A-1530, Medical and Dental Benefits

Revision 07-1; Effective January 1, 2007

A—1531 Texas Health Steps

Revision 19-3; Effective July 1, 2019

TP 43, TP 44, TP 45 and TP 48

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service is Medicaid's federally-required comprehensive preventive child health service (medical, dental, and case management) for persons from birth through 20 years of age. In Texas, EPSDT is known as Texas Health Steps. Through Texas Health Steps, children and young adults receive regularly scheduled medical and dental checkups. The Texas Health Steps program:

  • facilitates early detection and treatment of medical and dental problems;
  • provides health supervision for infants; and
  • enables persons to establish links with primary health care providers who can meet future needs for care.

Texas Health Steps' mission is to:

  • expand the public’s and recipients’ awareness of existing Texas Health Steps services;
  • encourage and increase use of Texas Health Steps services; and
  • make comprehensive services available through private and public providers so that infants, children, and adolescents can receive medical and dental care before health problems become chronic and irreversible damage occurs.

Texas Health Steps services comprise the following:

Medical Checkups— Texas Health Steps medical checkups include:

  • a comprehensive health and developmental history (including developmental and mental health, nutrition and tuberculosis screenings);
  • a complete physical examination;
  • laboratory tests (including lead screening);
  • routine immunizations;
  • health education;
  • dental screening and referral to a dentist;
  • vision screening;
  • hearing screening; and
  • referrals to other health care providers as needed.

Texas Health Steps offers checkups according to a recommended schedule. The frequency varies according to the stages of growth. In addition to an inpatient newborn screening, children and young adults may receive up to 29 outpatient checkups. The recommended schedule for periodic medical checkups is:

  • Birth to 35 months — 11 health checkups to ensure:
    • proper growth and development; and
    • immunizations are administered according to the Advisory Committee on Childhood Immunization Practices (ACIP) recommended schedule;
  • 3 years through 5 years — three health checkups (once a year);
  • 6 years through 10 years — five health checkups (once a year); and
  • 11 years through 20 years — 10 health checkups (once a year).

Dental Services — Texas Health Steps provides comprehensive dental care, including emergency, preventive, therapeutic, and orthodontic services. Children and young adults are eligible to receive routine dental checkups every six months starting at six months of age. Emergency or medically necessary dental services are available to children and young adults at any time from birth through age 20.

Vision Services — Each Texas Health Steps medical checkup includes:

  • a vision screening;
  • diagnosis and treatment, including eyeglasses every two years for defects in vision; and
  • one eye examination per state fiscal year (September through August).

Lost or destroyed eyeglasses are replaced with no limit on the number of replacements. The person may receive additional services that are medically necessary because of a vision change.

Hearing Services — Texas Health Steps medical checkups also include a hearing screening. Additional testing for hearing problems, as well as diagnosis, treatment, and hearing aids, are available through the Medicaid Program.

Case Management for Children and Pregnant Women — To encourage the use of cost-effective health and health-related care, Case Management for Children and Pregnant Women provides services to children from birth through age 20 who have a serious health condition or who are at risk of developing a serious health condition. Services are also provided to high-risk pregnant women of all ages. Together, the case manager and the family assess the medical, social and educational needs of the eligible recipient.

Texas Health Steps Comprehensive Care Program (CCP) — This program provides expanded benefits to Texas Health Steps persons. Under CCP, people under age 21 are eligible for any medically necessary and appropriate health care service covered by Medicaid. Limitations of the current Texas Medicaid Program do not apply to these people. Expanded benefits include durable medical equipment and supplies, prosthetics, orthotics, private-duty nursing, and therapeutic services.

