5710 Cervical Cancer Screening

Revision 23-4; Effective Nov. 17, 2023

General Considerations for Cervical Cancer Screening

Cervical cancer screening is primarily performed using the Pap test and the HPV DNA test. FPP uses United States Preventive Services Task Force (USPSTF) cervical cancer screening recommendations.

Clinical guidelines for cervical screening are as follows: 

• 21 – 29: Cervical cytology (Pap smear) alone every three years, with reflex HPV testing when cytology reveals atypical squamous cells of undetermined significance (ASCUS). 
• 30 – 64: Cervical cytology (Pap smear) alone every three years, with reflex HPV testing for ASCUS or cervical cytology and HPV co-testing every five years (preferred). 
• Under 21: Not eligible for cervical cancer screening.

Special circumstances may warrant alterations in screening intervals, as determined by a clinician. Special circumstances must always be documented in the client’s medical record. These may include: 

• Clients considered high-risk (for example, HIV positive, immunosuppressed, exposed to diethylstilbestrol (DES) in utero or history of cervical cancer). 
• Clients who had a hysterectomy for cervical intraepithelial neoplasia (CIN) disease. These clients may continue screening for 20 years. 
• Clients who have had cervical cancer. These clients may be screened indefinitely if they are in good health. 
• Applicants who have had a hysterectomy for benign disease and the cervix is still present. These people may be eligible for cervical cancer screening services. Funds can be used to pay for an initial examination to determine whether the cervix is still present.

Components of Cervical Cancer Screening

The clinical components of cervical cancer screening are pelvic examination, Pap test, HPV test (if indicated), clinical breast examination (CBE) (if indicated), client education, tobacco assessment and Quitline referral (if indicated). The contractor must document the CBE and cervical cancer screening components in the client’s medical record.

A cervical health history must be included as part of the cervical cancer screening. The health history includes the: 

• Date and results of the last pelvic examination and Pap test 
• Date and results of any past diagnostic procedures and treatments for cervical disease 
• Date of last menstrual period and pregnancy history 
• Medication history, including current or previous use of hormones (for example, hormone replacement therapy and oral contraceptives) 
• Risk factors for cervical cancer 
• Description of present pelvic symptoms

Clinical components of cervical cancer screening must be performed by a physician, physician’s assistant, nurse practitioner, certified nurse midwife or a qualified registered nurse with specialized training as required under standing delegation orders (SDOs). The RN’s specialized training for cervical cancer screening must be documented in the personnel record (for example, an educational certificate, a degree or continuing education credits).

Contractors must have policies and procedures to ensure health care providers follow evidence-based clinical guidelines and provide clinical services consistent with current nationally recognized standards of care.

HPV DNA testing is a reimbursable procedure when used for screening with Pap testing (that is, co-testing) and for follow-up of abnormal Pap results, as per the  American Society for Colposcopy and Cervical Pathology (ASCCP) algorithms. The following guidelines apply: 

• For women ages 30 through 64, the following screenings are recommended:
  • co-testing (combined cervical cytology and HPV testing) every five years;
  • cervical cytology testing alone, with reflex HPV testing when cytology reveals ASCUS, every three years; and
  • screening with the FDA-approved primary HPV screening test every five years. If the primary HPV test is used for screening, it should be done according to interim guidance provided by the ASCCP.
• It is reasonable to perform annual cervical cytology testing in women with in utero exposure to diethylstilbestrol.
• For any client with an abnormal result, further testing and follow-up should be dictated by findings, diagnosis and current evidence-based guidelines, such as that of the ASCCP.

Follow-Up for Abnormal Cervical Screening

When the results of the pelvic exam, cervical cancer screening test (Pap test), or both are abnormal, further diagnostic follow-up is required. A normal Pap test does not rule out cancer if a woman has a cervical lesion on pelvic examination. A colposcopy or cervical biopsy, or both, are allowed if determined appropriate by the clinician after an abnormal pelvic exam.

