language. Updates health history requirements and laboratory guidelines.
5410	Child and Adolescent Dental Services	Updates language. Updates procedure code limitations and education requirements.
5500	Prescriptive Authority Agreements, Clinical Protocols and Standing Delegation Orders	Updates language.
6100	Reimbursement, Data Collection and Reports	Updates language.

Forms

The following forms were revised in the Title V Maternal and Child Health Fee-for-Service Program Policy Manual:

Form No.	Title	Change
Form 3012	Notice of Eligibility	Changes title of form to Verification of Eligibility. Adds form to handbook.
Form 3029	PHC and Title V MCH FFS Application for Program Benefits	Revises form.
Form 3045	Presumptive Eligibility Notice	Revises form. Deletes instructions.
Form 3046	Statement of Applicant's Rights and Responsibilities	Deletes form from handbook.
Form 3048	Notice of Eligibility	Deletes form from handbook.
Form 3056	Request for information	Deletes form from handbook.

24-1, Updates Appendix II

Revision 24-1; Effective May 1, 2024

The following change(s) were made:

Revised	Title	Change
Appendix II	Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL)	Updates Appendix II, Optional Co-Pay Table Based on 2024 Monthly Federal Poverty Level (FPL).

23-2, Miscellaneous Revisions

Revision 23-2; Effective Sept. 8, 2023

The following change(s) were made:

Revised	Title	Change
1100	Contact Information	Removes helpline information and phone number.
1200	Purpose of Manual	Updates language.
2100	Program Authorization and Services	Updates language. Updates date for national Healthy People objectives.
2200	Definitions	Updates definitions throughout.
3100	Administrative Policies	Updates language. Revises civil rights requirements. Adds requirement to maintain appropriate exterior signage.
3200	Abuse and Neglect Reporting	Updates language. Revises abuse, neglect and exploitation requirements.
3300	Confidentiality	Updates language. Adds requirement to display certain civil rights posters.
3400	Client Records Management	Updates language.
3500	Personnel Policies and Procedures	Updates language. Revises immunization guidance.
3600	Facilities and Equipment	Updates language. Revises facility requirements. Adds laboratory standards. Removes Disaster Response Plan.
3700	Emergency Responsiveness	Updates language. Adds Disaster Response Plan.
3800	Quality Management	Updates language. Revises Quality Management requirements.
4100	Eligibility and Assessment of Copay and Fees	Updates language. Adds a process to apply for approval to use an Alternate Eligibility Tool. Revises client eligibility screening for postpartum services. Adds procedures and terminology when determining eligibility. Changes form for employer verification. Adds eligibility forms.
5100	General Consent	Updates language.
5200	Clinical Policy	Updates language. Defines case management requirements.
5300	Perinatal Clinical Guidelines	Updates language. Reorganizes information. Includes quit line information.
5310	Initial Prenatal Visit Requirements	Creates new section to reorganize existing requirements. Updates language.
5320	Return Prenatal Visit Requirements	Creates new section to reorganize existing requirements. Updates language.
5330	Postpartum Visit Requirements	Creates new section to reorganize existing requirements. Updates language.
5340	Perinatal Dental Services	Creates new section to reorganize existing requirements. Updates language.
5400	Child and Adolescent Clinical Guidelines	Updates language. Revises service and billing requirements. Adds anticipatory guidance resource.
5410	Child and Adolescent Dental Services	Creates new section to reorganize existing requirements. Updates language.
5500	Prescriptive Authority Agreements, Clinical Protocols and Standing Delegation Orders	Updates language. Revises PAA and SDO requirements.
6100	Reimbursement, Data Collection and Reports	Updates language. Removes guidance. Revises submission, reconciliation and invoice requirements.
Appendix I	Definition of Income	Updates language.
Forms	Forms	Updates form titles.

23-1, Appendices Revised

Revision 23-1; Effective Mar. 31, 2023

The following change(s) were made:

Revised	Title	Change
Appendix II	Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL)	Adds Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL)

TVMCH Contact Us

For technical or accessibility issues with this handbook, please email the HHS Form & Handbook Request mailbox.

For questions about the Title V Maternal and Child Health Fee-for-Service Program Policy Manual, email the Titlevffs@hhs.texas.gov mailbox.