A—1531.1 Accessibility of Texas Health Steps Services

Revision 19-3; Effective July 1, 2019

Medical Programs (except TP 08, TA 31, TP 32, TP 33, TP 34, TP 35, TP 36, TP 42 and TP 56)

HHSC’s Texas Health Steps Outreach and Informing contractors and local Texas Works staff provide initial and periodic outreach and information to help people access Texas Health Steps services. For example, the contractors and local Texas Works staff can help find a Texas Health Steps provider or provide information about HHSC’s Medical Transportation Program (MTP). The Texas Health Steps Outreach and Informing contractor can also help with scheduling a Texas Health Steps appointment.

When a person under 21 is certified for Medicaid, the enrollment broker sends written information to households that include a welcome notification at certification and letters when a child’s checkup is due per the Texas Health Steps periodicity schedule.

MTP provides non-ambulance transportation to a doctor or dentist office, hospital, drug store, or any place a person may receive Medicaid services. MTP is available to Medicaid-eligible people and necessary attendants when they have no other means of transportation. Children 14 and under must travel with a parent or guardian, and children 15–17 may travel alone if a parent or guardian fills out the proper consent form. An HHSC contractor or a private contractor of the person's choice, such as a parent, friend, neighbor or volunteer may provide transportation. A private contractor:

  • must have a written agreement with the MTP before providing the service; and
  • will be reimbursed for mileage to an authorized facility at the state rate.

If it is medically necessary for a person through age 20 to be away from home overnight, MTP approves cost-effective meals, lodging, and up-front funds for the person and the person's attendant.

Households may contact MTP by calling toll-free 877-633-8747.

Complete Form H1093, Texas Health Steps Extra Effort Referral, if a household requests help accessing MTP services.

For more information on MTP and a list of frequently asked questions visit the MTP page.

A—1531.2 Texas Health Steps Service Providers

Revision 19-3; Effective July 1, 2019

Medical Programs (except TP 08, TA 31, TP 32, TP 33, TP 34, TP 35, TP 36, TP 42 and TP 56)

Texas Health Steps is a Medicaid health care program for children from birth through age 20. The Texas Health Steps services are delivered by both public and private providers. Physicians, dentists, advance practice nurses, physician assistants, clinics, hospitals, Federally Qualified Health Centers (FQHCs) and others offer Texas Health Steps services to eligible people. Providers must enroll in Medicaid and enroll as a Texas Health Steps provider.

A—1531.3 Program Administration

Revision 19-3; Effective July 1, 2019

Medical Programs (except TP 08, TA 31, TP 32, TP 33, TP 34, TP 35, TP 36, TP 42 and TP 56)

To comply with the Frew lawsuit requirements, staff play a role in educating people about the Texas Health Steps program. Within the Texas Health Steps program, "outreach" and "informing" are terms applied to efforts, strategies, plans, events, organized activities, and courses of action taken to advertise, educate and increase the number of Texas Health Steps checkups.

A—1531.4 Explanation of Benefits

Revision 20-1; Effective January 1, 2020

Medical Programs (except TP 08, TA 31, TP 32, TP 33, TP 34, TP 35, TP 36, TP 42 and TP 56)

To help inform Medicaid recipients, Texas Health Steps Outreach and Informing staff provide the following materials to HHSC:

  • A desk reference containing Texas Health Steps program information. The desk reference has toll-free numbers, call center hours and website addresses for Texas Health Steps and the Medicaid Transportation Program. The desk reference contains information that is consistent with the current Texas Health Steps periodicity schedule.
  • The Texas Health Steps brochure, "Don't Miss a Beat," presents easy to understand information about the Texas Health Steps program.
  • The Appointment Education Brochure, known as “Keep Your Child's Checkups in Check,” provides helpful tips to make doctor or dentist visits a positive experience.
  • A current Texas Health Steps wallet card, “Checkups Help Children Stay Healthy!” is given to every Medicaid-eligible household with a child through age 20. Families use the cards as a quick reference for when a child is due for a Texas Health Steps dental or medical checkup, based on the child's age. The back of the card provides important information on immunizations.

Each household is given the brochures and a wallet card at:

  • initial certification or any time there is a reapplication;
  • renewal, if the household has not complied with Texas Health Steps requirements and a face to face interview is required; or
  • any time a household requests them.

