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 23-2; Effective Sept. 8, 2023

The Texas Health and Human Services Commission (HHSC) Title V Maternal and Child Health Fee-for-Service Program Policy Manual is a guide for grantees who deliver Title V MCH FFS 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 Title V MCH FFS 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 23-2; Effective Sept. 8, 2023

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

The purpose of the Maternal and Child Health (MCH) Services Title V Block Grant is to create federal and state partnerships to 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. Title V MCH Fee-for-Service 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 to 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, Title V operates within a framework articulated by the Texas Legislature and Texas Health and Human Services Commission (HHSC).

States are required to use federal funds awarded as follows:

  • at least 30% for preventive or primary care services for pregnant women, mothers, infants up to age one and children;
  • at least 30% for services for children with special health care needs; and
  • no more than 10% on administration.

Funding Sources

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

2200 Definitions

Revision 23-2; Effective Sept. 8, 2023

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

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 – With respect to pregnant women: services to assure access to quality prenatal, delivery, and postpartum care; and with respect to infants, children, and adolescents: 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 – Persons 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. The term client and patient may be used interchangeably in other sources.

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

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

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

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

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 age 2 and $175 per month for each child age 2 or older.  

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

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 according to 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 subgrantees.

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

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

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

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

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

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

Preventive Health Care – Services include, but are not limited to the following: immunizations, risk assessments, health histories and baseline physicals for early detection of disease and restoration to a previous state of health, and prevention of further deterioration and/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 an individual with current certification as a CHW issued by DSHS.

Provider – An individual 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 will provide a service for the Title V MCH FFS client that the Title V MCH FFS grantee does not provide, and it is not a reimbursable Title V MCH FFS service.

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

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

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

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

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

Unduplicated Client – An individual counted only one time during the program’s fiscal year for each Title V program they participate in: 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 Administrative Policies

Revision 23-2; Effective Sept. 8, 2023

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 healthcare facility.
  • Ensure clinic or reception room wait times are reasonable and do not present a barrier to care.

Important Information for Former Military Service Members

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

3200 Abuse and Neglect Reporting

Revision 23-2; Effective Sept. 8, 2023

Abuse and Neglect 

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

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

Child Abuse Reporting, Compliance and Monitoring

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

Grantees must develop an internal policy specific to:

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

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

Human Trafficking

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

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

References for human trafficking policy development:

Domestic and Intimate Partner Violence (IPV)

IPV describes physical, sexual or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.

Grantees must have a written policy related to assessment and prevention of domestic and IPV, including the provision of annual staff training.

Additional information on IPV can be found on the Centers for Disease Control and Prevention website.

3300 Confidentiality

Revision 23-2; Effective Sept. 8, 2023

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

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

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

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

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 (Code of Federal Regulations - 45 CFR Section 164.502(g)).

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

Nondiscrimination and Limited English Proficiency (LEP)

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:

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

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

  • Americans with Disabilities Act  
  • Know Your Rights – Clients and Applicants 
  • Need a Sign Language Interpreter?  
  • Need an Interpreter? 

Termination of Services

A qualifying person must never be denied services due to an inability to pay. Grantees have the right to terminate services to a client if the client is disruptive, unruly, threatening or uncooperative to the extent that the client seriously impairs the grantee’s ability to provide services effectively and safely, or if the client’s behavior jeopardizes his or her own safety, clinic staff or others. A person has the right to appeal the denial, modification, suspension or termination of services. If an aggrieved client requests a hearing, a grantee shall not terminate services to the client until a final decision is rendered by HHSC. Any policy related to termination of services must be included in the grantee’s policy manual.

Resolution of Complaints

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

If a client remains unsatisfied with how the complaint was handled, they can appeal to the HHSC Title V MCH FFS Office at titlevffs@hhs.texas.gov, or mail PO Box 149030, Austin TX 78714-9347. More information may be needed. 

Any client complaint must be documented in the client’s record.