FPP grantees must follow the algorithms for the management of the specific type of abnormal result and in consideration of special populations (for example, pregnant women and clients 20 years and younger or at high risk). 

5720 Breast Cancer Screening

Revision 23-4; Effective Nov. 17, 2023

The summary of guideline recommendations in this section pertains to people aged 64 and younger and does not include recommendations for people outside this range.

Risk Screening and Individual Counseling

All women should undergo a risk assessment to determine if they are at high risk for breast cancer. Women considered high risk include those who have: 

• a known genetic mutation such as BRCA 1 or 2;  
• first-degree relatives with premenopausal breast cancer or known genetic mutation; 
• a history of radiation treatment to the chest area before the age of 30 (typically for Hodgkin’s lymphoma); 
• a lifetime risk of 20% or more for development of breast cancer based on risk assessment models that are largely dependent on family history; or 
• Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.

Providers can choose whichever risk assessment method they prefer to determine if a woman is at high risk for breast cancer. Women at high risk for breast cancer should be screened with both an annual mammogram and an annual breast MRI.

All people should be counseled on breast awareness and advised to be familiar with their breasts and to report any changes such as a mass, lump, thickening or nipple discharge promptly.

All people should be counseled on the benefits and risks of mammography. If a person has the option of having a 3-D mammogram, she should be counseled on the benefits and risks of 3-D mammograms versus 2-D mammograms to make an informed decision.

Breast Cancer Screening Frequency

Women 40 and older may receive breast screening services every 1 to 2 years based on the women’s history and clinical presentation.

FPP recommends that grantees and providers counsel all eligible women, including transgender men and women, about the benefits, potential harms, and limitations of screening, and discuss individual risk factors to determine if screening is medically indicated.

Components of Breast Cancer Screening

The contractor must provide a complete breast cancer screening, which includes a mammogram, individualized client education, tobacco use assessment and Quit Line referral, if indicated, and may include a clinical breast examination (CBE). The contractor must document the breast cancer screening components in the client’s medical record

A breast health history must be included as part of the breast cancer screening. The health history includes: 

• date and time intervals of previous mammograms;
• results of previous mammograms;
• date and results of the last CBE;
• date and results of any previous breast surgery; 
• date of last menstrual period; 
• medication history, including current or previous use of hormones (for example, hormone replacement therapy and oral contraceptives); 
• other risk factors for breast cancer (personal history of breast cancer or family history of first-degree relatives with breast cancer); and
• description of breast symptoms, if any.

Breast Cancer Screening Follow-up and Referral for Treatment

Clients with an abnormality found on screening or a specific breast complaint (including, but not limited to a mass, lump, thickening or nipple discharge) should be promptly evaluated, as indicated. Providers should have procedures in place to ensure appropriate client education and counseling, referral for further evaluation (including other testing and biopsy) when indicated, communication and coordination with the person and other providers, and proper follow-up through the conclusion of the case.

For persons who require referral for services beyond those available through the grantee, grantees are encouraged to refer these clients to an HHSC Breast and Cervical Cancer Services (BCCS) grantee. Information is available at Texas Health and Human Services Breast and Cervical Cancer Services and Texas Works Handbook, X-900, Medicaid Eligibility.

Eligible clients in need of treatment for biopsy-proven breast cancer may apply for coverage under the Medicaid for Breast and Cervical Cancer Program. Additional information is available in Section 3354 of the Breast and Cervical Cancer Services Policy Manual and in the Texas Works Handbook, X-900.

5730 Sexually Transmitted Disease and Infection (STD and STI) Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for FPP (age 64 and younger) and do not include guideline recommendations for people outside this range.

Screening and treatment of STDs and STIs must follow the current guidelines for screening and treatment from the Centers for Disease Control and Prevention (CDC). A risk assessment should be completed for all clients to determine what testing is indicated and documented in the medical record. Following is a brief overview of STD and STI screening recommendations (for more detailed information, go to the CDC screening links above).