The materials can be sent by mail if the person is interviewed by phone or when no interview is conducted.

Texas Health Steps materials may be ordered online.

Supervisors must ensure that all staff have the following Texas Health Steps materials and use them as required:

  • a desk reference;
  • "Don't Miss a Beat" and "Keep Your Child's Checkups in Check " brochures;
  • "Checkups Help Children Stay Healthy!" Texas Health Steps wallet cards; and
  • Form H1093, Texas Health Steps Extra Effort Referral. This form is used to help people who need:
    • to schedule a Texas Health Steps checkup or appointment;
    • more information on Texas Health Steps medical, dental and case management services; and
    • services other than those listed above.

Fax Form H1093 to Texas Health Steps Outreach and Informing staff at 512-533-3867.

A—1531.5 Compliance Requirements

Revision 22-1; Effective January 1, 2022

TP 44 and TP 48

Starting at 2 years old, children under 18 must comply with the regimen of care prescribed by the Texas Health Steps Program. At the first redetermination, check for overdue screening dates. If one exists, contact the caretaker and allow the caretaker to self-declare that the child:

  • had the screening;
  • is scheduled for the screening; or
  • has not been screened, but has good cause.

If unable to contact the caretaker by phone, send Form H1024, Subject: Self-Declaration Notice, to obtain the information.

If the household does not return Form H1024, deny the EDG for failure to provide. If the household returns Form H1024 indicating noncompliance, schedule the caretaker for a phone interview and emphasize the importance of the checkups. Use the Health Care Orientation Quick Reference Guide and Enrollment Script, when a recipient has an interview due to noncompliance with Texas Health Steps or Health Care Orientation. If the person does not keep the appointment, deny the EDG for Noncompliance with Healthcare Orientation. Note: The denial applies to all Children's Medicaid EDGs for the household, except TP 45 for newborns.

At the next redetermination, if TIERS still shows the same overdue date for the child, the caretaker must provide verification that the child had the checkup or has a phone interview appointment before the redetermination.

Deny the Medicaid EDGs for all the children in the family, except TP 45 coverage for newborns, if any certified child’s Texas Health Steps screening is overdue and the caretaker does not comply with the requirements, show good cause or have a phone appointment. A parent or caretaker may self-declare on the Form H1024 or by phone if there is a good cause reason that the child has not had the checkup.

Related Policy

Continuous Medicaid Coverage, A-832
General Reminders, A-1510
Processing Children's Medicaid Redeterminations, B-123
Health Care Orientation Quick Reference Guide, C-1118

A—1532 Medicaid

Revision 16-4; Effective October 1, 2016

Medical Programs

Applicants must be informed that:

  • they will receive a Your Texas Benefits Medicaid ID card if certified;
  • they must show the Medicaid ID card to medical providers;
  • each individual can receive three paid prescriptions a month;

    Exception: The following Medicaid recipients are eligible for unlimited paid prescriptions:

    • managed care individuals;
    • nursing facility residents; and
    • individuals under age 21, through the month of their 21st birthday.

    Note: Lost or destroyed prescriptions may be replaced by contacting the pharmacy that originally filled the prescriptions. The pharmacy can call the vendor drug toll-free pharmacy provider line to obtain procedures for overriding the system.

  • if they lose their Medicaid ID card, they can request a new one by calling 1-855-827-3748 (providers can still verify Medicaid eligibility without the card); and
  • Medicaid will not reimburse them for any bills they pay.

Note: If the household has members who are elderly or have disabilities who wish to apply for Medicaid, but who do not qualify for any Medical Programs for families and children, refer them to HHSC's MEPD programs. Staff must provide the household with the address and telephone number of the nearest office, or the self-service website www.hhsc.state.tx.us/help/index.shtml.

Medical Programs (except TA 31, TP 32, TP 33, TP 34, TP 35, TP 36 and TP 56)

Applicants living in a managed care area must be informed that they are required to select a managed care plan and primary care physician.