Research (Human Subjects Clearance)

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

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

3400 Client Records Management

Revision 23-2; Effective Sept. 8, 2023

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

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

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

When information is requested, grantees should release only the specific information requested. Information collected for reporting purposes may 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, subrecipients and subgrantees must maintain for the time specified by HHSC all records pertaining to client services, contracts and payments. Grantees must follow contract provisions, maintain medical records for at least seven years after the close of the contract and follow the retention standards of the appropriate licensing entity. All records relating to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law.

3500 Personnel Policies and Procedures

Revision 23-2; Effective Sept. 8, 2023

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 according to 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 healthcare workers. All staff must be appropriately identified with a name badge. Personnel policies and procedures must include:

  • job descriptions, including those for contracted personnel;
  • a written orientation plan for new staff to include skills evaluation and/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 are provided annual training. Job evaluations should include observation of staff and client interactions during clinical, counseling and educational services.

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

The Title V MCH FFS medical director for the clinic must be a licensed Texas physician and the Title V MCH FFS dental director for the clinic must be a U.S. licensed dentist.

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

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

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

3600 Facilities and Equipment

Revision 23-2; Effective Sept. 8, 2023

Grantees are required to always maintain a safe environment. Grantees must provide clean and well-maintained facilities where services can be delivered with space for exam rooms, client intake, waiting areas, and space for clinical and administrative staff. 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 according to applicable laws and regulations;
  • the handling, storage, and disposal of chemical and infectious waste including sharps; and
  • an orientation and education program for personnel who manage or have contact with hazardous materials and waste.

Fire Safety

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

Medical Equipment

Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment including 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:

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

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 obtain 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 23-2; Effective Sept. 8, 2023

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.
  • There must be written protocols to address vaso-vagal reactions, anaphylaxis, syncope, cardiac arrest, shock, hemorrhage and respiratory difficulties.
  • Each site must maintain emergency resuscitative drugs, supplies and equipment appropriate to the services provided at that site and appropriately trained staff when clients are present.
  • Documentation must be maintained in personnel files that staff has been trained regarding these 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 (i.e., fires, flooding, power outage, bomb threats, etc.). The disaster plan must identify the procedures and processes that will be initiated during a disaster and the staff 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 orally to employees. 

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

3800 Quality Management

Revision 23-2; Effective Sept. 8, 2023

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

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

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

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

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

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

  • be reviewed annually;
  • include clinical and administrative standards by which services will be monitored;
  • include a process for credentialing and peer review of clinicians;
  • identify individuals responsible for implementing monitoring, evaluating and reporting;
  • establish timelines for 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 providing 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, order, etc. 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 23-2; Effective Sept. 8, 2023

Grantees must develop a policy to show how staff will determine Title V MCH FFS program client eligibility. The policy must outline the grantee’s procedures for determining program eligibility and who is responsible for eligibility screening. 

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

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

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

  • Grantees must request approval from Title V MCH FFS 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 subsequent 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 Title V MCH FFS program reserves the right to request more edits or withdraw its approval of the use of an alternate eligibility tool. Title V MCH FFS program will notify the grantee of the decision in writing and include the date that the alternate tool must be discontinued.  

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

If an applicant is determined to be ineligible for services after the screening process is complete, the applicant's 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.

Client Eligibility Screening Process

For a person to receive Title V MCH FFS 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 Title V Child Health and Child Dental program serves persons from birth until their 22nd birthday and the Title V Prenatal Medical and Prenatal Dental programs serve pregnant women of any age through three months postpartum, including following pregnancy loss.

Eligibility determinations for Title V 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 documentation is not available or is insufficient to determine eligibility, grantees staff should ask the individual to designate a contact person to provide the information.

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

Procedures and Terminology When Determining Title V MCH FFS Eligibility

Potential Eligibility and Referral to Other Programs Screening for other benefit programs must be documented on the Application for Program Benefits form. 