HIV Screening

• Grantees must provide HIV testing either on-site or by referral.
• If HIV testing is done, verbal or written consent must be documented in the medical record. If the patient refuses testing, the refusal must be documented. All clients aged 13 to 64 should be screened at least once for HIV according to a policy that provides HIV education and allows clients to opt out of screening. With an opt-out screening, clients are informed, before testing, that HIV testing will be done as part of the general consent for care and that they are free to decline testing. If they do not decline, the test is performed.
• Clients who engage in high-risk sexual practices or share injection drug paraphernalia should be tested annually.
• Clients who seek testing or treatment of STDs and STIs should be tested for HIV at the same time.
• Grantees may provide negative HIV test results to clients in person, by phone, or by the same method or manner as the results of other diagnostic or screening tests. The provision of negative test results by phone must follow procedures that address a person’s confidentiality, identification of the person and prevention counseling.
• Grantees must always provide positive HIV test results to clients in a face-to-face encounter with an immediate opportunity for counseling and referral to community support services. Test results must be provided by staff who are knowledgeable about HIV prevention and HIV testing.
• Clients whose risk assessment reveals high-risk behaviors should be provided directly, or referred for, more extensive risk reduction counseling by a Department of State Health Services (DSHS) HIV-STD program trained risk reduction specialist.  

Clients with a diagnosis of HIV should be referred to a DSHS HIV-STD program grantee for treatment and monitoring. To find a DSHS HIV-STD program grantee, visit DSHS HIV-STD Program.

Chlamydia and Gonorrhea Screening

• Grantees must provide chlamydia and gonorrhea screening.
• Annual chlamydia and gonorrhea screening should be provided for all sexually active women under age 25. If a pelvic examination is not performed, as in asymptomatic women under age 21 and other women who decline a pelvic examination, screening can be performed using a nucleic acid amplification technique on a urine sample or a vaginal swab obtained by the client.
• Testing should be provided for all symptomatic women and asymptomatic women with increased risk 25 years and older. Indications include, but are not limited to:
  • new or multiple sex partners;
  • a partner who has another partner;
  • exposure to an STD or STI;
  • symptoms or signs of cervicitis or an STD or STI;
  • history of pelvic inflammatory disease;
  • a positive test for an STD or STI in the previous 12 months; and
  • sex work or drug use.
• Treated clients should be retested three to four months after treatment to assess evidence of reinfection.
• All women who are pregnant or attempting pregnancy should be tested.
• Routine screening of males for chlamydia and gonorrhea should follow current CDC guidelines.

Herpes Simplex Virus (HSV) Screening

• Routine screening of asymptomatic clients for genital HSV infection is not recommended in the general or pregnant population.
• Testing, counseling, and treatment of symptomatic clients (clients who have genital lesions), as well as management of affected pregnant clients, should follow current CDC guidelines.
• The preferred tests for confirmation of the diagnosis in clients with active genital ulcers or mucocutaneous lesions are cell culture and polymerase chain reaction (PCR) assay.
• Type-specific serologic testing is appropriate in some circumstances:
  • for people presenting for evaluation of an STD and or STI (especially those who report multiple sexual partners) and persons with HIV infection;
  • for men who have sex with men and whose HSV infection status is unknown, type-specific serologic testing may be appropriate to evaluate an undiagnosed genital tract infection;
  • when infection is suspected, but no lesions are present (a culture or PCR assay is not indicated if no lesions are present);
  • when the diagnosis is uncertain and virologic tests (culture and PCR) are negative in a symptomatic client; or
  • for counseling clients about the risk of infection by a partner with known infection, especially during pregnancy.