Emergency Medicaid

Staff must explain that Medicaid coverage is limited to the dates of the emergency medical condition.

TP 40

Encourage the pregnant woman to start receiving prenatal care.

A—1532.1 Spend Down EDGs

Revision 15-4; Effective October 1, 2015

TP 56 and TP 32

For applications with spend down, staff are required to verbally explain the following:

  • Children or pregnant women in the certified group are not eligible for Medicaid until spend down is met (i.e., the household's excess income is depleted with medical expenses incurred by members of the budget group).
  • TIERS mails Form H1120, Medical Bills Transmittal/Insurance Information, and Form H3087S, Spend Down Medicaid Identification, to the individual. Form H1120 provides the Medically Needy Clearinghouse with information needed to determine spend down for clients and provides the individual with information needed to submit medical bills to the Clearinghouse. Form H3087S summarizes the spend-down amount and potential eligible months and explains to providers how they can assist the individual by submitting bills.
  • The household or a provider must submit bills to the Medically Needy Clearinghouse. The Clearinghouse must receive the bills within 30 days of the later of the following dates:

    • the day Form TF0001, Notice of Case Action, processes; or
    • the last day of the application month.

    The individual should be advised to contact the Clearinghouse if the 30-day time limit is near and there is a delay getting bills from a provider, third-party resources (TPR) information, etc. The Clearinghouse allows bills paid during the month(s) of potential eligibility by:

    • members of the household composition, and
    • state or local government agencies (County Indigent Health Care, Children with Special Health Care Needs, MIHIA, etc.).
    • The Clearinghouse also allows unpaid bills that are itemized regardless of when they were incurred. Itemized bills must include:
    • name of the provider,
    • date the service was provided,
    • date(s) and amount(s) paid toward the bill, and
    • balance due.


    If a bill was incurred 60 days or more before the applicant submits it, the applicant must provide a current itemized statement.

    Staff should assist the individual in determining whether bills are current, itemized, and complete, if requested.

  • The individual must submit claims to TPRs, if any, before submitting the bills to the Clearinghouse. When submitting the bills, the individual must provide the Clearinghouse with verification that a TPR will not pay certain bills or portions of bills. An Explanation of Benefits (EOB) provides this information.
  • The individual must answer the Clearinghouse's request for additional information no later than 30 days after the:
    • last day of the application month, or
    • date of the Clearinghouse's request.

Staff should advise the applicant of the types of assistance available to help the individual with the spend-down process.

On the same day the advisor approves the EDG, the advisor gives or TIERS mails to the individual:

  • Form TF0001, Notice of Case Action;
  • Form H3087S, Spend Down Medicaid Identification;
  • Form H1120, Medical Bills Transmittal/Insurance Information; and
  • a preaddressed Clearinghouse envelope for the applicant to use to submit bills to the Clearinghouse.

Do not give Form H1120 to anyone other than the applicant or the applicant's AR. Explain that it is best to submit all bills at the same time because the Clearinghouse must establish a hierarchy when processing bills to meet spend down. This hierarchy ensures that spend down is met by nonreimbursable bills before reimbursable bills because nonreimbursable bills:

  • were incurred before a month of potential eligibility, or
  • are not for Medicaid-covered services.

A—1533 Transitional and Post Medicaid

Revision 15-4; Effective October 1, 2015

TP 08

The individual should be informed that the household may be eligible for additional months of transitional Medicaid and child care if TP 08 is denied because of earned income (TP 07).

The household should be informed that they may be eligible for four additional months of post Medicaid if TP 08 is denied because of spousal support income.

The individual should also be informed that if the household is not eligible for transitional or post Medicaid, the household may be eligible for other medical program coverage.

A—1534 Requirement to Report Accidents

Revision 15-4; Effective October 1, 2015

Medical Programs

Staff should instruct the individual to report accidents. This is to determine whether the individual has any TPRs other than Medicaid that could cover medical expenses.