The Title V MCH FFS Program is the payor of last resort. Applicants must be screened for Medicaid, CHIP, CHIP Perinatal, and any other benefit programs. Title V MCH FFS 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 Title V MCH FFS, 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 Title V 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 Title V MCH FFS 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 Title V MCH FFS must apply for the CHIP Perinatal program to receive health benefits for the unborn child and newborn. 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 (2) clinical prenatal care visits will be allowed for women who are 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. 

Household

The household consists of a person living alone, or a group of two or more people related by birth, marriage (including common law) or adoption, who live together and 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. Eligibility will end on the last day of the month the child becomes 18 years old unless the child is:

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

Legal responsibility for support exists between:

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

Documentation of 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 Title V MCH FFS 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 Title V MCH FFS 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

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

Documentation of income for Title V MCH FFS 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.

The maximum monthly income amounts by household size are based on the U.S Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change 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 is unable to provide required documentation for verification purposes. These types of special circumstances should be appropriately documented.

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 is unable to provide required documentation for verification purposes. These types of special circumstances should be appropriately documented.

Client Fees and Copayments

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

  • No Title V MCH FFS 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 greater than $30 per visit. 
  • Grantees must have a written copay policy which clearly defines how copay amounts will be determined.
  • Clients who are assessed a copay must be presented a 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 Title V MCH FFS 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.

Date Eligibility Begins

An individual or household is eligible for services beginning with the date the grantee determines they are eligible for the program and signs the completed application. To notify an applicant of eligibility, the grantee must issue the following forms to the client:

Presumptive Eligibility

Presumptive eligibility provides short-term access to healthcare services for up to 90 days when an applicant screens as eligible and has a medical or dental need but lacks the required documentation or verification. For clients who submit all required application documentation during their presumptive eligibility period, the eligibility expiration date will be 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. 

Clients without final eligibility for services determined who present with a medical or dental need may receive Title V MCH FFS funded services on a presumptive eligibility basis during the time that eligibility determination is pending. If a medical condition makes eligibility determination impossible, make an appointment to complete the process at the first possible opportunity.

If eligibility cannot be determined because of missing eligibility criteria components, the grantee may issue Form 3056, Request for Information.

To notify an applicant of Presumptive Eligibility, the grantee must issue the following forms to the client:

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

Annual Recertification

Annual eligibility determination is required for all clients who receive Title V MCH FFS services. Client eligibility must be redetermined every 12 months, using the most recent version of Form 3029, Application for Program Benefits. Perinatal benefits expire at 3 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 23-2; Effective Sept. 8, 2023

Grantees must obtain 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 during which a client does not receive services, a new general consent must be signed before reinitiating delivery of services.

A client’s verbal consent for general treatment may be obtained by phone. This type of consent is adequate for routine treatment provided through telemedicine. To record a client’s verbal consent, the staff person obtaining the consent must read the consent form to the applicant and document that the applicant affirms by giving their verbal consent for treatment. The documentation must include the date and time of the applicant’s consent and the signature of the staff person obtaining 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 a manner that is understandable. 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 (i.e., 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 in compliance with 22 Texas Administrative Code Section 108.7 regarding 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 risks and hazards about medical care and surgical procedures must be disclosed by health care providers or physicians to their patients or persons authorized to consent for their patients; and
  • establish the general form and substance of such disclosure.

The grantee is responsible for assuring that informed consent is obtained from the patient for procedures per TMDP. TMDP has developed List A (informed consent requiring full and specific disclosure) for certain procedures, and is found in 25 TAC Section 601.2.

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. This includes:

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

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 according to 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

Consent for Human Immunodeficiency Virus (HIV) Tests

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

  • Section 81.105, regarding Informed Consent; and
  • Section 81.106, regarding General Consent.