Syphilis Screening (Men and Non-pregnant Women)

• Men and non-pregnant women who are at an increased risk of syphilis infection should undergo screening for syphilis.
• Men who have sex with men, and men and women who are living with HIV, have a higher risk for syphilis infection.
• Other factors associated with increased prevalence of syphilis infection include a history of incarceration or commercial sex work.
• Routine screening for syphilis in a non-pregnant population that is not at increased risk of syphilis infection is not recommended as it may yield a high false-positive rate, leading to overtreatment.

Other Screening and Pregnant Women

Screening for other infections and more frequent screening should be considered as appropriate based on the person’s condition, risk factors and concerns.

Pregnant Women

• All pregnant women should undergo screening for syphilis, HIV (by an opt-out policy), and hepatitis B surface antigen as early as possible in the pregnancy.
• Clients under age 25 and women at increased risk should also have chlamydia and gonorrhea testing.

Expedited Partner Therapy

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

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

5740 Diabetes Mellitus Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

Grantees must evaluate all clients for risk factors for diabetes annually and provide screening lab work as appropriate. Grantees must have a process and policy in place for the diagnosis and treatment of clients with uncomplicated diabetes. 

While treatment protocols for diabetes are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as the American Diabetes Association Standards of Care in Diabetes, American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention’s Information for Diabetes Professionals. Providers are responsible for having a policy and process in place for the referral of clients with complex needs that are not covered services under FPP.

5750 Hypertension Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

Grantees must screen all clients for hypertension annually. Grantees must have a process and policy in place for the diagnosis and treatment for clients diagnosed with uncomplicated hypertension.

While treatment protocols for hypertension are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as The American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. Providers are responsible for having a policy and process in place for the referral of clients with complex needs that are not covered services under FPP.

5760 High Cholesterol Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

Grantees must screen all clients for high cholesterol annually. Grantees must have a process and policy in place for the diagnosis and treatment for clients diagnosed with high cholesterol.

While treatment protocols for high cholesterol are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as The American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. Providers are responsible for having a policy and process in place for the referral of clients with complex needs that are not covered services under FPP.

5770 Postpartum Depression Screening and Treatment

Revision 23-4; Effective Nov. 17, 2023

Postpartum depression screening must be performed if a client was pregnant in the past year.

Providers are encouraged to review The Texas Clinician’s Postpartum Depression Toolkit for a more detailed review of screening for postpartum depression.

As postpartum depression can be a serious and sometimes life-threatening condition, all new mothers should have screening for postpartum depression at their initial postpartum visit. For those who screen negative, repeat screening should be conducted at a later visit.

A standardized self-administered screening tool with review and follow-up questions in a face-to-face interview with the provider will ensure consistency and efficiency in the screening process. The following postpartum depression screening tools are available online and have been validated for use in postpartum clients:

•    Edinburgh Postnatal Depression Scale (EPDS); Cox, Holden and Sagovsky, 1987
•    Patient Health Questionnaire-9 (PHQ-9); Spitzer, Kroenke and Williams, 1999
•    Postpartum Depression Screening Scale (PDSS); Tatano Beck and Gable, 2002

Postpartum Depression Treatment

FPP covers screening and initial treatment for diagnosis of postpartum depression.

While treatment protocols for postpartum depression are beyond the scope of this manual, providers are encouraged to seek information from trusted sources such as the Texas Health and Human Services, the Texas Clinician’s Postpartum Depression Toolkit, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. Providers are responsible for having a policy and process in place for the referral of clients with complex needs that are not covered services under FPP.

The Perinatal Psychiatry Access Network, PeriPAN, can enhance provider capacity to provide the perinatal mental health standard of care FPP clients need. There is no cost to FPP providers or clients for this evidence-based, clinician-to-clinician program. Texas PeriPAN offers real-time access to a multidisciplinary network of mental health experts—including reproductive psychiatrists for peer-to-peer consults by phone and vetted and personalized referrals and resources. Contact information and other details on how to access this resource are available on the PeriPAN website.

For severe and persistent behavioral health issues, please consult with Local Mental Health Authorities or Local Behavioral Health Authorities, or call 211.