5200 Clinical Policy

Revision 23-2; Effective Sept. 8, 2023

Telehealth

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

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

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

Client Health Records and Documentation of Encounters

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

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 of the provider, the provider’s title and 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 (e.g., latex);
    • if the patient has no known allergies, this should be listed.
    • this information should be prominently displayed in the patient’s record and updated at each encounter;
  • a plan of care, updated as appropriate, 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 assistance 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 (obtaining required client consent with appropriate safeguards to ensure confidentiality, i.e., adhering to HIPAA regulations);
  • advise the client about her or his responsibility in complying with the referral;
  • follow up to determine if the referral was completed; 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 separate 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 23-2; Effective Sept. 8, 2023

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 Title V MCH FFS for allowable services provided in clinical prenatal care visits for women during the CHIP Perinatal Program enrollment process. See 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 patient;
  • tracking of test results and documentation in patient 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, to include fetal number, viability, presentation, dating measurements, complete anatomical survey; placental localization characterizations and amniotic fluid assessment.
  • Follow-up or limited ultrasound – A brief, more limited evaluation of the pregnant uterus that may follow a previous complete exam, be it an initial exam before 12 weeks or be it an initial exam after 12 weeks which is limited in scope. Includes fetal number, viability, presentation, dating measurements, limited anatomic assessment, placental localization and characterization, and amniotic fluid assessment.

Non-Stress Test (NST)

Fetal well-being assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age is reached. May be billed as often as the provider deems the procedure to be medically necessary.

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

Prenatal test used to check on a baby's well-being. 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.

Perinatal Education and Counseling Services

Grantees must have written plans for patient education. These include goals and content outlines to ensure consistency and accuracy of information provided, and that identify mechanisms used to ensure patient understanding of the information. Education must be appropriate to patient’s age, level of knowledge and socio-cultural background and presented in an unbiased manner. Plans for patient education must be reviewed and signed by the medical or dental director at the contracted facility.

Tobacco Assessment and Quit Line Referral

All women receiving prenatal services should be assessed for tobacco use. Women who use tobacco should be referred to tobacco quit lines. The Texas Tobacco Quitline provides confidential, free, and convenient cessation services to Texas residents ages 13 and older, including quit coaching and nicotine replacement therapy. Services can be accessed by phone at 1-877-YES-QUIT (1-877-937-7848) or online at YesQuit.org. 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 Title V MCH FFS. Refer to Women, Infants and Children (WIC) for nutritional counseling.

State-Mandated Education

Information for Parents of Newborns Requirement

Chapter 161, Health and Safety Code, Subchapter T requires hospitals, birthing centers, physicians, nurse-midwives, and midwives who provide prenatal care to pregnant women during gestation or at delivery to give the woman and the father of the infant or other adult caregiver for the infant with a resource pamphlet that includes information on:

  • postpartum depression;
  • shaken baby syndrome;
  • immunizations;
  • newborn screening;
  • pertussis; and
  • sudden infant death syndrome.  

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.

Information for Parents of Children

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

Provision of Information about Umbilical Cord Blood Donation Requirement

Chapter 162, Health and Safety Code, Subtitle H requires 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

5310 Initial Prenatal Visit Requirements

Revision 23-2; Effective Sept. 8, 2023

Comprehensive Medical History – Initial Visit

A comprehensive medical history documented at the initial prenatal visit must at least address 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 assessment 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, to include living arrangements;
    • family dynamics with assessment for family violence including safety assessment, when indicated (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
  • review of systems with pertinent positives and negatives documented in the health record.

Physical Examination - Initial Visit

For any portion of the examination that is deferred, the reason(s) for deferral must be documented in the patient 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 (In accordance with Chapter 167A of the Health and Safety Code);
  • fetal heart rate for gestational age greater than 12 weeks; and
  • other systems, as indicated by history and the health risk assessment.

Laboratory and Diagnostic Tests – Initial Visit

Lab tests should be performed as recommended by accepted standards of care for patient’s weeks of gestation or indicated by risk assessment, history or physical exam (see 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 patient, who must then be referred to anonymous testing (Mandated by Health and Safety Code 81.090) CDC’s recommendations for HIV testing can be found here
  • Syphilis serology (mandated by Health and Safety Code 81.090)

Education – Initial Visit

Patient education should be based on history, risk assessment and physical exam and must cover the following:

  • nutrition and weight gain;
  • intimate partner violence and abuse;
  • human trafficking;
  • physical activity and exercise;
  • sexual activity;
  • environmental or work hazards;
  • travel;
  • alcohol use and substance abuse;
  • breastfeeding;
  • when and where to obtain emergency care;
  • anticipated course of prenatal care, including prenatal testing;
  • injury prevention, including seat belt use;
  • cocooning infants and children against pertussis (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 23-2; Effective Sept. 8, 2023

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 patient 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, the reason(s) for deferral must be documented in the patient 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 indicated by history or other findings.

Laboratory and Diagnostic Tests – Return Visit

Lab tests should be performed as recommended by accepted standards of care for patient’s weeks of gestation, mandated by law, and indicated by risk assessment, history or exam (see 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);
  • selecting a provider for the infant; and
  • postpartum family planning.  

5330 Postpartum Visits Requirements

Revision 23-2; Effective Sept. 8, 2023

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

For any portion of the examination that is deferred, the reason(s) for deferral must be documented in the patient health record.

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

Laboratory and Diagnostic Tests – Postpartum Visit

Lab tests should be performed as recommended by accepted standards of care for patient’s weeks of gestation, mandated by law, and indicated by risk assessment, history or exam (see Monthly Reporting Packet (MRP) for covered lab tests).

Education - Postpartum Visit 

Patient 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 23-2; Effective Sept. 8, 2023

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

See 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.

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

  • After premature loss of deciduous or primary tooth first or second molar(s) tooth identification (TID): A, B, I and J for clients who are 1 through 12 years old (procedure codes D1510, D1516).
  • After premature loss of deciduous or primary tooth, first or second molar(s) TID: K, L, S and T for clients who are 1 through 12 years old (procedure codes D1510, D1517).
  • After loss of a permanent first molar(s) (TID: 3 and 14) for clients who are 3 years or older (procedure code D1510).
  • After loss of a permanent first molar(s) (TID: 19 and 30) for clients who are 3 years or older (procedure codes D1510, D1517).

The following age restrictions and limitations will be enforced during quality reviews:

  • D2950 is a benefit for clients 6 years or older.
  • D2952 is a benefit for clients 13 years or older.
  • D3320 and D3330 are benefits for clients 12 years or older.
  • D2933 and D2934 are benefits for primary teeth C through H, M through R only.
  • Direct restoration of a primary tooth using of a prefabricated crown is a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pretreatment 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

At the initial dental visit, a medical and dental history must be documented. A 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 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 as mandated by 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 nutritional education and counseling is provided by dentists or dental hygienists as it relates to prevention of dental disease and achieving oral health. Therefore, a registered dietician is not eligible to perform these services. Education should include:

  • How to develop positive oral health behavior.
  • How positive oral health behaviors impact the pregnancy and unborn child.
  • Education on proper oral health care for infants and children.
  • Any other education as indicated by history, exam, procedures, treatments or risks.

Resource

5400 Child and Adolescent Clinical Guidelines

Revision 23-2; Effective Sept. 8, 2023

Child and Adolescent Services

Services must be provided based on recommendations of the American Academy of Pediatrics (AAP), per the current Texas Health Steps Periodicity Schedule, and as indicated by history, risk assessments or exams through 21 years. All staff who perform child health exams must follow the Texas Health Steps periodicity schedule and must have completed the online Texas Health Steps module entitled Texas Health Steps: Overview. See 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

The health history must at least address the following:

  • reason for visit;
  • current health status, including:
    • family medical history;
    • neonatal history for 5 years and younger;
    • physical and mental health history;
    • developmental history;
    • immunization status and history; and
    • nutrition and feeding history;
  • significant history, including:
    • hospitalizations;
    • surgery;
    • biopsies; and
    • blood transfusions and other exposure to blood products;
  • 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;
      • number of partners;
      • gender of sexual partner; and
      • sexual abuse;
    • gynecological and urologic conditions;
    • STIs and HIV risks and exposure; and
    • cervical cancer screening, beginning at 21 years. 

Any pertinent history must be updated at each subsequent visit.

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:
    • Developmental screening should be completed 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.
    • Mental health screening should be conducted 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.
    • Screening for maternal postpartum depression should be performed at infant checkups up to 12 months. Screening tools can be found 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 according to the current Advisory Committee on Immunization Practices (ACIP). Find the ACIP schedule at the CDC Immunization Schedules website.
    • Title V MCH FFS grantees are recommended to become a Texas Vaccines for Children (TVFC) provider. Providers may obtain 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.

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 patient. A sick child visit includes problem-oriented history, physical exam and lab tests, as indicated by condition.

Resources

Child and Adolescent Visit Laboratory and Other Diagnostic Tests

Grantees can submit all Title V MCH FFS laboratory testing (except for Newborn Screening (NBS) testing) to the laboratory of their choice.

Grantees and subgrantees 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 and will be responsible for payment in full.

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 patients’ records.
  • A mechanism to notify patients of results in a manner to ensure confidentiality, privacy and prompt, appropriate follow-up.

Child and Adolescent Laboratory and Diagnostic Tests

Well child and adolescent checkups may include various laboratory tests appropriate to age and risk.

Documented laboratory results within the prior month are acceptable for use for children 2 years and younger and up to 90 days for those 3 years and older.

Well child and adolescent laboratory tests should follow the Texas Health Steps Periodicity Schedule (PDF). Tests should be appropriate to age and risk (see Title V workbook for covered lab tests).

Resources

Child and Adolescent Education and Counseling

Patient education must be face to face. Bright Futures literature is preferred, found here. Education and counseling should be based on health history, risk assessment, and physical exam and must cover the following:

5410 Child and Adolescent Dental Services

Revision 23-2; Effective Sept. 8, 2023

Providers are expected to 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.

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

Restorative treatment is limited. These procedures must be documented as medically necessary and appropriate. For children under 6 months, medically necessary dental services may be provided due to oral trauma early childhood caries, or both.

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

  • After premature loss of deciduous or primary tooth first or second molar(s) tooth identification (TID): A, B, I and J for clients who are 1 through 12 years old (procedure codes D1510, D1516).
  • After premature loss of deciduous or primary tooth, first or second molar(s) TID: K, L, S and T for clients who are 1 through 12 years old (procedure codes D1510, D1517).
  • After loss of a permanent first molar(s) (TID: 3 and 14) for clients who are 3 or older (procedure code D1510).
  • After loss of a permanent first molar(s) (TID: 19 and 30) for clients who are 3 years or older (procedure codes D1510, D1517).

The following age restrictions and limitations will be enforced during quality reviews:

  • D2950 is a benefit for clients 6 or older.
  • D2952 is a benefit for clients 13 or older.
  • D3320 and D3330 are benefits for clients 12 or older.
  • D2933 and D2934 are benefits for primary teeth C through H, M through R only.
  • 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 pretreatment 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

At the initial dental visit, a medical and dental history must be documented. 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 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; and   
  • use of tobacco and alcohol including type, duration, frequency and route; and
  • screening (and reporting, if indicated) for abuse and neglect as mandated by Texas Family Code, Chapter 261).

Child and Adolescent Dental Examination

All dental visits must include an oral examination. The initial/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 nutritional education and counseling is provided by dentists or dental hygienists relating to prevention of dental disease and achieving oral health. Therefore, a registered dietician is not eligible to perform these services.

  • How to develop positive oral health behavior.
  • Education on proper oral health care for infants and children.
  • Any other education, as indicated by history, exam, procedures, treatments or risks.

Resources

5500 Prescriptive Authority Agreements, Clinical Protocols and Standing Delegation Orders

Revision 23-2; Effective Sept. 8, 2023

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

Prescriptive Authority Agreements (PAAs)

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

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

References 

  • Texas Occupations Code Title 3, Subtitle B, Chapter 157 Regarding Authority of Physicians to Delegate Certain Medical Acts 
  • Texas Administrative Code Title 22, Part 11, Chapter 222 APRN’s with Prescriptive Authority 

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 now be included in a PAA if both parties agree to do so. The PAA and/or protocols need not describe the exact steps that an APRN or a PA must take with respect to each specific condition, disease or symptom.

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

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 would name the RN, LVN or NLHP that will perform the task, the steps to complete the task, the ranges for normal and abnormal and the process of reporting abnormal values.  

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

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

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

References 

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 orally or in writing a service, task or procedure to a dental hygienist who is under the supervision and responsibility of the dentist, as specified by 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 as specified by the Dental Practice Act. Physical presence does not require that the supervising dentist be in the treatment room when the dental assistant performs the service as long as the dentist is in the dental office/clinic. A delegating dentist is responsible for a dental act performed by the person to whom 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 23-2; Effective Sept. 8, 2023

Grantees shall bill for allowable services provided to eligible clients and receive reimbursement up to their grant award amount. Child Health and Dental Reimbursement request for the month of September must be submitted and reimbursed by Dec. 31 . Submissions that do not meet the above requirement will not be processed.

Prenatal Medical and Dental Reimbursement request for the month of September, must be submitted and reimbursed by Nov. 30. Submissions that do not meet the above requirement will not be processed. Once all award funds have been expended, no other funds will be available for reimbursement.   

Continuation of Services

Grantees who have exhausted their awarded funds must continue to serve their existing clients. 

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

The MRP for both programs are available for grantees to download from the Grantee Portal. The MRP will be available to download 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. Monthly submission should be sent to HDS.ADS@hhs.texas.gov.

Grantees will need to:

  • complete the date and contact information on the Monthly Reimbursement Request (MRR);
  • complete the service quantities on the 185 and 186 tabs; and
  • complete demographic data for the Monthly Activity tab.

Additional instructions are included in a separate tab at the end of the MRP.

An important note about the Monthly Activity tab is that this report counts the unduplicated number of clients receiving billable services by age, race and ethnicity on their first visit. A client’s first visit during a state fiscal year will be counted as an unduplicated client for each Title V program they participate in. All subsequent visits within a program should not be counted again in the unduplicated client count. The four Title V programs are Prenatal Medical, Prenatal Dental, Child Health and Child Dental.  

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. 

Grantees must maintain records that document the necessary information for services provided and billed for reimbursement. Documentation will be audited during HHSC on-site quality assurance reviews and fiscal monitoring reviews.

Supplemental Invoices

Instances can occur that result in missed reporting of a prior month’s services that have not yet been billed to Title V MCH FFS. Any services performed prior to the current service month must be submitted as a supplemental invoice, with a separate invoice for each service month applicable. Please use your MRP to submit the supplemental invoice to HDS.ADS@hhs.texas.gov and included “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. A 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 is required to 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. You may claim any additional services by submission of a MRP prior to Oct. 15. Please mark this as FINAL. 

Submit all claims for reimbursement for services delivered within 45 days of the end of the contract term. 

Reimbursement requests submitted more than 45 days following the end of the contract term will not be paid. If the 45-day deadline falls on a weekend, the final invoice and MRP must be submitted prior to this date.

Submission of Financial Reconciliation Report (FRR)

The FRR must include all reimbursements and adjustments in payment for the contract term and be submitted within 60 days of the completion of the contract year, i.e., Oct. 31, to HDS.ADS@hhs.texas.gov

Altering of Forms

Grantees must use the most current version of their organization’s MRP for ease of processing. No billing or reporting forms may be altered in any manner. 

The tabs on the MRP are locked to ensure they remain in the original order. Alteration of order can create an error in the reported reimbursement amount and thus the invoice will have to be corrected causing delay in payment.  

Maintaining Appropriate Supporting Documentation

Grantees must maintain a monthly billing log, also known as billing strips, (automated or manual) to support their Monthly Reporting Packet (MRP) submissions. The log should contain a unique client number, patient’s age at time of service, date of service, and procedure code for each service billed. These logs will be audited during HHSC quality assurance reviews and fiscal compliance monitoring reviews.

Appendix I, Definition of Income

Revision 23-2; Effective Sept. 8, 2023

Definition of Income

Types of IncomeCountableExempt
Adoption Payments X
Cash Gifts and Contributions*X 
Child Support Payments*X 
Child's Earned Income X
Crime Victim's Compensation* X
Disability Insurance BenefitsX 
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*XX
Military Pay*X 
Mineral Rights*X 
Pensions and Annuities*X 
ReimbursementsX 
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)*XX
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. 

Forms

ES = Spanish version available.

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

24-1, Updates Appendix II

Revision 24-1; Effective May 1, 2024

The following change(s) were made:

RevisedTitleChange
Appendix IIOptional 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:

RevisedTitleChange
1100Contact InformationRemoves helpline information and phone number.
1200Purpose of ManualUpdates language.
2100Program Authorization and ServicesUpdates language. Updates date for national Healthy People objectives.
2200Definitions Updates definitions throughout.
3100Administrative PoliciesUpdates language. Revises civil rights requirements. Adds requirement to maintain appropriate exterior signage.
3200Abuse and Neglect ReportingUpdates language. Revises abuse, neglect and exploitation requirements. 
3300ConfidentialityUpdates language. Adds requirement to display certain civil rights posters.
3400Client Records ManagementUpdates language.
3500Personnel Policies and ProceduresUpdates language. Revises immunization guidance.
3600Facilities and EquipmentUpdates language. Revises facility requirements. Adds laboratory standards. Removes Disaster Response Plan.
3700Emergency ResponsivenessUpdates language. Adds Disaster Response Plan.
3800Quality ManagementUpdates language. Revises Quality Management requirements.
4100Eligibility and Assessment of Copay and FeesUpdates language. Adds a process to apply for approval to use an Alternate Eligibility Tool. Revises client eligibility screening for postpartum services. Adds procedures and terminology when determining eligibility. Changes form for employer verification. Adds eligibility forms.
5100General ConsentUpdates language. 
5200Clinical PolicyUpdates language. Defines case management requirements.
5300Perinatal Clinical GuidelinesUpdates language. Reorganizes information. Includes quit line information. 
5310Initial Prenatal Visit RequirementsCreates new section to reorganize existing requirements. Updates language. 
5320Return Prenatal Visit RequirementsCreates new section to reorganize existing requirements. Updates language.
5330Postpartum Visit RequirementsCreates new section to reorganize existing requirements. Updates language.
5340Perinatal Dental ServicesCreates new section to reorganize existing requirements. Updates language.
5400Child and Adolescent Clinical GuidelinesUpdates language. Revises service and billing requirements. Adds anticipatory guidance resource.
5410Child and Adolescent Dental ServicesCreates new section to reorganize existing requirements. Updates language.
5500Prescriptive Authority Agreements, Clinical Protocols and Standing Delegation OrdersUpdates language. Revises PAA and SDO requirements. 
6100Reimbursement, Data Collection and ReportsUpdates language. Removes guidance. Revises submission, reconciliation and invoice requirements.
Appendix IDefinition of IncomeUpdates language. 
FormsFormsUpdates form titles.

23-1, Appendices Revised

Revision 23-1; Effective Mar. 31, 2023

The following change(s) were made:

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

22-4, Section 4000 Revised

Revision 22-4; Effective Dec. 12, 2022

The following change(s) were made:

Revised Title Change
4000 Eligibility and Fees Adds section description.
4100 Eligibility and Assessment of Co-pay/Fees Adds hyperlink to Form 3047, Office of Primary and Specialty Health Notice of Ineligibility.